Good morning, everyone, and welcome to the Green Mountain Care Board. My name is Kevin Mullen, chair of the board, and we're about to get started on discussions on the hospital budget guidance for 2022. Before we do that, we have a couple of things on the agenda, and I'm going to go to Susan first just because I believe that she has another engagement over at the Senate testifying there. Our executive director's report, Susan Barrett. Yes, thank you, Mr. Chair. Just a reminder for our advisory committee. We are accepting written public comments from them until April 1st. We've actually received a few so far. Thank you to those members who have already submitted your comments. We will post those. We're also sharing those with our partners at AHS and the director of health care reform at AHS as they lead the way in terms of a subsequent agreement with the federal government on an all-fare model. I also, Kevin, thank you for saying Lori Perry and I will be popping off of this meeting at 10.30. Senate Health and Welfare has asked for a financial update on hospital, Vermont hospital. So thank you, Lori, for helping us out. We know that, obviously, Kevin and Patrick, who probably normally would do the update for them, will be otherwise occupied here at this board meeting. So when we finish up over there, we'll come back over to this meeting. So that is all I have. I guess, lastly, our April schedule should be out. We're going to try to get it out by the end of this week. It may be Monday. We're just tying up a few scheduling items. And that is all I have to report, Mr. Chair. Thank you. Thank you, Susan. Next, I'm going to go to the health care advocate who just wanted to clarify a few things from last week, Mike Fisher. Thank you, Mr. Chair. I wanted to come back to the HCA hospital budget questions. We think the right thing to do at this point is to go ahead and submit our four questions to the hospitals. We want to do it now because we want to give hospitals plenty of time to consider them. That's part of the purpose. With regard to the first part of question one that the board, I think, has a placeholder about whether some version of that fits within the board's questions, we certainly would, if that process plays out in a timely way and there's a better way of asking the question, we will adjust question one in line with that workgroups. With regard to the second part of question one, I just want to call your attention to I know hospitals said that they're not sure they can answer it. The question says, to the extent your organization tracks the information. So the HCA is doing our very best to be respectful of how various hospitals manage things and the time in front of us. We've shown incredible restraint. You should have seen our list of questions before we cut it down to four. And so I want to repeat my offer to individual hospitals. If you have questions or clarifications or if the way we phrase the question makes it difficult for you to answer them, we're happy to talk. We had some great conversations. I think it was with Northwest last year between Northwest and members of my team that I think was useful to both parties. And so we would welcome any need for clarifications or any need for assistance and them figuring out how to best answer our questions. We're really after the spirit of the questions. Thank you, Mike. And just as I said last week, the health care advocate absolutely has the statutory right to ask whatever questions they deem appropriate. And again, I want to thank the health care advocate and his team for, I believe, trying to follow the same basic premise that the Green Loud and Care Board has this year and trying to simplify the process and trying not to ask anything that doesn't need to be asked. And obviously, if you put 10 people in a room, you'll get 10 different ideas of what needs to be asked. And but again, everybody's goal is to make this as easy as possible on the institutions that are dealing with the front lines of this pandemic. So thank you, Mike. Thank you. The next items on the agenda are the minutes of Wednesday, March 17th. Is there a motion? So moved. It's been moved by Tom Pelham and seconded by Maureen Usper to approve the minutes of Wednesday, March 17th without any additions, deletions, or corrections. Is there any further discussion? Hearing none, all those in favor of the motion please signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show the minutes were approved unanimously. So at this time, I'm going to turn the meeting over to Patrick Rooney and his team to lead us through a brief recap of where we're at and start to take us through the decision points that will be necessary to be made today. And I'm going to ask all board members, must it be a clarifying question on a particular slide, to please hold your questions to the end, because I think that at this point everything seems to be interwoven. And at the end of the slides, it might be the best approach to focus on a presumptive approval motion first and then move from there. So with that, Patrick. Thank you, Mr. Chair. Good morning. Good morning, board members of the public and stakeholders. We're here today on March 24th at the third of three scheduled meetings to discuss and consider the FY22 hospital budget guidance. So we had some incredible feedback last week and some very solid dialogue on the topics that we discussed at last week's guidance based on the slides that were presented and some of the recommendations. So we've taken in that feedback and kind of broadened the options and brought some more considerations before the board today. So that will be encompassed in what you see on the screen on slide two is a review of the third iteration of the guidance as we've come to know it over the last couple of weeks. And then hopefully we can get to some decision points today where we could get a vote by the board and then the staff can go back and make any appropriate changes in context to the guidance as we know it and then have that delivered before or by next Wednesday, March 31st per the statute. So should we get to that point today, a little over a hundred days from now, we will be accepting hospital budget submissions on July 1st. So as the board chair discussed, we're going to move through this slide deck today in its entirety. It's only about 15 slides, so that won't take long. We have a process by which we work through this with MPR, change in charge, etc. That is by no means an explicit direction for the board. They can pick and choose topics as they wish. So should they choose to discuss the exemption parameters and criteria first, certainly they have the ability to do so. So this is not the way we're going to roll through this slide deck, does not mean that the board has to follow suit on those decision points. So keeping with common themes here over the last couple of weeks, we're acknowledging the public comment that we've received in the interim between these meetings that we've had in public here. And so since our last meeting on March 17th, we've received further public comment from Boz and the University of Vermont Health Network on March 18th and 19th, respectively, as highlighted on the screen here on slide three. And then we went and we made some changes based on that I just want to clarify that I believe there might be one item missing on the public comment slide. And that is that I want to make sure that we acknowledge receipt and the fact that board members have received and read a letter that came from Kat McGraw on behalf of all the chief medical officers around the state. So just wanted to make sure that that was acknowledged as well, even though it came in more recently. Thank you, Mr. Chair. You are correct. I did come in after we published the documents for today's meeting. So I will do some toggling back and forth after I read through the list here. These are some of the changes we made since last week. Our legal team went in and reworded some of the language around the board's establishment of MPR growth and its order to review and adjust hospitals for operating expenses commensurate with any adjustments made to the hospital's MPR fee in order to protect margins. We also added a placeholder for exemption from public budget hearings in the guidance document that discussion on exemption from public hearings really took hold last week throughout the time we were in our meeting. So we've added a placeholder for that and we can make appropriate changes as the board reaches decisions today. And then we added a question C under other operating and non-operating income based on the ACA's question around potential amounts received by hospitals related to COVID. So we included their question in our guidance document. And then that actually triggered us to go back and look at our appendices and I'll show you this as well that in fiscal year 22 of the relief fundings appendices we actually had a received portion for fiscal year 22, which doesn't really make a whole lot of sense when you think about it because they aren't going to book what they don't know they may or may not have. So we've pulled that out and we really focused on 22 as what are you realizing from what you have received from 21 or 20 and then what is still sitting on your balance sheet. So we've pulled that received part out of there thanks to the ACA's question around potential amounts to be received. And then finally, and we just had an update to this from Mike Fisher. We did set a placeholder for the ACA's question so we will go back and with a vote today and put their four questions into part E of the appendices. So with that I'm going to toggle over real quick to the actual budget guidance and I will just quickly note where we've made those changes. You can see here shaded in gray on page five of the budget guidance that we have the language that was reworked by our legal team around operating expenses. And we have our placeholder for public exemptions and some of the criteria that you will see on the slide that goes through it and the corresponding language from Act 91 to bring that exemption from public hearings into reality in this guidance document. Moving further down into the narrative section we added part C here for the ACA and we also corrected what I discussed earlier around the appendix for receipt of funds in 2022. We will not know what that is and I will toggle over to that real quick. As you can see here on the screen, 20 and 21 have a column for amounts received. Both hospitals don't know that. We certainly don't want them putting imaginary numbers in there. So we will show what dollars have passed through from here and it's potentially going to be recognized in 22 or is continuing to be recorded as a liability. So those are the changes that we have made since our last meeting with some of the feedback that we've received. And today overall for the board, these are some of the decision points that we want you to consider. One is value-based care questions three through five on the guidance document. There was discussion last week about potentially removing those and including them in sustainability where they may be more of an appropriate fit. But we also wanted to acknowledge that some of that information may want to be kept in the budget guidance document as well. So we'd like the board to have a discussion and reach a conclusion on whether or not to keep or remove those items. And then we have to make decisions on whether or not we set an NPR FPP growth guidance and charge guidance. And you'll notice we've removed the term ceiling from those items as opposed to last week and there's a reason for that to a moment. And then we have setting public hearing exemption guidelines in which we would also need you to set NPR or charge parameters around that. And you will see the terminology using ceiling there as opposed to those broader bullet points above. Then we have the standing enforcement policy that we'd like you to consider for today that does not mean you necessarily have to act on whether or not to waive it but it's whether or not to adopt a standing policy or not. And then finally with some of the feedback that we got from last week we brought some suggestions forward from the staff for the board to consider about potentially reducing some work options in this guidance process from what we've presented thus far. And we'll get to those as we near the end of this slide. So moving through the NPR growth component we've added the option at 3.5 percent budget to budget NPR growth. And the rationale behind that is consistent with the Moss Economic Growth and Prior Budget Guidance in 2020 and 2021 two pandemic years. But we're taking a little bit of a different spin on it and this is where we've removed the term growth ceiling is that we feel that it might be useful to have a point of reference for the board hospitals and GMCB staff analysis moving forward without it having to be a ceiling. So as I alluded to we've established 3.5 because it relates to Vermont's economic growth and that considers the highs and the lows over time of how Vermont's economy grows. We are certainly in a state of flux right now as I think we all understand as it relates to hospital finance. But establishing that 3.5 percent number we pull ourselves out of the man-made 12 month increments that we look at fiscal years in and we look back it might be helpful to have that reference point to say wow in 2020 we had negative 6.3 percent growth so of that 3.5 percent potential the system missed by 9.8 percent and then what occurs in 21 and then what occurs in 22 and those three years are probably going to be the most significant years under this pandemic that we've lived in. So we think there's some value in keeping consistent with that but having that 3.5 percent serve more as a reference point so it's something the board is familiar with when looking at budgets understanding that it may or may not be the right number but as a reference point how can we establish something so that we look back over our materials we can say how everything shook out once we cleared this pandemic and then option two we have the 3.5 percent budget to budget that we bought last week based on analysis of actual growth now with both of these numbers it should be understood that with the system coming in at negative 6.3 percent last year and this year yet to be determined there is the potential that there could be as we've all acknowledged a little bit a little bit of room for more growth should our situation with the vaccine improve dramatically over the course of the summer so that brings us to an option here that's not on the screen that was floated last week and we do think it's a fair point for the board to discuss as well and that's no NPR figure now that would pose challenges to us looking back in assessing how the system fared against a certain demarcation point but it certainly should be a discussion point for the board here today that potentially they don't want to act on and an actual and then to round all of that out the board does establish these guidelines but it it it's not a hard and fast number they do allow hospitals to exceed it they do consider the budgets and specific needs of hospitals but it's set it's a number that set there more as a reference point on an annual basis and this year it's a little bit more of a wild card as to what that could be but it's still within the ability of the hospitals to exceed whatever number the board may pick so those are the options that we brought here today for discussion we hope you will consider each one of them in reaching your final decision on whether or not to have an NPR FPP growth guidance for fiscal year 22 and then we have some language here around this to assist with any motion that the board would like to make we do hope that you will use this language verbatim and then fill in the blanks where possible so that we can cover our bases on appropriate motion language and then slide eight we're moving into the charge request growth guidance discussion option one is to adhere to past practice and have no ceiling but the exception of those exempted from hearing parameters and the rationales that we heard a lot of valuable feedback last week from hospitals and other stakeholders about opposition to having a ceiling in a year in which utilization could be all over the place and is widely unknown then we have option two which is the four percent charge request that we brought last week from the staff analysis based on actual growth plus a little bit of headroom there based on that historical growth so we brought it up to four percent then we have option three at three point five which is more explicit when compared to the numbers you see below that the five year average and medians of three point six and three point four over twenty seventeen to twenty twenty one and five year average and median of charge request for twenty sixteen to twenty twenty twenty three point two and three percent so we've got a variety of options there no ceiling four percent which is based on historical information with some headroom and then a much more explicit three point five percent based on actual information from past five years and then we have some motion language here if you choose option one no ceiling for the system with the exception of what parameters you set out in the exemption component of this this language only applied to two and three because you would be setting an explicit ceiling there for a hospital system as a whole should you choose option one you can feel free to ignore this motion language moving on the exemption from public hearing we clean this slide up from last week there was a lot of good dialogue around an interest in this topic so we do recognize that the board would need to use this act 91 authority to open the exemption to public hearings all hospitals so if folks remember that the existing rule now does say that the largest hospitals need come in for a budget hearing this would basically waive that and open this potential up to all of the hospitals and from us community hospital system and then important point here is that should the board choose to exempt a certain hospital that their budget will not be adjusted so if the board chooses to exempt them that is their budget for fiscal and then we cleaned up some of the criteria here around two important decision points that we need to hear from the board MPR rate requests in charge increase request ceilings of whatever you choose to be the the maximum there continued involvement in value based care reform the budgets the budget assumptions should be deemed reasonable the schedule should reconcile and the content should comply with guidance and we will make a decision when we present preliminary budget presentations to the board on July 28th so we will make a decision on that day as to which hospitals meet these parameters and do not have to come in for a budget hearing we did as a note here we did remove financial indicators from this board member homes brought up last week that if you use a median for example on days cash on hand you automatically exclude a group of hospitals none of those financial metrics are done in the vacuum they are all interconnected and so every time we try to add one or subtract one we ended up removing a large swath of our hospitals based on the variability we've seen in some of those numbers over the last couple of years so we stripped that out completely and we think the criteria here are the merits by which hospitals should look if they're going to produce a budget which would meet these parameters for the exemption from public hearing so with that we also have some motion language here to assist with your motion and it recognizes the act 91 authority and it also recognizes this enhanced criteria for fiscal year 2022 that we've just discussed then we have our enforcement policy so in the first iteration of these meetings three weeks ago our legal team brought to the presentation a standing enforcement policy that would sit over this process year in and year out unless there are substantive changes that need to be made that we cannot yet foresee so you have two possible actions one which i encourage you to do is to adopt a an enforcement policy and you would want to state as you can see here on the screen in the first part whether or not that policy becomes effective in fiscal year 2021 or 2022 and then the second component of that is based on your decision you have the potential to waive enforcement or not today so you have two parts here enacting an enforcement policy and then whether or not to actually enforce based on 2021 budgets so there's two things you can do today and certainly the latter part of that you can choose to ignore if you want to finally here based on the feedback we received last week we went back and looked at some of the documents we presented thus far and the content within it and we found some areas that we'd like you to consider should you want to lighten the load on budget submissions for 2022 a big part of that is when we originally put together all this work as i discussed a few weeks ago we did take a good long look at what last year's process brought through the presentations and deliberations in august and september and decisions in october and we wanted to make sure that we fortified some of those points that we thought could add content to the discussions and deliberations this year based on what we learned from last year however if that's become a little bit more of a burden than we intended then we want to recognize that and so the parts that we would want you to consider is refining the capital investment section in the narrative and that would be stripping out a good portion of that detail and dialing it back to just a couple of questions around what are you still planning to do has it been put on hold and then are there any items that are outside of your control that you have to do to maintain accreditation or something like something along those lines so i'm not speaking in direct terms of what we would state but that's to give you an idea of what we were thinking about stripping out some of those items to ease that discussion on capital investment and then in the appendices we have four items here that were either added based on the lessons learned from last year where we thought clarity could bring better decision making or items that we added back because there's been changes so those would be the reconciliation or bridges tables and with the feedback last week and the unknown around budgets perhaps additional detail in that area may cause more questions and more headaches than maybe it's worth this year because of all of the unknowns so requesting detail and adding detail based on budgets that the folks the hospitals may not even be comfortable with we could probably bring about more questions and issues than we originally intended then we have the utilization table we all know the challenges around that and again that was with the intent of building upon what we learned last year at some of the discussions but if those if the hospitals are comfortable with the workload and the accuracy of that again there's another item that could be more trouble than it's worth at this point here today where we're looking to make decisions then we added the inflation table this year that was a discussion that permeated the budget hearings last year so we wanted to see what we could do to better inform the board this year again if that is more trouble than it's worth we would consider that for removal as well and then value-based care we added that back in this year after hiatus last year but we've had some movement with Rutland Regional Medical Center adopting the Medicare program in value-based care and then the Vermont State Employees Union signing on under the commercial portion of that so we wanted to attempt to build that out a little bit this year but again we think these are the areas where in the appendices there could be consideration about removing which would leave us with the charge table that we reworked with the assistance of laws this year and whether we're in a pandemic or not that is an important factor in the board's decisions we would also have the financial breakout of revenues and expenses from the work that the hospitals are doing to vaccinate their staff and the community at large and that is important because if we're going to hold them harmless from the revenues and expenses to arrive from that at those activities then we want to make sure that we're appropriately accounting for those and then finally the relief funding table that I showed you earlier so that's COVID related as well and in an environment where COVID creates every corner of this process we think that that needs to be there as well so that would leave us potentially with a minimum of three items in that financial work and then finally we would keep the adaptive submissions around income statement balance sheet pay or mix staffing and capital as they are so that's kind of the nuts of of this product that we have here in budget guidance and hospital budget so we would not want that to change at all for the sake of having an engaging conversation come August and September so with that we do have some potential motion language here for the board once they reach a decision to adopt the guidance and we would also want to notify the public that should the board do this there may be changes that need to occur and the staff can make those changes here in the next couple of days we can circulate the guidance based on the vote today to the board to review and then have that out either before or on March 31st of the coming this coming week so with that Mr. Chair I turn it back over to you and the board for a discussion on these topics we presented this morning thank you so much and if we could get everybody to mute who's not speaking that would be great again I'm going to open it up to the board for questions first on everything that you've seen so far keep in mind that I am going to try to move in an order that I think might create some efficiency I may be totally off base but the first questions I'm hoping that we can have a motion on when we get to that point is on the presumptive approval so with that I'm going to open it up to any board member that has questions for Patrick I don't have a question for Patrick but I do have a question for you so Kevin do you mean what Patrick's slides have titled exemption from public hearing criteria when you say a presumptive approval yes I do Robin okay just wanted to make sure that there wasn't another concept out there I was missing thank you for that clear I just have a quick question for Patrick Patrick in your last recommendation about removing in the appendices the value-based care table as a possibility I guess my question to you would be if the board goes forward with the presumptive approval one of the conditions that you recommended was continuation in value-based care programs or you know value so I'm wondering how would we know if they've met that condition or not is there another way that we would know that they've met that condition if we remove that table you're muted Patrick well after four weeks of presenting that's the first time I've done that so I feel all right about that yeah I think we can ask them just as we have any year whether or not they're enrolled in what programs they're enrolled in we did that last year without this table so we can certainly do that again it wouldn't take much effort to do so so are you suggesting include making sure that we included in the narrative there yes and absolutely thank you so the narrative questions would be would suffice for that meeting that condition yes great okay thank you sir and again as I said two weeks ago I actually hope that the narrative question doesn't just focus on participation in an accountable care organization but basically a move towards value overall which could be talking about communities working more closely together with all the different organizations so that the reducing hospital readmissions by doing things differently and things like that so hopefully when the staff does ask for that to be put in the narrative we can have it a little bit broader than just ACO participation other questions from the board um yeah Patrick I wanted to um talk about a topic that has been getting a little bit of press lately and if you could maybe go go to the part the slide that shows where we talked about NPR and potentially adjusting operating expenses and the reason I want to do that is I want to clarify at least from my perspective and I think it it really goes with the board what what this was meant to do and I want to just talk a little bit about it because there's been something circulating that basically says that the board is ignoring current reality hindering recovery threatening sustainability and it said to call out one particular concerning development without process or input the board is proposing to give itself the ability to regulate hospital expenses putting itself in the role of deciding where our resources should be invested we do not support a future in which the board can decide the clinical services of what we offer in response to the need of the communities and I would say that's completely missing the purpose of what we're saying here and what we've done in the past and so I want to give a very specific example we've done this the past couple of years and in the case where we've done it I'm not going to call out which hospital it was but a hospital had requested an 8.7 percent increase in NPR and a 12.3 percent increase against their prior year projections and the board you know specifically wrote in the orders we are concerned about NPR FPP forecasts that are not supported by utilization and result in corresponding expense budgets to meet their NPR FPP forecasts when hospitals fall short of NPR FPP targets and are unable to adjust expenses in a timely manner lower and at times negative operating margins are offered or often the results for these reasons we approve a reduced NPR of 3.5 over the fiscal year budget a six percent increase over the prior year projections and expect the hospital to make appropriate reductions and operating expenses based on this more realistic increase in NPR FPP so we have done this in the past for the reason really to help make hospitals more financially stronger and sustainable and there were several hospitals who repeatedly came in with high numbers for NPR miss those NPR numbers but yet their expenses stayed right on where they budgeted them and then they fell into negative operating margins so after seeing this happen several years in a row for several hospitals including one that went into bankruptcy that we specifically said the same things to over the top over the over several years that's really what that was for so i just want to make sure that's out there at least on record from my perspective i can't speak for the rest of the board about why we have that in there it was not intent to limit what hospitals are doing to to actually you know go line by line on expenses to cut clinical operations or anything it was really to help preserve the hospitals financials because again repeatedly we've seen where it's very difficult for a hospital to be able to make adjustments to their expenses that they budgeted and they missed the top line and anyone's talked me about it offline happy to do it there's several examples of where we've done that and i just wanted to make sure that's at least out in the record so if there's any more reporting about it you know it's that's not the intent that we were getting into the weeds of expenses and managing expenses the intent was really to make sure we have strong hospitals that are financially sustainable and in cases where we've shown there's been the aspirational budgeting i know people probably hate that word but it's repeatedly same hospitals that have done that year over year we started to say look you know we're reducing you to three and a half or in this case it was seven percent against a prior year and we actually told that hospital if you're actually exceeding that come back and talk to us we're not telling you to cut clinical services we're just trying to make it more realistic and to budget appropriately expenses so that you can make it so just wanted to get that out there and uh anyone wants to give feedback that's fine but um i just just didn't want to leave it unsaid because there's been a lot of write-ups lately that i i think have been um putting a different narrative out there so thanks this is Robin and Maureen i totally agree i think that was a great clarification because i i do not think that there have been instances where the board has been getting into a line item micro management i think we've been very careful not to do that so thank you for um clarifying that um i would also just say it's my understanding from staff that this was also something that uh that banking insurance securities and healthcare administration did when they were managing hospital budgets so it's not like this is out of the blue new uh process but actually was something that's been in place for quite a long time um but related to this i had a suggestion in the new operating expense language that might add for their clarification that i wanted to propose for people's consideration which is so Patrick maybe you could bring up the guidance part so people could see that when i um make my suggestion i think it's page five of the guidance document there it is so what i would suggest is um that where so it says currently in connection with the establishing a hospital's npr fpp growth limit the more the board may review and adjust the hospital's proposed operating expenses and this is where i would make the change i would say the the hospital's proposed operating expense growth in the aggregate uh and then commeserate with would from there on would remain the same so it would basically just be a little clearer that we're looking at the upper like we're looking at the aggregate growth here we're not getting into line items um or micro management of actual expenses so um that would be my just a small suggestion to maybe add further clarification along the lines of what we've done in the past and what you were saying Maureen is that a motion robin yeah i'll go ahead and move that we modify uh the budget guidance on page five to read um in connection with establishing a hospital's npr fpp growth limit the board may review and adjust the hospital's proposed proposed operating expense growth in the aggregate commeserate with any adjustments made to the hospital's npr fpp in order to protect margins is there a second second is there further discussion i just wanted to thank maureen for at the last meeting and at this one for um you know explaining what has happened in the past and that it hasn't been uh an instance where the green green mountain care board kind of uh engage in the weeds or line items on an operating budget but it's trying to overall match the revenues and operating expenses so that uh you know they're reasonably related and so uh thank you for that maureen and thank you for the motion robin other discussion from the board and what i'm going to do on any motion before it's voted on and just open it up to the public for any comment so not hearing any further discussion from the board i'll open it up for me to any member of the public who wishes to comment on this motion hearing that i'm going to ask general counsel barber to call the roll member palem yes member lunge yes member usford yes member holmes yeah mr chair no so left the record show it was a four to one vote and um with that if we could go back to further questions of patrick from members of the board yeah i i have one question this has always been a bit confusing to me um uh going to slide eight i think it was having to do with charges yes um i'm just wondering patrick if you could dig a little bit uh deeper there in terms of profiling how the changes in charge at these proposed rates or with with with no um uh ceiling at all how they relate to to say an npr uh figure that that um we might pick three percent three and a half percent whatever it is you haven't gotten there yet but how does it the change in charge and the npr um align themselves you're new thank you um it's a little more complex than that charge is just one component of what ultimately drives npr utilization is the other so the utilization being as unknown is inconsistent as we've seen over the presentations the last few weeks whether it's fiscal year 20 or what we've heard from hospitals so far i cannot tell you conclusively that there is a perfect number for this because of that there's no uh reasonability to utilization right now we have hospitals who are telling us that they're seeing rebound and we have hospitals who are saying the exact opposite of that so as this only relates to one major component of what ultimately drives npr there's no perfect answer to that in relation to npr from my perspective well i i mean i get i get the relationship of the rate and the utilization rate times volume i get that so um but that all happens totally off our screen i think that's a um a a calculation uh that gets made at the hospital level and maybe in in conjunction with with the payer and i'm just wondering your thoughts about you know whether or not this is an area where um you know when we look back on it the the back calculation that happens outside our purview is one that ends up with an npr uh revenue number that is much higher than expected or lower than expected i cannot comment on that i'm sorry i do not have an answer for you thanks um maybe to try to like move forward some of the things we're talking about maybe looking at the npr guidance that you had the different suggestions um and you know i think when we talk about you know i would just throw out a discussion when we talk about an option like potentially number one which was a 3.5 budget to budget um and then you know i could see potential where if a hospital um may exceed that if it was supported by utilization shifting from prior years because we know you know really we had actually put that you know kind of concept in the guidance last year expecting that um this current year we may get you know utilization shifting in and probably really hasn't happened yet because we didn't expect we'd still be going forward with the pandemic as long as it has and so you know that may shift from um 21 until 22 where you know finally people may feel comfortable going back to the hospitals or going back for appointments and it may exceed so you know i'm okay um you know under the current conditions with the pandemic that you know not putting a ceiling and maybe um you know maybe even talking about if supported by utilization shifting from the prior years and you know and i do like the last bullet which you know as it has been in the past and if you read through you know all of the prior orders that we put through you know they really are very targeted to the specific hospitals that we're dealing with in their conditions so i think that you know when we talk about the establishing these guidelines we do consider budgets and specific needs of each hospital and maybe you know we could be more explicit about that um as we talk about the guidance so thank you marina thank you for filling that void of silence i was on mute and didn't realize it as i was speaking when patrick stopped but i do think i'm going to try to stick to that original framework that i laid out to try to um be as productive and efficient as possible today and i'm going to ask everybody to focus their discussion on um the waiver of hearing or as i have referred to it the presumptive approval and if patrick if you could go to the language on the motion that might be able to help board members focus on the discussion as um we move there because i don't think that anybody is talking about a waiver of a ceiling or anything on um presumptive approval i could be wrong um but if we could begin the discussion on um the extension for public hearing and focus there i think that we'll be able to move through very efficiently so board members sure i'm happy to jump in here um kevin um so i think that where i sit as i i'm very comfortable with the criteria that's been laid out having it be an exemption for all hospitals using our act 91 authority um involvement in value-based reform the basic assumptions being reasonable submission schedules reconcile um you know budget content compliance of guidance and having the deadline be july 28 so i'm comfortable with all of that and i would throw out there as a ceiling two parameters uh npr fpp rate request at or under 3.5 percent and the charge increase request at or under 3.5 percent and i'll tell you where my um kind of uh my justification so the 3.5 this has been the median budgeted growth for the past five years actual median actual has been lower it's been closer to three uh but i think that there is a real possibility of pent up demand so 3.5 is aligned with what we've previously budgeted but it also allows for the fact that there's probably some pent up demand in there and actual has come in at three so we're allowing for that possibility in terms of the change in charge at 3.5 uh that was the median for 2021 which had some higher than normal adjustments that year to address prior year losses um i think also if you look at the cms national health expenditure report that was actually submitted to us by boss um in there they are projecting price growth for medical goods and services to be 2.4 percent for 2022 that's their health care price index um so i think that's a median starting point at least if we're thinking about that the cms is projecting for median price growth and i you know i hope you have to recognize that uh 2.2.4 you know is just the inflationary component that often the change in charge has to acknowledge that um the realities of creating a margin and also you know is probably going to have to absorb some of the uh cost shift that we know exists in the system so for me 3.5 gives them that cushion above what the projected medical inflation is so that's where i would feel comfortable for a presumptive approval thank you jess other board members thoughts on the exemption from public hearing um yeah i'm supportive of of the ranges that uh or the numbers that just came forward with i agree with the 3.5 um it gives a 3.5 npr it gives room for you know any of that utilization and and the 3.5 on the commercial or the rate um maybe a little bit higher than where some places people were last year but i think with trying to streamline the process and allow some hospitals to be able to move forward without having hearing i think if we went much below that we may find not many would would qualify and and obviously the hope is that and and belief is that the hospitals are only going to ask for what they need in that area and we have seen in the past hospitals have asked for under under three we heard cfo's talk last week you know they have different parameters for for what drives their decision on commercial rate so so i would support um support that as well and then just somewhere in at least that filing if a hospital comes in and and you know meets the criteria to not have a public hearing um allowing them the option to either come in and just talk to us at that time or maybe they'll feel more comfortable after budgets are fully approved you know like i've gone through but you know coming in because i think it gives them an opportunity to you know just just tell us their story what's going on with risk and opportunities are um and so you know again either doing it you know we wouldn't we would it wouldn't prevent them from coming in to talk to us you know that sounds crazy that they want to do that but we have heard some some of the hospitals and you know and even through you know people at bossa they do you know appreciate at least being able to tell their story so they've met that criteria that's going to be approved and they want to come in maybe it's either skinning down meeting or or post um you know post approvals maybe it's a little bit after but uh we just like to at least have to check the box for them if they want to come in and they may all say no but let's you know give them that option okay are there board members so i just want to understand are you recommending those uh npr increase rates in this motion or is this uh we still looking at this motion in its kind of generic form so uh as i understand she didn't make a specific motion yet but it looks like she's indicated that she would like to make a motion just for the purposes of the extension from public hearing um that would um keep the july 28th deadline as outlined by staff and set the npr and the charge request at the same rate of 3.5 percent but i haven't heard a motion yet tom and this is only for the purposes of the exemption from public hearing yeah just to build on that um kevin yeah tom i'm only these are the these are the parameters for exemption from public hearing so um as you may recall from the last meeting i am not um going to support uh npr ceilings or the new word guidance or change in charge overall so i'm really just setting the parameters that i'm comfortable with for the public hearing exemption great thank you other board members i think i heard you start to talk yes um so i am supportive of doing an exemption from public hearing um i appreciated the public comments that came in that were more explicit and actionable sort of oriented to action um that we received so i did want to make that note um i like moraine's idea also of allowing flexibility so that if folks after you know whenever want to come in to discuss that that's good but i also think that having the quick process be clear is important um i am supportive of the 3.5 percent npr guidance i'm probably a little bit higher on the charge like i would i would err more towards four and i do realize that this is the exemption not the overall um so i'm gonna continue to think about that as we discuss so like the motion that came from jess i would be comfortable with an exemption for hospitals from the public hearing at the 3.5 rate anything higher than that um i really believe that they should have to come in at and make their case before the board and you know again that's just one board member other board members yeah i'd like to add to that kevin i um i'm i'm fine uh with the exemption um from the hearing process um at 3.5 um i do want to take a minute here and just paint in some context about anything at least from my perspective about anything higher than that elsewhere um so it'll take me maybe a minute just to give this profile but if you go back to the the emergency board on august 12th of 2020 um they reported to the the diva reported to the emergency board that uh there they were 34 million dollars below their fiscal 20 budgeted amount for medicaid um later on august 19th diva as as we know and when we put it in all of our our budget orders that they'd be level funding medicaid reimbursement rates in 2021 um except for those that are federally mandated um the uh but so that's kind of what's going on um you know in terms of of medicaid you know and the department of labor release just came out on march 15th and it shows that there's still 30 000 unemployed romaners relative to a year ago january 20th and the state general funds as of report uh on the 23rd are up 31 uh 0.4 million dollars above target for february and 46.53 million you know um over the target to the year today and then we have this obviously this notice of information that vermont is uh according to senator lehi is is likely to get 2.7 billion dollars um in additional uh cove covert relief money so i know that the green mountain care board that we don't have the money we either um but but we are kind of a broker for and i think some people just assume that the um rate payers premium payers co-payers people with deductibles are kind of the default for anything that that the public sector isn't uh it isn't contributing its fair share and i just want to emphasize to some of those that are frustrated with us we're trying to be a regulator that there are other players here that they can influence um and and in an extraordinary environment where state revenues are coming in over the gunnels um federal money is coming in uh over the gunnels and uh um so i i'm just i would be resistant uh i think 3.5 percent is a fair share it's the all pair model it's it's the number that we've been trending with and we should stick to that in terms of what what we look to the insurers to help fund but anything about that um uh we shouldn't go and in my opinion we shouldn't go there thank you tom i was a little bit worried there for a minute that you were going to try to set the uh reimbursements for medicare and medicate if i would i could if i could i would other board discussion um maybe it would be helpful um jess if you actually put your thinking into a motion and try to get a second and then we'll continue the discussion sure okay so i'm using the language that's that's here uh so for the 2022 hospital budget review process agreement and care board pursuant to its emergency authority under act 91 establishes an exemption for the from the requirement for public budget hearings for hospitals that meet that criteria identified the by the board which would be an npr fpp rate request at or under growth guidance of 3.5 charge increase request at or under 3.5 continued involvement in value value-based care reform budget assumptions are deemed reasonable budget submission schedules reconcile budget content complies with guidance and meeting the exemption decision deadline we would have imposed by july 28th is there a second second it just as a friendly question i know that moraine asked this just would you um yeah possibly consider adding language that just gave hospitals the choice even if they were presumptively approved to come in and uh tell their story absolutely i agree with with moraine's comment i enjoy hearing from the hospital so absolutely this does not preclude hospitals from coming in and sharing an update on uh what's happening in their communities and in their hospital okay and moraine as the seconder you're fine with that aren't you yes second okay thank you so with that discussion from the board i guess i'll just say i can count to three so um i'll go with the 3.5 percent because i'm supportive of everything else in the motion uh with the exception of the charge increase so but i'm obviously in the minority i thought you're going to say you could count to 3.5 i can't do that too i can even count to five other board discussion before i open it up to public comment hearing none i'll invite any member of the public to add any comment at this time on the motion that's in front of us and i do see mike del treco has his hand raised mike thanks uh chair mullin and thanks for the dialogue and conversation i i have it's really hard to separate all of the discussions around rate and charge uh just to um uh exemption from the public hearing so i apologize if i sort of tie some things together specifically to slide six and eight and the recent discussion around your your motion that's on the table um to speak to uh jessica home's conversation around the 2.4 percent from medicare that's certainly the personal health care spending amount which is which which is proposed to drive where hot where patients and and folks in the public start to come back to hospitals it doesn't reflect the hospital's actual inflation for buying medical supplies pharmaceuticals and such and this is where i tie back to slide six and eight i i have a really difficult time um listening to uh the board deliberate are on um why three and a half or four is the right number and it's steeped in history when we keep looking at history we ignore the financial results that we have seen we we know that our hospitals are um in financial distress not not only because of the pandemic but that's partly the reason um i think we need to consider and and i'd love to hear what the board has to say around how do we balance and look at not only health care inflation what it costs our organizations to pay for workforce pay for medical supplies pay for new pharmaceuticals that aren't in their book of business pay for the inflation on existing pharmaceuticals and the alignment there um is well above three and a half or three percent growth rates so so i just i just can't can't ignore that fact of of looking forward is more important than looking backward so on on how we've historically performed so i'm sorry i commingled a bunch of things together on this specific uh vote but it was hard to break apart so thank you for the opportunity to speak that's completely okay mike and i guess you're gonna have to lower your own hand because usually i can lower people's hands i can do that but somebody just did it so somebody had the ability um mike just to say that uh i think that the board will be looking forward and trying to make sure that vermont has a sustainable health care system but i think the whole um purpose of trying to align um the growth in hospital spending with the growth in the economy is that we saw a a tremendous run-up between 1990 and 2010 and the growth of health care spending as a percentage of the state's economy and that requires everybody to try to figure out new ways to do things and new ways to create efficiencies because in the long term if that had kept on that growth trajectory it would be unsustainable vermonters would not be able to afford to pay for their care and a number of vermonters would have to no longer buy insurance so not to try to get into a debate with you but just to to point out that um the board recognizes the fragility of the system the board recognized it a few years ago and uh was very vocal about it at that time um we recognize that the fragility continues but we also recognize that we have to all together keep the conversation going which has been muted um throughout the past year because of the pandemic but how we might be able to do things differently so that vermont can afford their health care system and have the best health care system in the country so would you mind if i made one comment to that all right ahead mike thank you i appreciate that couldn't agree more and and you've heard me say before we we've taken taken our system from a growth rate of over eight percentage points year over year from a net revenue point of view down to ones that are below or hover around three percent not only has our revenue come down but our operating expenses have followed suit and and i think patrick has pointed out on more than one occasion we've become so heavily dependent on uh the other operating revenue in our systems that we that we i think we tend to forget that um and and maybe i'm speaking of myself there sometimes and i don't want to put that on you but i but i think we have done all of the things you described and i think it's all in the spirit of of affordability and caring for our communities i just think we're at a really interesting inflection point that i don't think we can keep doing what we're doing and i think the sustainable sustainability conversation is um one that's uh complex and and will take many much time and i suspect that in that time we'll have many hospitals continue to have margins that are negative and i just think you know i'm speaking from a little bit of passion here that we we are at a really interesting point in time where i think we need some growth opportunity and and at three three and a half percent it doesn't do it so thank you very much thank you biker and again this is just so that someone could be resultively approved and have their hearing waived this is not precluding anybody from a higher amount if they make a compelling case at hearing thank you okay other members of the public hearing none um the motion before us is to um create an exemption from hearing for all hospitals using our um authority under act 91 and um utilizing a deadline of July 28th and utilizing um the following numbers for npr slash fixed perspective payment 3.5 percent and for charge growth 3.5 percent um keeping the ability to still have a presentation and just what language have i left out sorry just all that there's that criteria that had to be met there was that list of criteria um you may find that slide now um continued involvement in value-based care reform not limited to ACO participation budget assumptions are deemed reasonable budget submission schedules reconcile budget content complies with guidance okay is there any further discussion from the board if not all those in favor of the motion please signify by saying aye aye aye any opposed signify by saying nay hearing none let the record show that the motion was approved unanimously so um with that um if we could um start to proceed um working through some of the other questions that are before us today um I would like to um go first towards the question on um value-based care questions and I believe it was three to five Patrick if you could go to that particular slide so um I believe it may have been um member homes again at the last meeting that suggested um removing questions three through five and uh so we'll we'll start uh and see if there's any um consensus to um remove anything or to keep it as is so um board member discussion this is Robin first okay um so I think uh questions three through five raised very interesting and important parameters however I don't think we need to discuss it as part of this process um it it is information which is really quite central in terms of the future of uh the ACO model and healthcare reform so it is a conversation that I think is very important and necessary to have but again I can support taking it out of the hospital budget guidance because I think that that conversation could happen as part of sustainability or as part of the public process around the all-care model um and and the future of that agreement um so in the in the spirit of trying to streamline this process um I can support taking it out along that lines I guess my question is um do we need both the narrative and the uh spreadsheet like is there a way to either choose one or the other I think I probably can be satisfied with one or the other um and so I just wanted to throw that concept out there for other people to react to before I throw it out to other board members um Patrick what was your intent we had no intent here we um added questions to help tie together the value-based impact and hospital budgets and then it was proposed that um we could potentially do without and transfer these this information to the sustainability planning process so it's simply up for discussion and consideration by the board the staff have um no perspective on this whatsoever I think about my question I probably should have framed it a little bit better but I think that board member lunge was asking the question if it would still be part of the narrative no my question was broader my question was so right now we're asking for information in the narrative that is redundant of the spreadsheet and so could we either get it in the narrative or in the spreadsheet and not in both places so so that was my question my answer that would be yes I think that depends on whether the board feels the narrative adds more context um than just numbers on paper or if they're more comfortable with the table in the appendices instead of having the background from narrative so that I think is a preference decision on behalf of the board okay board members yes I'd like to chip in here a little bit um I worked on this language with Elena and the reason I kind of pursued it is that it uh it's it's very clear that FPP is foundational to healthcare reform in Vermont it's foundational it's not a tangential uh concern it's foundational and um if you look at the 2021 budget over 2020 um the amount of FPP is flatlined at around 14 percent and this is FPP that um as Elena will say is is not good FPP because it includes all the Medicaid with the true ups etc so it's um you know so I so from my perspective we're sitting here four years into the all pair model our blueprint for reform we don't have any guiding star at all in terms of what the FPP level is that we need to achieve the kinds of capitation mild capitation that will achieve the efficiencies that we're looking for and that we could be using now and we're already kind of talking about um all pair model number two um we you know we um you know we I just I just think that we're flying blind here and so from my perspective I thought hearing from the hospitals um as to what they think about where they should be have no idea hospital by hospital um where they think they should be to achieve the kinds of efficiencies in healthcare reform that that the all pair model offers we can look at southwestern um they're at 22 FPP um and they clearly according to that bigger article have used uh the freedom um that that fixed perspective payments allow to dramatically restructure how they relate to the community in terms of of transitional services so um you know this is this is something that I that that I think we should have had resolved a long time back and it's also a budget issue in the budget um this will get addressed every single year in a disciplined kind of way you kind of push the ball down the court to um to achieve the goals of the all pair model and I you know one can make an argument that it belongs in the sustainability project but sustainability is a one is a one time kind of effort maybe over a couple of years but I think that we have to give more definition to FPP we have to understand what folks in the field feel about it where they expect it to go um um you uh we've all seen the images of the two canoes you know and I sometimes feel that um you're looking at at the the the the flatlining of FPP 21 over 20 even UVM medical center which owns 50 percent of of the ACO they had a slight decrease in their FPP 22 over 21 so I think that we've got to put a spotlight on this and uh this is a way we thought or I thought of with Elena's help to put a spotlight on it so that we can push this element of reform um you know to the forefront and um and help advise us in terms of of even relating to in rate review you know what do we have to say to the insurers in order to get them to participate with hospitals in transitioning to FPP so I think this is I think we're already a day late in the dollar short and uh after four years and um I would I would I would support keeping it I do support keeping it in in in the budget budget guidelines thank you Tom and I just want to say that I too share some of the concerns that you've raised and I think that um I want to be consistent with where the all-pair model improvement plan made suggestions for ties into the budget process um not that we obligated to anything like that and I do think that um as part of our obligations under the current model to create a report to the federal government by December that we're going to have to have the stakeholder engagement with the hospitals now we probably can get that through a different means than um the budget process but I'm not sure what time we really save the hospitals by taking it out of the the budget process because I think that you know this discussion is going to have to occur Tom well I mean I I agree with that Kevin I think that uh and again this isn't a highly restrictive request of hospitals it's just asking them to explain to us you know you how they see this unfolding it's aspirational I mean if they all come back to us and say hey look we're fine at 14 percent you know we don't want to go any farther then maybe we should roll up our tents and go home you know but if they say gee we we should get the 30 35 40 percent before it really starts to kick in well that's good to know that uh so that we're not feeling that we're pushing something down their throats that they really don't want so um here we are four years out and nobody can tell me you know whether or not 14 percent is going to make or break it in terms of health care reform in Vermont and and fpp is a foundational aspect of that I just want to say I don't disagree with anything either of you said but if we're waiving hearings for hospitals who meet the targets it's not going to be a consistent process across hospitals so we're going to have to do a second process anyway so in my mind like if this were a normal year I'd be like absolutely let's hear about it we do need the information we need it quite frankly sooner than later to meet the December got uh December deadline um so I agree with absolutely all of that I just think that it will end up being a redundant process because we're going to have to do it and I agree getting it I want to know from each individual hospital their views and how it's working because I think that will make for a better proposal next year and I think hospitals want to be involved um you know assuming there is another APM proposal I think hospitals would want to be leaders there so um you know I certainly don't disagree with any of the intent through the conversation or the desire to get the information I hundred percent with you I just think it will end up being duplicative because there will be some hospitals presumably that will have their hearings waived and be presumptively approved and we'll need to circle back and talk with at least those I think just to clarify though if we're waiving we're waiving the hearings but they still would have to provide all of the information I'm actually okay if we remove an included sustainability but just to clarify I think the expectation right is the hearings are waived but the materials are submitted so that we have all the materials so I would suspect we will have questions because in order to thoroughly answer a question how has the hospital changed the way the hospital delivers care that's not like a three-sentence answer right like that's to me that's a much longer discussion and so part of the challenge will be you know this I think the questions if we're either going to get bad not bad but we're going to get minimal answers that aren't that helpful or there it needs to really be a dialogue that's just my thoughts. I just want to clarify to make sure you know from the hospital and from everyone's perspective everyone they do have to answer the questions and submit you know full submission but you write certain things many expectations and I'm okay with moving in sustainability I just wanted to you know I'm pretty flexible on this one but let's see what see where everyone else wants thanks. Other board members? I'll just say I can go either way I think that to me it's very important to everybody's point that we hear from the hospitals about these issues to the degree that fixed payment is the foundation of how we're going to achieve delivery system reform we need to understand that we need to understand that for any negotiations we're making with the federal government we need to understand that with respect to the ACO with respect to sustainability planning all of that you know information is going to be important for all of those efforts to me this is just a question of does it appear here or does it appear in another process that the board is undertaking and so to me to some degree this may give some flexibility to the timing of when this material you know has to be submitted I think the sustainability planning will be a little bit delayed you know past the hospital budget submission it'll probably be later in the summer that that work is is happening so this might give some relief upfront as the hospitals are trying to prepare their budgets for some of these deeper questions about how we move forward towards value-based payments so but I could go either way I proposed it as a way of some some short-term relief but certainly we need the information before December and in fact before we submit even our hospital sustainability report to the legislature in September would anyone wish to make a motion if there is no mode if there is no motion does it does it stay in well that would depend on the final motion over the adoption of the total guidance I I don't think it makes any sense to put this decision off I think we should come to an answer one way or the other so hopefully somebody will make a motion if you want Tom or you can no no no I would I know I know what your motion would be I think so I'll just I'll make a poorly worded motion I move that we retain the value-based care questions three through five in the 2022 budget guidelines is there a second I'll second it because Tom likes to have it second that we can have discussion if we need thank you Maureen it's been moved and seconded to reclaim retain questions three through five on value value-based care is there further board discussion hearing that I'm going to open it up for public comment on the motion that's before us regarding value-based care questions members of the public hearing then the motion before us is to retain questions three through five on the value-based care and I'll ask general counsel barber to call the roll member is there who put me on the spot right um I said I could go either way on this one so I'll say yes member lunge no member palem yes member holmes uh usually I'm going to say no and mr chair yes so let the record show that uh by a three to two vote um questions three through five concerning value-based care will remain in the guidance so um the next question I think if we can try to keep things efficient and moving a good question might be to decide whether or not we will adopt a standard enforcement policy realizing that many people may opt to not want to have any enforcement um and that's certainly where I am for the current here but I do believe that we should have a standing enforcement policy and um board uh do you want Patrick or Russ or Mike to run through that again or can everybody remember um what they heard I'm good yeah I'm good okay would anybody wish to start discussion or to make a motion to start discussion I'll go ahead and make a motion um I moved but for the hospital view process uh we approve the hospital budget enforcement policy in the form presented to the board to be effective starting for fiscal year 2022 a second and as I understand your motion Robin it would be a standing policy that would carry on into the future but would start with fiscal year 22 is that correct that's correct thank you so board discussion I'll just hop in I think having a standing policy makes sense um since it doesn't tend to change very frequently certainly if there were extraordinary circumstances in a given year we could adopt a special policy so it wouldn't prevent us from doing that or from waiving it in future years so um that's why I'm supportive of it and I chose 2022 because I think first of all it provides uh notice to the regulated entities uh a little bit in advance and I uh am in favor of waiving enforcement for fiscal year 2021 um so that was also part of my thinking yeah I'll just go on um I think I've been pretty consistent on on whether or not to waive and um I don't think we should waive enforcement for for any given year and really I say that because enforcement is for if favorable or unfavorable so you know I'd be more concerned about hospitals that maybe are going quite unfavorable and whether there was an opportunity for us to do anything to help them you know I would just you know don't think I don't think we need to waive enforcement but that's my point of view on that and I think we can always do that at a later time as well as we have in the you know as we did this past year um but I know last year I was consistent with that as well it was it's just not we're going to in this way of course it's more to again be helpful and um there may be chances uh where we have that opportunity to meet with the hospitals or get information from them and maybe there's a way to react um if we don't have it and there's we kind of don't have that formal option so are you looking to amend the motion Maureen I'll put it out there for discussion I I know where this went last time so it was a four one I was the only one that that felt that way I I just don't want to go unsaid and again enforcement people always look at it negatively for those hospitals that are above the number but when you read the language it's above or below and um you just kind of think in this case most if anything the hospitals would be below and get it because there's nothing we can do but if there is any way to to intervene and make any changes and have hospitals come and talk about that um it goes with us so just to clarify Maureen um if a hospital is say underperforming not meeting their budget targets and they would like to request a rate increase mid-year or have some sort of mid-year budget adjustment uh voting for this motion would not preclude that opportunity from the hospitals coming forward and and adjusting mid-year or right or yeah it wouldn't it wouldn't preclude that I think it just um there would be we would get information from the hospitals based on their year-end information we would make decisions whether there was anything that we wanted to do but now it doesn't preempt that so is there a second to um the motion to amend the motion sorry I just want to make sure I understand so the the amendment would be to approve the policy effective fiscal year 2021 that's the way I'm understanding Maureen's motion yeah um and I would just say I'm I'm happy to to do it that way if that makes it if the people prefer that um it doesn't not preclude waving 2021 and Robin I'm in the same boat that you're in in that uh I would vote for this motion but I would hope um unless there's some truly compelling reason that there would be no enforcement for for this year but I'm not opposed to Maureen's suggestion other board members I still haven't heard a second to Maureen's uh amendment to the motion well it may be semantic so why don't I accept Maureen's as a friendly amendment and then I'll do a second motion about waiver okay and does the seconder of the original motion accept it as a friendly amendment did I second it I can't remember who's second is remember either I believe I believe it why don't I restate it so the motion would be for the hospital budget review process the board approves the hospital budget enforcement policy in the form presented to the board to be effective starting for fiscal year 2021 and would somebody like to second that since we don't have someone owning that original second second second it okay it's been moved and seconded for the hospital budget review process for the green mount care board to approve the enforcement policy to be a standing policy in the form presented to the board to be effective starting for fiscal year 21 is their discussion hearing that I would open it up to the public for any public comment on the motion before us regarding the enforcement policy jeff teamon uh yeah thank you mr chair I guess I'm so if what's on the table is to apply enforcement to FY 21 I guess I would just be confused as to why enforcement was waived for FY 20 and we're still very much in the middle of an incredibly uncertain time so why enforcement would be applied to 2021 is just a question and then and then a comment is that we you know I would just like to go on the record saying that given the the uncertainty and the conditions we continue to face and the difficulty of budgeting in this environment that the board actually waived both FY 21 and FY 22 enforcement because it's so difficult to budget so a question and a comment thanks thanks jeff and I totally agree with you that budgeting for this year has been completely impossible but I think everyone knew that coming in that there were more questions than answers and I think this is just not closing a door at least from this board members it's not my perspective that I would like to seek enforcement but others can speak for themselves other comment from the public yeah I'll just clarify too you know for me it's just um there's a standing enforcement policy and that enforcement policy will be out there and and that's what we've put forward here um and then any waivers to that um whether that decision doesn't need to be made now um and that decision could be made in the future and as you saw we didn't do it this past year and most likely we will not do it for 21 but rather than um give that up right now when who knows what's going to happen for the rest of the next six months in this year and if there would be a need for that again positively or negatively to be looking at the hospital's performance and doing enforcement which is not always a negative action is really where I was just gives the flexibility remains open is there other public comment okay back to the board for further discussion on the motion to adopt a standing enforcement policy starting in fiscal year 21 as presented to the board by staff hearing none all those in favor of the motion signify by saying aye aye aye those opposed signify by saying nay nay so um for the rules that um are established for um these type of team meeting votes I'll call on general counsel barber to call the roll member holmes no member pelham yes and we used for yes number lunge yes mr chair yes so let the record show was a four to one vote to um adopt the standing enforcement policy so next um I'm gonna ask patrick if he could um put back up the slide Kevin before you move on I do want to move to waive enforcement for fiscal year 21 due to the uncertainty of the pandemic so to me like what I was suggesting I was happy to amend it so that we could agree to a standing policy but I do agree with waiving it now to provide certainty moving forward um for fiscal year 21 so I believe that I just heard a motion from you member lunge to waive enforcement for fiscal year 21 is that correct yes is there a second second it's been moved and seconded to waive enforcement for fiscal year 21 for discussion hearing none I'll open it up to any public comment on the specific motion hearing none and just to be safe I'm going to ask general counsel barber to call the roll on the motion member homes yes member use for no member lunge yes member pelham yes and mr chair yes and in my apologies if I made that more complicated than it needed to be I just thought that the standing versus the timing it made sense to bifurcate those okay thank you member lunge next patrick I'm going to ask if you could call up the slide that shows other potential changes to the tables and the guidance and if we could start to go through those one one by one are you referring to the staff's items within the slide deck that could potentially be stripped from yes I am oh I apologize I interpreted that incorrectly okay here we are okay I think we're here though okay so let's start with the bridges tables and start a discussion on that doesn't seem to be a lot of thought one way or the other on the bridges table does the board member wish to make a motion um well I'll speak to the bridges table I mean you know the bridges table to me is very helpful and I would think for the hospitals when they're going through to identify what the key drivers are the changes in um budgets are always wrong and obsolete every number in there it's a budget but I mean the actuals will be different from that but when they build the budget you still have the ability to build a bridge for what went in the budget to determine what the changes were in npr and expenses and what the drivers were and I think it's been you know for me it's been something where it kind of clearly shows what those drivers are and how they get from one place to another um I would I would hope that when budgets are being prepared by hospitals that that's something that they all look at and understand when they're building their budgets so that it shouldn't be that difficult to do that that's kind of the drivers of well but how they built their budget again it's always based on assumptions but within those assumptions you you build in whether it's due to utilization whether it's due to do a change in commercial rate you know what the drivers are so so I think the the tables are valuable and I think it should be part of a budget process um and discipline in a budget process when they're putting those together so that would be my point of view on the bridges I think it should be included other comments from the board yeah if I could I'd like to uh join Maureen in that and uh applaud Maureen for being the creator of of this I found the bridges to be a very helpful table to to walk from one place to another in a very complicated environment of you know payers and moving cards so it is something that I regularly use during hospital review the others I didn't use as much but that table I found valuable other comment from board members um I guess I would just say that look at all the four of these tables some of which are new some of which we've had before I find them all very helpful and particularly I think if we're really trying to understand utilization and trying to understand inflation as components to NPR growth over time I think having those two tables is important I think to Maureen and Tom's point reconciliation table is really really helpful and to the point that we have been talking about earlier about understanding the movement towards value-based care of that fourth table the value-based care table is important um I also so I I think they're all very very helpful and really deep in my understanding of what's happening in hospitals and provides the justification for some of the charge requests and some of the NPR growth that the hospitals are making without those tables I think it's harder to justify some of the requests if they're on the higher side but I will say that you know I recognize that there is you know a burden on hospitals right now we are still in the middle of the pandemic or hopefully towards the end of the pandemic but we don't know there's a lot of uncertainty so I guess I would throw out for discussion and it applies to all the tables perhaps that we could move the deadline of submission of these tables one more month right August 1st is a submission of these tables that would give some hospitals some room to be able to complete this work it's helpful for us in the budget hearings that'll be prior to those hearings and perhaps for hospitals that meet the presumptive approval parameters you know maybe there's some leeway there if they've met the 3.5 and the 3.5 then maybe there's less need to have that justification and the utilization and the inflation tables so I guess I'm open to thinking differently about this I'd probably prefer an August 1st deadline to omitting them all together because I think they're helpful and I think that next year it'd be good to be able to look back on this work to understand what were the predictions and what were the realities and so that's I find them all very helpful but I'm open to sort of thinking differently about a deadline that might give the hospitals a little more wiggle room and timing particularly we're hearing you know from our governor that we'll have a normal July 4th so I hope that we will and maybe that would give them some time to complete this work so I'll throw that out there other board members yeah I would be open to moving the date as well and and maybe there's you know maybe as we go through this we can talk about all four tables if we're in agreement to to keep those in there you know I also think that for I hope that many hospitals I hope have you know get get in the you know presumptive and and don't have to come in and present but I would like to still see the tables because that then helps for that carry forward you know particularly the those that you know we're not going to necessarily be speaking to so let me use the prerogative of the chair in the purpose of which to be efficient is there anyone who wishes to make a motion to remove any of these four tables I don't want to do that but I do have a technical question when about one of the tables when it's appropriate I think it would be appropriate now Robin do we need the vaccine clinics and testing table in order to determine whether or not someone's in the 3.5 percent range if those things are exempted from the 3.5 percent range I guess I don't think that anything like that has been exempted from the 3.5 percent range so maybe I misunderstood the motion at that time or maybe I did I I so what I guess my question was in the written guidance um it was not I guess it wasn't clear this is raising the fact that it wasn't clear that when looking at the the three and a half percent NPR for the purpose of waiving the hearing whether or not the stated exemption in the written guidance that income from from COVID these COVID related activities would not be counted in that 3.5 percent so I because that was in the written guidance I in my mind had moved it into the hearing waiver piece as well but maybe that's not what other people were thinking yeah I would have interpreted that as well native but I think Robin to your question right now and Kevin I don't feel a comment on whether it was in the 3.5 but whether or not we would still want that table even if they're below the 3.5 I think it's still important to be able to see that particularly as we're going to be bridging again year over year the next year so so if for a hospital so maybe I misinterpret what you're saying but if for a hospital was you know it was one percent it was it was a very large amount of their change you know we would want to be able to track is that something that continues the next year which it might right if we end up having to do this having to do vaccines every year for this or or maybe it goes away so I think having that reconciliation would still be important yeah and I think my question was not very clear I was thinking that if we are waiving hearings by July 28th and Jess is proposing we get this table on August 1st we would not have the information in the table in waiving in the hearing waiver analysis so which I think is fine I agree with you would be helpful to collect it but I think that's fine for all of the tables but I wasn't it seemed to me like we might need table five in order if if our intent was that the 3.5 excluded any income from these activities we would need to know the income I think before July 28th well I think we we want all those activities to have that income excluded and I think we've made that clear in trying to work with the hospitals to try to make sure that it's it's it's not going to be a detriment to them revenues or expenses related to either testing or vaccination so in my mind uh I was thinking that um Jess was proposing here on these specific tables and not uh not referring to any other table but okay sorry yeah Bob maybe to clarify maybe it shouldn't be August 1st maybe it should be July 28th because I think the presumptive approval right isn't it July 28th it has to be in so just for you know the case that you know these tables could be done by July 28th which then we wouldn't have to do a separate motion for those people that may be exempt and you know I think the intent is there and um maybe the wink wink is if it came in August 1st we're not going to penalize you if you weren't one that was getting exemption or something but um maybe it's July 28th just the July 28th deadline is our decision deadline but I think wasn't that when everything had to be sent in though or no that was just yeah that's when we would like to send it okay maybe July 28th is the is a date for that or we could talk about what those hospitals would have to provide for the exemption so mr chair can I may I jump in you may so I'm thinking about this from a future logistical perspective and I think the the thought that maybe we accept this information to later date is going to cause some issues with presenting the full package on the 28th of the board to consider who may be exempt and who may not we have to have everything prepared by that date for your decision so if we push some of these items off then the exemption that you've approved already um it's not beating the spirit of the requirements in the documents to um meet all guidance requirements and amongst others um be reasonable because all of this builds into that equation so if we move that date back I think we're potentially going to create a mess for that July 28th potential decisioning on exemptions and and yeah you know I'll just make another comment which is we might think we're being helpful I mean if assuming we keep these tables in which which seems kind of like the direction we were going we might think we're being helpful saying they could delay submission of these tables but in reality as they're preparing their budgets they probably they need if they know they need to do the tables it's going to have to be supporting of their budget and they would probably be doing them at that time if I were doing it I would do them at the time I was preparing that budget and reconciliation you know with with my staff rather than you know do it a month later even though I totally understand the intent was to try to help them out we you know we might find if we pulled 14 of the hospitals 12 of them would say if I have to do it I'm going to do it when I submit for July 1 it's not going to really help me to delay it because I'm going to have to track back to that those numbers so I think it's kind of part and parcel that if we need them you know and unless when we go for comment we hear differently again assuming they have to do them I'm not sure it's helpful to delay I'm going to ask Mike Barber as the parliamentarian if there was any motion that was on the table I did not hear one thank you I didn't either but I just wanted to be clear on that so I just ask one thing Kevin do we need a motion if it's something we were was already in there and we had to prove this is exactly what I was about to say Maureen I'm thinking we don't really need a motion we were talking about changing it we're not so whether than confuse and have a motion it might just be that's exactly what I was going to say that that hearing no motion that the language would stay intact does anybody wish to make a motion regarding these hearing none I'm going to move to the discussion on the capital investment cycle section and the discussion here should be on whether we keep as originally presented the adaptive submission which would include the capital expenditure sheets but to reduce the narrative component in the capital investment cycle section of the submission discussion from the board so this is Robin I personally I can do without that as much in the narrative this year given the circumstances obviously at some point the capital investment cycle is going to really be an important issue given that we did see many capital projects pushed out into the future and some of those may be getting more urgent so I'd be in favor of streamlining the questions would anybody wish to make a motion for the point of discussion sure I move that we um sorry I'm looking looking at the actual language right now in the guidance whether you call it streamline or reduce narrative component I think either way Robin gets to this I was trying to be a little more specific so it was clear on what we were actually reducing or streamlining but for purposes of discussion at least I'll move that we um streamline the questions in the capital investment cycle section of the guidance I'll sign in. Just to be clear and we would be keeping the the adaptive submission including the capital expenditure sheets yes I haven't really heard any public comment or other suggestion that we shouldn't keep those I just want to make sure we're all clear okay um or discussion hearing none I'm going to open it up for a public discussion on the motion to um keep as originally presented the adaptive submission including the capital expenditure sheets but to streamline the narrative component in capital investment cycle section public comment and yes I see a hand raised from Mark Stanislaus. Hi Chair Mullen uh let me share my camera I think I am this is just one of a technical um question um nothing about the motion but this is one of the areas specifically on the capital if we could have more time to submit the adaptive numbers it would be very helpful because that detail is something that you do kind of fill in um you know sometimes at a later date or the tail end so I would just put that out there for consideration um um you know there's no objection to the motion as it is but you know if we're thinking about you know creating time um unless that capital is used to make the decision um if we could have more time to submit that capital detail in adaptive I think it would provide the hospital some relief. Thank you Mark is there other public discussion public comment hearing none um is there further discussion among the board? I was wondering if Patrick had thoughts on Mark's suggestion to push it out I I look at it I would say at a higher level in terms of thinking about um margin and that kind of thing but I'm not sure that I would necessarily need it for the waiver of the hearing so I could personally I could see pushing that piece out but I would appreciate uh what the staff might think. Patrick? Yes board member Lange I agree with you I don't think it's something that's going to be pertinent to that July 28th presentation there's a lot of detail there and it really is more for the narrative component anyway for them to build their story around so I would also look back to Mr. Stanislas for an idea on what type of extension their hospital and others may seek I think it would be ideal to have that information at or around the time of those July 28th hearings so prior to August 1st but I would cordially request that they provide us with some input on what type of extension they would be seeking. Mark can you answer that question at this time? Yeah I mean I think any extension is helpful so you know if it's the July 28th or August 1st that does provide some you know relief if say I think back the last year cycle I don't think we submitted this information until October so you know I would just put that in perspective but any relief that the board can provide is you know would be gratefully appreciative. Robin did you want to amend your motion or stay with the existing motion? I'm happy to amend it unless you'd rather deal with it as two separate issues. Do you have a preference? I'd rather get it over with in one swoop but okay then I will amend my motion to streamline the narrative section relating to capital investment cycle in the guidance and to extend the time to submit the adaptive numbers related to capital investments until July. I'm going to just pick a random date but actually what do you think Kevin about if I say that we delegate to the staff to work out an extension on the submission of the adaptive numbers and that way they can work that out. Yeah I think you could make that motion I mean in my mind I don't think we even need to have it by July 28th. I could even envision extending this to September 1st but that's that's just in my mind so others may have a more pressing reason why we should have this information before the 28th of July so it's whatever you wish to make as your motion. Okay so then my motion is going to be to streamline the capital investment cycle narrative and delegate the authority to staff to extend the time for the submission of the adaptive numbers relating to capital investments. Is there a second to the motion? Okay. It's been moved by member lunch and seconded by member homes. Is there a further board discussion? My dog apparently has something to say about the issue. If not I'm going to call the question. All those in favor of the motion signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Let the record show that the motion carried unanimously. Okay so I believe that we are next to a discussion on NPR FPP and on charge growth request and I notice that it is the lunch hour. I do think we're making really good progress. I would be inclined to continue to try to move forward and get things finished but I want to be sensitive to other board members so does any board member wish to recess at this time for lunch or would you prefer to proceed? I'm happy to proceed but I could use a five-minute bio break. So I am going to put this meeting in recess for 10 minutes just to make sure that everybody has a chance to get that bio break and we will be back at 12.15. And before we go this might be the appropriate time to wish one of our board members a very happy birthday. Happy birthday Maureen. Happy birthday. Okay the meeting is recessed until the better place to be. Happy birthday. I'm worried about you Maureen. Better group to spend it with on my birthday but no thank you. Okay see everybody back at 12.15. Welcome back to the Green Mountain Care Board meeting. Just to confirm I'm going to call the role of the board just to make sure that everyone is back. Jessica Holmes. Yes. Robin Lunge. Yeah. Tom Pelham. Here. And Maureen Usberg. Yes. Great. So we're going to resume and we're looking at the NPR FPP growth guidance for 2022 for discussion. Sure one thing you know I put out before potentially to consider is the three and a half percent budget to budget NPR FPP growth or higher if supported by utilization shifting from prior years. So we would expect that would expect then to have some type of bridge above if if a hospital came higher than three and a half percent to be bridging out with utilization that had shifted from prior years. Hey other board members does any board member wish to make a motion for the purposes of jump starting this conversation. I don't know Patrick you have motion language anywhere or is it just so for the fiscal year 22 hospital budget review process the Green Mountain Care Board establishes a net patient revenue fixed perspective payment growth of 3.5 percent over the hospital fiscal year 21 approved budget for NPR FPP with the ability to go higher than 3.5 percent if supported by utilization shifting from prior years. Is there a second to the motion? Seconded for the purposes of discussion. Okay it's been moved and seconded to move that for the 2022 hospital budget review process the Green Mountain Care Board establishes a net patient revenue fixed perspective payment growth guidance of 3.5 percent over the hospital's fiscal year 2021 approved budget for NPR FPP with the understanding that the request can be higher subject to utilization. Maureen do I have that wording correct? Yes subject from utilization shifting from prior years. Board discussion. I guess my question is I think like it makes sense to me that certainly we may see some utilization shift but I'm not sure how we know if it's utilization that shifted from prior years versus new utilization. So I guess my hesitation my sort of hesitation and what I wanted to kind of talk through is I think you know since this is guidance the hospitals have the ability to request higher than 3.5 for any reason and certainly I think what you're maybe trying to do Maureen is signal and understanding that there may be some pent up demand out there. I'm just wondering whether it they're having it explicit in that way makes it harder for them to justify in a way because it kind of implies that other sorts of reasons aren't acceptable which I think certainly there could be other justifications that were acceptable. So that was why I was hesitating and why I wanted to kind of talk it through. So Robin are you suggesting a friendly amendment to member use for that would be after the motion calling for the language saying that hospitals may request a higher NPR FPP growth ceiling removing the language subject to utilization from previous years. Sure I was just trying to make sure I understood. But yeah I'm happy to I'm happy to propose that. So basically I think what your the proposal that she's asking you to consider Maureen is the language that's on the slide with the caveat at the end that says that acknowledges the fact that hospitals may request a higher NPR FPP growth number subject to their demonstration of that need I guess would be the language. Yeah and I guess my my question there would be you know then I think it's going to get to where we may have a motion from another board member at some point which is going to have you know no no guidance right because that that to me starts going on to the to the no guidance if it's three and a half but you know if there wasn't any specific piece there so I'm not sure how that would differ from not having necessarily a guidance because we always have the flexibility to and we have shown historically every year not just in the pandemic that we've reviewed each hospital's individual situation and made recommendations based on that. So here I was I understand what Robin's saying you know is it clear in black and white that you know this moved from one year to the next and to identify that but I think what is has been clear is that certainly we're operating in a time where hospitals are still not back to to normal as as far as what what's happening and you know people have been delaying care for things that could end up shifting into the next year and so that was you know potential reason to go over three and a half. So again what you're saying Robin I guess I'm just not I would throw it out in the discussion that it's all it's really not not really having potentially a guidance ceiling it's just saying we're going to look at each hospital based on the you know circumstances that they're in to to identify what the NPR would be. To me it's almost a matter of semantics because I think that this board has historically demonstrated that it will listen to each hospital as an individual story so I don't share your same concerns Maureen that this just throws out no ceiling because I think that it it's there never has been a true ceiling we've always been willing to listen to the individual stories of each of the hospitals so to me I just think that what Robin is suggesting is just consistent with what we've always done but I'll leave it to you whether or not you want to accept it. I'll accept your amendment so we can continue. Okay. Board discussion? So can you repeat the amendment the amended version of this again? So it's the language that you see on your screen with a clause at the end that just clarifies that the Green Mountain Care Board will hear each hospital budget submission as an individual story and a request higher than the 3.5 would be considered. Tom did you want to say anything? I'm just trying to I mean it's I for me I think I'm caught between a rock and hard place you know on on the one hand as we know through rate review the hospitals use the insurers use hospital approved budgets as a driver for their rate increases and I think that you know in the overall system it is structured I have a quote here from Mr. Brumstead last year when during his appeal he basically said you know under the all-pair model the commercial rate must quote solve for the lack of increases in our reimbursements from public payers and so it just it's this embedded logic you know that the premium payer the co-payment and deductible are kind of the last resort for making up a budget and so and I get that but I'm also on the one hand seeing you know a 34 million dollar under budget in 2020 for diva a level funding of reimbursement rates in 2021 the general fund revenues as I said earlier are coming in at 46 million so far and this is just since January 19th at 46 million dollars over target the as required by law the an increase in one one percent increase in reimbursement rates costs about five million bucks in general fund and I'm and then you've got this 2.7 billion dollars coming in as well and so I'm just I'm trying to find a way to deal with hospitals on a case-by-case basis to deal with the facts that they face at the local level but at the same time to to break this syndrome of us relying on premium payers co-payments and and higher and higher deductibles to kind of make up the difference for for what this Medicare we can't really control but Medicaid the state can control so that's that's that's where I get lost I you know I I don't like voting for a blank check when I think the system is just taking the insurance people who have private insurance whether on the exchange or not what takes them for granted as a pair of last resort here you come I think but if let's say hypothetically the hospitals lobby the legislature and the legislature says yeah we have this Medicaid money let's increase it that would be present in an mpr fpp number two so we get right argument is applicable to the charge component of the discussion and I certainly did not see my language as doing anything more than clarify the existing process and certainly didn't see it as a blank check so well um I that that's my delight you know there's definitely a dilemma here I and I can't I can't fix it from from this position unfortunately you know uh I you know it's it's the kind of thing at one point my career I probably could have fixed this but I I can't I can't do it here but I I don't like being complicit I don't like being complicit in knowing that there's a billion literally billions of dollars out there in this domain this year and um we are having a process that is is uh um and encourages the cost shifts encourages as I said premium payers and and the deductibles etc as the payer of last resort it's a set of horns for me I don't like being in this position because it is not fair it is not a fair place to be well I guess what was is any different than in years past where we've always been willing to come in and let hospitals tell their individual stories Tom well and uh what is different um nothing I I I want them to come in I want to hear I just wish that some of their fire uh maybe wasn't directed so much against us which we've seen some of that you know in the media and in some letters that some of their fire was directed at where the money is follow the money um it's uh you know every every five million dollars is a one percent increase in Medicaid rates and um they were under budget for fiscal 20 by 34 million dollars so there are solutions out here that um that uh and alternatives to having this cost shifted on to insurers and I'm just speaking up as the urging the hospitals to go where the money is especially in these you know in in this period of time isn't that what Willie Sutton said when they asked him why he robbed banks he said that's that's because that's where the money is yeah well so a lot of a lot of wisdom there so I would just say that uh I don't think we here at the Greenmont Care Board are going to fix government funding and um I think that um I'm not sure if this whole discussion on the NPR FPP growth guidance um necessarily falls into that discussion I think we need to continue to push to um make sure that everything that uh every increase that occurs in the healthcare system doesn't just fall on the backs of the commercial rate payers but I think that the discussion here is probably getting a little bit um more far range than uh what's necessary no I agree with that I mean I think a fixed percentage increase which I'm not recommending would would would would health fix it and it's uh and we also have rate review that's the other side of the equation in terms of of managing this but it's it's it's at some point it's going to implode um Kevin can I hop in here maybe and um and I appreciate Tom your concerns about the cost shift I share them um and hopefully maybe we can address that through some of our sustainability planning work that we're doing at least understanding how much of it is exists and and are there ways to um mitigate some of that but um I think this probably isn't going to surprise you all but I I still feel I think still from last week that given the uncertainty due to the pandemic I prefer not to put uh the language has changed right we started with targets then we went to ceilings and now it's guidance um and I think it feels a little like semantics to me uh it's still suggesting to the hospitals that you meet this fill in the blank although I know I recognize that we always um leave room for individual case by case conversations about where hospitals are in my mind um I think we've signaled where we hope hospitals can land with our presumptive approval criteria but beyond that I feel like I just want to hear where hospitals are what they think their most realistic most appropriate budget to serve the needs of their communities are without trying to uh fit hospitals in this box with this guidance or this target or this ceiling or whatever we're going to call it um so for me I feel like the presumptive uh approval criteria works really well for signaling our our aspirational hopes to work where hospital budgets will be but beyond that I'm going to vote no even though I actually want to share with both Robin and Maureen my appreciation for your trying to actually add wiggle room into the motion to allow for that I think my preference is simply to just say if you don't meet the presumptive approval I would like to see your budget and we'll look at it on a case by case basis given the needs in your community so and that will actually I so I don't have to repeat myself when we get to the charge that will also be my position I think unless I'm you know in the conversation uh I feel the same way about that for the charge conversation so I appreciate your perspective Jess I do think that based on the current motion though it's not really that much different than what you're saying in that uh it's still giving the latitude which hospitals have always had historically at Greenmont care board to come in and make their case on why they need a higher amount and I suspect that will have several that will come in and make their case on why they need that higher amount and I suspect that will prove several of those requests but I I don't think that there's anything in the current motion that's in front of us that really is any different than a motion that you suggested last week other than it's just a wording semantic but that's just my opinion is there other discussion from the board yes I have just one question um so like I'm looking at the uh the total system-wide budgeted FTP for 2020 and was 2.717 billion dollars and the actual came in at uh 2.425 billion dollars and so um so does that um does that mean that and and so during those two during 2020 and 2021 some of that capacity wasn't used obviously and it so is it that built and since we're going you know budget year to budget year is that unused capacity built into the base of the proposal for um 2022 so the answer to your question is that this this guidance is referring to budget to budget and that in the case where those hospitals that did not recognize in advance a decline in revenue and a decline in volume um that they foresaw for the 21 year that it would be off their budget so that I think that's part of the individual stories that we will hear we may hear a hospital say well we realistically came in and our forecast was more accurate than others and at the time everybody probably thought that their forecast was the most accurate nobody has had a crystal ball a year ago nobody has a crystal ball today everyone made their best foot forward with their budget presentation and it just will find we'll find that some will prove to be more accurate than others but this guidance is from budget to budget not actual no I I understand that I'm it's just it's budget to budget with some of the capacity not having been used uh in prior years um but it's still being carried forward and into the capacity it's being carried forward in their npr I get that yeah other board comments so at this point I'm going to open it up to public comment on the motion before us regarding npr fpp growth guidance members of the public jeff teamon thank you mr chair I wasn't sure if I effectively raised my hand um I just went up at the top but it didn't go up next to your name at first so I'm having some um weird computer things going on today okay well well as long as we can hear each other now thank you um I just I want to start by saying I'm encouraged by the the direction of the motion in this conversation um I want to thank the board for their thoughtful approach here um particularly supportive of uh board member holmes um as she articulated her approach because I think it allows the hospitals to develop the budget they need without artificial constraints and then allows the board to evaluate each organization on its merits individually um that said I do want to just reiterate a couple of mike del treco's very well mentioned points earlier um acknowledging the unique moment we're in and the importance of looking not only to historical growth averages but also to some of the other circumstances here like the critical importance of margins hospitals are constantly working to control costs and ensure their stability um but shouldn't be asked to do that by pushing margins and expenses to the breaking point and I think the national scene is a helpful um if if sort of distressing illustration there was a kaufman hall report um mr chair that I think was shared with you um that said by the end of 2021 calendar year 2021 hospital margins could be um down 80 percent from pre pandemic levels um and the last thing we need to do is find sort of additional ways to to squeeze margins or force hospitals to do more with less um I don't I don't think we create an affordable healthcare system by by minimizing margins and um doing that would just sort of create an insufficient um system that's ill-equipped to manage day-to-day responsibilities let alone a pandemic and I think the pandemic has taught us how important and vital our hospitals are and that their financial strength is critical when they're trying to manage a major crisis and serve public health so for those reasons and lots of others like improving aging facilities um workforce challenges text teaching the next generation of doctors um and investing in health reform um when we weren't given transformation dollars that were promised we need the capacity to grow responsibly um at a rate that's more closely correlated with the reality on the ground in medical inflation in any arbitrary limit or ceiling and and that and that includes um a new cap on um on rates when you already have the ability within your purview to manage that through npr and other mechanisms thank you thank you jeff and I just want to acknowledge that uh all members of the board are in possession of the kaufman hall report and uh we thank uh um Steve gordon um for sending it to us we already had it but um it doesn't hurt to make sure that we have things so um very appreciative of uh Steve's uh effort to get that information to us um other members of the public and I see mike fischer's hand is up uh yes thank you mr chair um I um I put my hand down um um I can't resist uh to at least want to respond to some of the cost shift discussion I also recognize that it is not really what is being discussed in front of you right now so um uh with this short interruption today um I would be happy to talk with board members or uh talk more at length about some questions I have about this concept of a one-to-one um uh that the cost shift works in the way that people talk about it uh at a later date and um and hold myself short uh to allow you to continue to talk about the uh what's really being discussed thank you mike appreciate that other members of the public hearing oh did somebody start to say something uh mike if you could just mute yourself I think it's coming from your end I don't see any other hands raised and I'm not hearing anything so just to repeat for the board that the motion before you is for the fiscal year 2022 hospital budget review process the green mountain care board establishes a net patient revenue slash fixed perspective payment npr fpp growth guidance of three by 3.5 percent over the hospital's fiscal year 21 approved budget for npr slash fpp with the understanding that any hospital may come before the board to ask for a higher amount given their ability to demonstrate it and I'm going to ask uh general sorry can I just suggest that it it's probably a different amount right because they could also ask for a lower amount well I I thought that was explicit but it may not be in any case I think that you know the staff can words that that I don't think anybody uh thought otherwise but um I agree with you it's always better to be explicit so thank you robin with that I'm going to ask uh general council barber to call the roll board member lunge yes member palam yes member usper yes member holmes no mr chair yes so let the record show it was a four to one vote and patrick if you could move the slide to the discussion on the charge growth and maybe you could go straight to the the language piece patrick of the motion for the purposes of discussion does anybody wish to uh make comments from the board or to offer a motion and I'd like to make which is um I so for me I think that the reason why I was interested in uh providing guidance around charges this year is uh quite frankly last year we got a lot of pushback from the hospitals that there was no no guidance about it um and so you know I'm of a couple minds here because certainly we haven't always had explicit percentage growth guidance around charges in the past um so you know to that extent I don't feel like I absolutely have to have it this year um but I I do feel like it's responsive to the request for more from the discussion last year around how it would have been helpful to have uh some general guidance on that so um and so I'm I'm interested to hear where what other people are thinking and certainly the public comment around it but for me like I think it is helpful to include it because it does sort of give a sense of direction again it is guidance and we would fully expect some hospitals to come in with a different amount higher or lower based on to Maureen's point earlier what um what they feel is necessary and to Tom's point earlier um you know it it is a frustrating uh is where you really have this one lever that disproportionately impacts a relatively small part of the Vermont population when uh inflationary increases should be more widely shared across the entire population other board members yeah I support what what Robin was saying as far as and um people may forget last year some of the hospitals you know did did bring up that we had didn't have guidance and they they felt you know maybe that would have been helpful I'm open to to being flexible with with either putting a number or not in here and and maybe we just need to be I think maybe where the disconnect has been is um kind of the statements that have come back at us like I met my npr so if I have this really high commercial rate ask that that's okay because I met the npr and I think that's that's kind of you know why we were contemplating whether we put in guidance but maybe there's a way to at least be more explicit that we will be looking at commercial rate ask and potentially making adjustments and I think you know one one of the pieces we haven't talked a lot about um we you know we've talked obviously the cost shift and we you know we've talked about inflationary pressures at the hospitals and we've talked about you know the need to be able to provide you know the quality care that we need and we all want that what we keep missing in the piece is that many people aren't going for care because they can't afford insurance or they can't afford their deductibles that we have so that's that's kind of the the the lemma and the crossroads we have I'm not saying hospitals are not considering that but we hear it from both sides where people you know are going to get rate increases or they get rate increases they go to high deductible plans they don't get care because they can't afford it so we can't give them quality care if they can't afford to go there and that's you know one of the reasons why we tried to put in um last year you know the ability to ask for a higher rate put it in in this bifurcated which you know which we didn't do as a bifurcated rate because of the issue of not being able to potentially get COVID relief money for that it was set up that way but that was the intent I understand you know with everything still going on um probably can't hold you know that will be a consideration I think when we look at a hospital for what they're requesting in 22 but I I don't see that we're going to have an explicit motion to say we'll reduce for that but I just think you know that that's kind of just the miss in this right I mean we certainly could have hospitals that come again again in 22 asking for double digit rate increases to get them financially healthy they need to be financially healthy but on the other hand the large vast majority of the commercial consumers are not financially healthy and can't afford to get care and they're getting priced out of the market so you know and this gets built in these increases year over year and they compound so last year we had some pretty big increases that are built in and then now we're going to go again so so I know we're all working together to try to get the strong health care system and I think the intent of all of us is to do that it's just that you know that's that's kind of the dilemma so I guess you know I could be okay with not putting a specific number in and just you know putting something in the language that says we're certainly going to look at what the commercial ask is and you know be considering what the burden is on the consumers as well so thanks marine I'll jump in here just offer my thoughts again I think that the board has always historically listen to any request and base it upon the information that the hospital presents in the presentation and for me I would prefer to see a number in here and the number that I would like to see in this is 3.5 percent and the reason for that is if you take it and exclude last year historically the charges have been growing just over 3 percent and so I think 3.5 is a good number for this but I also recognize that there are going to be some stories that we're going to hear that are going to be able to justify the need for a higher increase in order to have a sustainable institution moving forward but I I believe strongly that there should be a number here because I think that lacking a number I think the message could be misconstrued other board members well I agree Kevin I think that some guidance is better than no guidance and you know the you know obviously if it needs to go higher given the realities of specific hospital then that's what should happen but I think having a number that is tied to the economy which this 2.5 percent is is a better place to be than not having any number at all other board members or does anyone wish to make a motion yeah I'll move I'll move that for the fiscal year 2022 hospital budget review process the agreement and care board establishes charge request growth guidance of 3.5 percent over the hospital's fiscal year 2021 approved charge increase is there a second well hearing none but also recognizing that I typically do not wish to make a second as the chair I understand that it is a prerogative that I have I'm going to second the motion for the peer for the purposes of discussion so board members other board members I mean I can go with a number but I'm I think I'm probably at four just because I think that given the uncertainties around utilization 3.5 is low this year although I certainly recognize why other folks would go with that number so that's why I didn't second the motion so it may very well be low but my point would be that we're allowing flexibility and people could come in at a much higher number and we'll likely approve numbers that are higher than this but I just think back to what Maureen commented about the higher approved charges last year which at the beginning were somewhat thought to a piece of them to be a one-time limited duration only increase and that is not the case and that we're we're moving this base forward to a time when hopefully utilization is back to normal and that is somewhat troubling to me agree as well I mean I don't disagree with those thoughts you know I I am also troubled by building it into the base other board members hearing none I'll open it up to the public for public comment on the motion and I see Mike Deltraco's hand up Mike thanks chair mullin and board for the conversation here I think the proposal on the table should contemplate what fiscal year 20 net revenue performance actually did it did a couple of things one it helped us meet the goals of our all-payer model the 3.5 per capita spend so having 290 million dollar net revenue shortfall helps in that in that arena this the second thing it did and I want to be sensitive here because I understand this might not be widely liked it changed the payment levels of our insurance companies we we all know that that net patient set net patient revenue shortfall created some savings in that space so to move from 21 budget to 22 budget creates this potential windfall we all know that we all received a rebate from our current insurance companies because of those savings we didn't see that from health care insurance and this would only perpetuate that savings I know you do look at that so again I say that with a great sensitivity to my colleagues in the insurance companies so I just think we have to think about more more specifics around what this with this proposal does and how it actually impacts the industry I and this isn't a shot at my employer I have a high deductible plan and I know I look at my out-of-pocket and I say geez am I going to go in or not and I say that so I'm marrying all these things together and I just think the whether it's three and a half or four percent it doesn't recognize the burden that these our organizations are carrying going into into next year and I'd prefer to see no no ceiling or no guidance here and allow you to judge both all of the all of the aspects including that revenue and rate when you get their budgets so thank you thank you Mike and I do think that regardless of whether there's a number or there's not that we will take all factors into considerat