All right, Amy Schumer. I see you edit again. So in 2015 you had trainwreck and I thoroughly enjoyed that movie It was well received by everyone from my recollection and it made a decent amount of money at the box office Now last year around this time 2017 you had snatch and that was not well received It was a textbook definition of a box office bomb and me myself. I just didn't like it as much as trainwreck But now we have I feel pretty and what did I think about it? Well, let's find out My name is Brennan Keith Avery and this is just my opinion Hey, what's good everyone? It's be Avery here and I want to thank you so much for tuning into my opinion slash review For I feel pretty so we got I feel pretty now. It is a comedy by Amy Schumer As far as is, you know, do I like Amy Schumer me? Yeah, I'm not the biggest fan of her stand-up Performances you can go check a lot of that out in Netflix, but just like I said in the intro of this video I really did like trainwreck story and LeBron James snatched not so much but now we have I feel pretty But besides that something that I'm really curious about is normally I would not give a crap what the box office Would be for I feel pretty but I am very eager to know now or one reason is because a couple of months ago You know, you had the incident where a monique called out Amy Schumer Well, she didn't call out Amy Schumer. She brought Amy Schumer up In her argument when she was trying to negotiate with Netflix for a higher pay And there's so many opinions going on in that story and people just like you know Amy Schumer is a bigger pool and you know, I'm not gonna give my opinion on that entirely now I can you know, you know make another video for that, but with Trainwreck doing very well at the box office been snatched not being With snatched not doing well at the box office is split down the middle But when I was just you know trying to analyze it whole situation I was like what trainwreck had LeBron James in the film and it also had him in the marketing So was it Amy Schumer that made the film have make a lot of money or was it LeBron James all in the marketing? I don't know, but you know, if I feel pretty has a great box office return and that can go to show that okay Amy Schumer has an audience, you know, if she doesn't I will probably Probably backtrack myself on a few words to send. Okay, you know, I thought that she did have a poor but you know The trainwreck success was just strictly for Because of LeBron James, but speaking about the movie itself you guys this was not on On my well it was on my radar. I knew the movie was coming out But I was not entirely interested in seeing I feel pretty it didn't seem like I could relate to this at all While you know Amy Schumer is funny for the most part in her films not too much a stand-up that you know The parts that I've tuned into I just you know kind of roll my eyes when I saw the trailer for this movie I'm like, okay, you know, they're gonna have a couple of laughs But it's just nothing that I can relate to you know, nothing that speaks to me Now as far as you know, who's behind this film that you know kind of open my eyes after I saw it was the director and the writers Who I wrote? No, I didn't write it down. Let me look that up. Let's write here I wrote down movies that they put together, but I didn't actually write down their names But I think you should know the names the writer and director Abby Kohn and Mark Silverstein now this is their directorial debut Other than some short films that they've worked on in the past and they do work as a duo But they have written films like never been kissed. He is just not that into you, which I think came out like oh 809, you know That was a very popular film for me and just some people that I know around that time You know, it just kind of spoke to us and you know have a lot of conversations and things like that And also how to be single and all those films, you know, why they may not be my favorite I mean, they are written well. So, you know, we're getting that talent over and I feel pretty now Usually when I do my reviews when I get my opinions sometime I'll let you know how I felt about the film early in the beginning I just don't waste no time especially when I'm very excited about it Sometimes I will you know make you wait and give my you know my assessment at the very end You know But before that, you know talk about all my likes and dislikes, but I just don't feel like, you know leading you guys on it or You know waste your time or anything like that I mean this video I already been on for more than five minutes, but guys you may be surprised But I really didn't enjoy this film. I liked it a lot. I'm very very surprised You know how much I liked it.  You know, I can imagine we had we I mean, I don't know I'm but I would imagine that we don't have much in common But you know as far as the story and what's going on between the characters in this movie You know, I could have took Amy Schumer out and put myself in not in every instance, but in a few and Just a great thing about it is this is the most genuine real True relatable movie that I have seen in a long time because it just deals so much with what everybody in the world deals with You know from varying degrees that has to do with confidence self-esteem Insecurities that you may have about yourself I mean, that's what this movie is about and I don't care who you are If you are the most fit person in the world or if you're the most sloppy as built person in the world Everybody has dealt with confidence security insecurity security and self-esteem issues at some time in their life And you know this film tackles that just something I mean One thing that really impressed me is the very very beginning of the film in the very end of the film Like the opening frame of the film and the ending frame of the film Those are possibly one of my favorite parts in the entire movie The reason why is we got two shots at the very beginning and the end of Amy Schumer and you see her growth from the first shot of the film towards the last and When the camera is just zoomed in on her.  It felt like a comedian on stage or a comedian, you know In a movie, you know, whether they're trying or not. You can it just you know, it didn't feel real But you know in this movie know Amy Schumer's character. What's her name? Renee Bennett.  I was like, oh my gosh sister girl You know, I can't believe I called sister girl. But hey, you know, Amy Schumer I feel you right now. Like I know what you're going through right now And what what this film also does it just makes it so real is it's just a true reflection on society And how people treat people based off their looks.   It just it just really like shows how You know, um, just how ugly people can be and how people that have the looks that society gives them how they are treated much better than I guess the average looking person Now as far as the concept itself, I told you that that's real, but the actual plot in the movie Let's talk about that. You know Amy Schumer.  I mean there was one scene in this movie to where it was She was uh, uh, she got off work. She was going home. She was looking in the mirror You know, not, you know, too happy because she was single She took off all her clothes and she looked in the mirror.   She wakes up.  I'm like, look, okay, you know, you see me You see what size I'm I'm I'm extremely small now.  You know, I'm saying like it's it's intimidating You know what I'm saying?  You know what I'm saying? Or like, what is this machine here? I have no idea how to use it and then you're getting on the machine And you don't know if you're using it correctly and things like that And then you just you worried about everybody if they're looking at you and you just kind of looking frilled and just like You know, okay, maybe I should come back at 3 a.m. In the morning That was kind of Amy Schumann's character in this movie at one point I'm just like me. I've been there before, you know, and um It's been a while since I hit the gym I'm just hitting with like years since I like been consistent with like weights and stuff like that But like I've been there before and I I could you know I I just really really did understand where Amy Schumann's character Was coming from and someone she hits her head And uh, she has all the confidence in the world. It is just like a beautiful transformation. She is completely different I mean this movie is like you All male. I mean, you know in the dating game or whatever The male always pursues the woman for the most part. I've had a woman in my life shoot me a number It's like, hey, you know, I think you're cute. You should call me and things like that You know, that's cool.  What was I talking about my goodness gracious? See what I need I need to stay on top I had a good point Uh, hold on I'm not adding this out either. I don't care. Uh I got this right here. Uh, oh, yes What the movie does so well when she got her confidence.  You want a date woman? That's great But rule number one Is you got to have confidence you will not get nowhere in life You or you will not get any women or any woman if you don't have confidence That's just like one of the base things right there the number one most important thing Other thing is, uh, nobody likes to pity party. I mean those I remember those were one of the two lessons that I learned once because somebody taught me Also do uh self experience, but this movie does such a great job Just showing the power of confidence like how much power, you know, you have behind confidence No matter what anybody thinks of you if you think that you are the sh it Then everybody else will think you the sh it too.  This is the owner. They delusional Yeah, because you know, Amy Schumer's character did come across delusional here and there But it is at the same time She still got darn thing done because she just had so much confidence because she was the same person She thought that she looked she thought that she looked better Um, then what she perceived herself, but she really didn't but she saw herself, you know, and a whole new life And it just really transformed her world. You know, I'm just like man because I feel I mean There's been times where I would put on I would walk out the house suited and booted and nobody could tell me nothing You don't understand. I'm just like yes. I know who I am branding every women. Come come I'm joking. I mean, I never did that but I have been that confident before But I also have been the insecure guy in the back in the corner just afraid to Afraid to talk to a woman. I mean when I went to my first party where it was dancing I was freaking terrified or whatever But you know, I ended up getting in there and all that good stuff But it just with this film doesn't just a great dot great job of just showing, you know, the power of confidence Relationships, you know, the ups and downs the miscommunications here and there. It's also very funny I laugh.  We got uh, tom hopper in here as well He was game of thrones. I was like, I knew I was like, I know, I know this guy from somewhere I looked up him up on imdb. I was like, yeah game of thrones. We also got Naomi Campbell and her Naomi Campbell in this movie her fine self and uh, she her role fit in this film very very well, uh, so they all did a great job to This film also does a great job of just showing how people that consider themselves up here the elitists Or whatever, you know, how they just don't understand the average joe the average jane or people in the lower class or, you know, uh, you know A lower economic group or whatever and you know, Amy Schumer's character was the breeze that brought those two worlds together to possibly create a better Walk of life, you know for everybody, uh, you know, this fan spoke to me in a lot of ways The only thing that I did not like about it was um, it's only I think an hour and 50 minutes. Let me look Yeah, hour and 50 minutes and I felt that that was still a little too long And why is that the reason why is towards the end so Excuse me, you know in the trailer that she hits her head.  Of course. Yes. That's obvious My problem with the film One of the few ones is the length and then like after that I kind of thought that her character was just acting a little too ridiculous I mean, I could understand when you finally see it's like, like, whoa, I thought I was beautiful this whole time But I'm really the same I can understand you being scared for a little bit But there was just a scene or two to where she just took it too far.  So this is the cheaper out of her last three So i'm very curious what it will do at the box office, uh, you know, because it's a good film You know, it is straight up and I really did enjoy it if I were to rate I feel pretty out of a one out of ten. I will give this In eight. I had to look eight out of ten. Yes in eight out of ten But guys, I said all that but in the end, you know, that is just my opinion. Okay, but what did you think? I'm curious to know your opinion as well. Um, you know, have you seen I feel pretty or do you want to see it?  Do you agree with me or do you not disagree with me? Let me know in the comment section below Let's get this conversation going and keep you flowing if you like this video Go ahead and give me the thumbs up and if you don't like to be or hey, that's fine But you can still subscribe to my channel You can also go to my website check me out the bookmark and also look me up on social media Facebook instagram and twitter It's right there at the bottom of the screen and I made it very easy By providing a link to all that good stuff down in the description box below And really guys, if you really want to help me out and I've been getting a lot of positive feedback I really appreciate it. Please like my facebook page. There is a link down below Because what I have planned for the future? It really helped me out and You know, this is just kind of rash roots to do that But guys, I just want to thank you so much again for tuning in to my opinion slash review Of I feel pretty and before you go. Don't forget. They're my name is brandy Keith Avery And that's just my opinion. Peace


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the present when the budget was presented earlier on so one in terms of the FY 21 results the amount of federal and state funding that the UVM Medical Center has received is 85,000,000 not 39 or 89 so looking at that margin of 50 million the financial situation this year as has been highlighted would have been even worse so just to make sure that that context is is understood as we highlighted in our response last week as well like we have many times when we put together a budget this far in advance our Medicare rate increase assumption is no longer valid and so in addition to the rate reductions being contemplated today we also have about a $7 million rate assumption for Medicare that is not going to that won't materialize for FY 22 so if you were to combine both of those factors that's $12.6 million of revenue assumption that at this point would be different than what we than what we submitted the last thing I'll point out just because there was a lot of discussion about expense control in our presentation this year as we've done in the past if you look at slide 47 and 48 the UVM Medical Center compared the other academic medical centers is been the last five years near the near the 25th percentile in terms of cost and this is cost from the provider perspective not from the patient and payer perspective so absolutely there's always work to be done to control costs and that's a focus that we have with everything that we do but again to highlight the place that we're starting at is a very low cost starting point in addition we highlighted that the shared services that we provide as a network is starting to have an impact as a percentage of net patient revenue we have gone down in this year's budget compared to last year and as before we have all the systems that will enable us to accelerate that cost reduction so I just thought important to point out those those factors as they're as they're connected to the to the discussion that you're currently having thank you thank you Rick I see him Davis's hand raised thank you Kevin I've just got a quick technical question for Patrick the change of 7.05 reduced to 6.05 and that's the overall charge is that the same number that would affect what people call the commercial ask Patrick be in other words the amount that they could the could increase the charges to just insurance companies yeah I didn't did I not he not hear me no I heard you I'm contemplating your question oh I'm sorry so are you set I'm not sure I follow what you're what you're stating or asking okay so we'll just just the thing is you can if you the change in charge you could imply that that's a that's simply a number that applies to the charge master that would then apply to all the charges across the whole book of business of UVM um if the the critical number uh because it doesn't because because Medicare and Medicaid don't pay the bill anyway uh then the real question is how much in in in uh in Robin's motion how much will UVM be able to increase the charge or care that they purchase that is purchased by Blue Cross well it's my understanding that they don't increase charges by pay or they increase them by service so I'm not sure I have the number for you ham well to ham's point this is Robin I think UVM typically actually requests not a change in charge but an effective commercial rate so I should probably change my motion to effect to use that language of effective commercial rate because I think that was what the 7.05 percent was if I'm not mistaken yeah I think also if you turn to page 122 because in the past many hospitals don't increase their gross charges the same across each area but UVM was projecting to do that in their submission so the 6.05 should go across inpatient, outpatient and professional um and then you can see when you look at the payer type ham if you were getting to you know that won't change Medicaid and Medicare so it really will just have the impact on commercial and maybe self-pay thank you all for that I uh I'm not sure I understand it but uh that that's probably that's that's my bad I have a comment which is simply this that there's a huge sort of disconnect with reality that it's not everybody but it just sort of a sense that goes across this discussion that makes no difference none whatsoever what you set for NPR but you can't run the face of it they can't get people through there fast enough the more they put through the more the NPR will go up and if it sets do you expect something different than you're living in a cave so that really doesn't that really doesn't matter if the UVM in fact goes over way over what they went huge level which they did in 2017 um the NPR and and and in your judgment um too much money then dropped to their bottom line okay then you can get it back and it was exactly what you did in 2017 and it was a fact that helped you get uh and some alleviation of the the mental health bed problem so the question really is the real the question really is whether you is is really what you can charge Blue Cross you can't get any more money out of Medicaid you can't get any more money out of Medicare okay and so so the question is is is the one that Jessica Holmes raises is is UVM going to get enough and one of the things I've never heard this board talk about even once maybe I missed some okay the fact of the matter and Robin says today I don't know if I think if we can afford UVM UVM is the UVM network is cheaper than the state average by 20 percent and is cheaper per capita across across its service area from the high places like Rutland okay Bennington Gifford those places are 30 percent higher per capita and those those numbers are age adjusted they're all in the Dartmouth Health Atlas which was born by the way in Vermont and so so the question is so the question do you want to make UVM if UVM if people can afford the bill the insurance bill then what about Rutland what about Bennington what about Gifford okay you know what about what about the other 1.2 billion in the system the I just can't I don't I I I don't get it if this board this the UVM is the only really serious heavy duty medical structure here it's all tertiary care it's all we have Dartmouth too Dartmouth is every bit as important to us as UVM even though we never talk about them so all I'm saying is it is it just sounds ridiculous to me you the you want to you're afraid of this cost it's too much chip away here and nickel there chip away and nickel there it's the cheapest you've got okay you say nothing about the people that did a did a way over over spending anyway that that's that wasn't a comment Kevin that was kind of a rant thank you ham other public comment Kevin could I just point one thing out you know addressing some of what ham was saying if we look at slide 121 so on on 121 you know you addressed npr and we didn't put any cap on npr but look at the history you know 2017 yet they were over budget but it was 4.7 percent above the prior year 18 3.5 2.5 minus 6.7 8 and 15.8 and if they don't achieve the 15.8 they certainly have the expenses lined up to go against that and there could be a massive decline so you know we're putting that responsibility on on UVM and not capping the npr as you said but it'll be interesting to see next year whether that really came in or not because there's there's certainly risks there but the board chose not to cap the npr let it come in as stated and you know knowing that UVM should be able to manage that to a degree but it's pretty big growth year over year but Maureen it doesn't matter what you do about npr they're going to get npr public comment I agree with you I agree with public comment is not a period of debate I'm going to recognize like Fisher next Good morning Mr. Chair members of the board a couple of comments I want to make in the context of the UVM budget though I think it should be noted that that much of what I have to say is applies to many many Vermont hospitals and the board's consideration of many hospitals first I just want to remind us a little bit of not so ancient history not too long ago there was a discussion of a one-time COVID bump that would not go into the base I remember the details of why that came out and and that decision last year became part of a recognized as an increase not as a separate increase for COVID and and there was discussion at that time about about the importance of being able to back that out I have missed if there's been any discussion this year about a decision not to back that out there may have been and I missed it but I bring it up now because it's my hope that and it might be a reasonable decision I'm not debating whether it's a reasonable decision or not to to back the the one-time COVID the discussion of one-time COVID increase last year out this year but I think that it should be discussed in future years I want to remind us of that and then I also want to make a more global comment about sort of the meaning of the bad debt line it you know to a hospital administrator it is something that is written off and and and goes away it's a an accounting tool we asked for stories this year about the impacts of medical debt on Vermonters lives most particularly the impacts of medical debt on Vermonters decisions about getting care and you know it won't surprise you you hear these stories like we hear these stories but but it was relentless it was a difficult comments to read and a difficult number of comments to read and I'd be remiss if I didn't say it out loud in this context that that medical debt and the impacts of medical debt on Vermont families pushes in exactly the wrong direction of where we're all trying to go with right care at the right time it's it's so important that we make progress in how we in how payers and providers organize themselves around promoting care but if we don't touch the the significant pressure on Vermonters it will be even harder to make real progress on delivery reform thank you Mr. Chair thank you board for your hard work thank you Mike other public comment hearing none is there any further board discussion on the motion in front of us hearing none all those in favor of the motion please signify by saying aye aye any opposed signify by saying nay but the record show is a unanimous decision Patrick I'm going to turn it back over to you for the next hospital thank you Mr. Chair and for clarification of the process can we assume that will be the template for the next two there will be a motion made on the budget with pursuant to the work that legal is going to do around the commercial fixed perspective payment topic I think it makes sense okay all right we will proceed then next up is Porter Medical Center and I'm going to wait hold on a minute Patrick sorry so I'm I should have actually I'm sorry to do this but I think I should have amended my motion before we voted on it that to clarify that the 6.05 was the effective commercial rate not the change in charge we as in years past we didn't receive a specific request for commercial effective rate we would only receive the request for the increase to gross charges and quite frankly the board made it clear that we weren't going to have two different standards one for one hospital one for another so to go back to what what it was done in the past we're just stomping on ourselves I'm fine with that it's it's just not how I read this submission which says aggregate commercial insurance rate increases of not change in charge but I'm comfortable with everybody else's I just want to make sure that I'd done it correctly so hearing nothing Patrick might as well presume okay as I was stating next up is Porter Medical Center and I'm going to turn it over to Kate Hoffman to walk through the hospital's budget profile Kate thanks Patrick good morning yes sorry still morning everybody so to go through Porter for FY 21 we're looking they're coming in about four percent below their 21 budget um their FY 22 request of about 94.1 or two million dollars is about 4.9 percent over their 21 budget which is over the 3.5 growth rate guidance and they are their request is about 9.2 percent over their 21 budget to the right for their charges they're requesting a 5.86 overall charge master increase which is mostly allocated to commercial but some is also going to Medicare and with a small deduction to self-pay and other when we look at their performance versus the 3.5 trending they are almost exactly where they would be at the pre-pandemic 2019 actuals being projected 3.5 percent year over year it's like thirty thousand dollars short I believe some of the justifications the hospital discussed which are consistent with other hospitals are the staffing challenges and the desire for capital investments to improve their patient access they discuss also the LNA training program they want to be sustainable and affordable and their rate request sorry is for incremental inflation only so if we look at their waterfall graph their increase from FY 21 is about 4.3 million dollars 3.7 of this is utilization 3.7 million sorry 2.6 million is attributed to rate with offsets to the FY 21 rate difference bad debt free care and their reimbursement slash payer mix the operating expense drivers for Porter they're increasing about 2.9 million mainly due to inflation increases of 2.2 million dollars equipment and software of 1.7 million dollars and new positions of 1.2 million dollars their offsets include compensation to non-medical staff of about 1.1 million purchase services of about 1 million and fridge fringe of about 560 thousand dollars so when we look at Porter's quarterly performance they ramped up up to Q3 and are projected to drop in quarter four however they are projecting a positive operating gain for fiscal year 21 for Porter's historical performance this hospital is operated slightly above budgeted NPR FPP from 2017 to 2019 with their missing oh sorry got a little feedback Tom let you coming back through if you could mute yourself it would be great sorry with their missing NPR and FY 20 and projected in 21 as we discussed earlier operating margins continue to be positive with a budgeted margin of 5.1 percent in FY 22 this is the second highest budgeted operating margin for all hospitals in FY 22 also to note in the 2019 and 2020 actuals Porter has had the highest operating margin across the hospital systems as well however what's not reflected in here is the money that is used to support Helen Porter which likely also deteriorates their day's cash on hand of it I believe if I remember correctly they were thinking about two million dollars last year was going to support Helen Porter so slide 131 breaks down their charge request the 5.86 percent that they're hoping for the NPR due to change in charge was about 2.6 million dollars which we saw in the waterfall graph the percent broken out by commercial Medicare and Medicaid is shown here as well they like the UBM Medical Center are increasing this all-service areas by 5.86 percent again you can see the breakout of the request to the individual payers and finally with their charge increases if we remember the slide that showed everybody's averages um Porter's was zero but if we consider their commercial rate asks they were in the five-year average they were about the middle of the road when compared to all hospitals so our next slide shows their their net revenue collection rates for all payers we can see it dropping overall a bit in the 22 budget from 51 to 50 percent from the projection however their commercial collection is slightly higher at 61 percent um they also have charge increases um oh excuse me um their pair mix shown here you can see a bit of a shift to commercial um when compared to the projection on the graph on the right and then finally um our recommendation so I'm actually going to start with the charge recommendation so the staff supports a four percent um charge increase um and we also are supporting as with the medical center um and approve as submitted for NPR FPP we believe they could make up for the cut in the change in charge in volume also if Porter did not um make up for this in their charge request in volume this would reduce their operating margin to about four point five six million dollars which is about a six hundred thousand dollar reduction um they have estimated approximately two point one million dollars of loss to be covered by Porter at Helen Porter which is based with our based on previous correspondence with um with the health network this would ultimately leave Porter with a two point four six million dollar operating margin um and yeah we support the growth is submitted if we drop it by the charge reduction the NPR growth would be approximately four point three percent however as I said we believe Porter should be able to make up through the for this reduction through volume so I'll kick it off and uh just say that uh I hate to ever hear the words make it up through volume and it's one thing to say that it's we're making it up through uh reducing the pent up demand but we have to realize that cost is really a function of price and utilization and we should not be encouraging utilization unless it's the right utilization and the right care at the right time in the right place so um that's just a pet peeve that I have but I do support the staff recommendations completely um I think that the fact is that it's next to impossible to accurately at the time budgets were submitted budget for revenues given everything that has been occurring in the world around us um with that I do think that the two point four six million operating margin after taking into consideration other expenses is still a healthy operating margin and so I support the reduction to the four percent other board members sure I'll go um I also support this recommendation you know as submitted um and um I do want to point out and and I'll refer to Mike Fisher I've I've pointed this out every ever to every hospital that did get a COVID adjustment the year before so maybe you missed me bringing it up but I have pointed it out every time um and this hospital did receive uh one percent in what we would have assumed as a temporary adjustment last year in their four percent rate request um so considering this reduction to four percent I would for me that is a factor in in bringing forward the reduction from 5.86 to 4.0 I'd also point out that they have a similar forecasting um in bad debt and free care where the actual in 2020 was 5.2 million the projected in 2021 is 5 million and the projected in 22 is 7 million um on a 2 million dollar increase on a 10 million dollar increase to NPR so that's that's pretty significant shift in how much we would think is going to occur in bad debt and free care so I would if things shake out anywhere close to where they are the past two years then they'll make up that difference in rate change which is 600,000 um by their projected budgeted increase of 2 million dollars over the prior year again from 5 to 7 on bad debt and free care um so I'm fully supportive of this recommendation other board members um so I'm comfortable with approving the the NPR as submitted I think that you know those projections are roughly in line with other hospitals and on par with what NPR would have been if we had annualized that three and a half percent growth rate since 2019 so I'm comfortable with it I also think to the degree that the medical center may have to push down uh care to a more appropriate setting in its other affiliated hospitals um we might be seeing some of that excess demand up at UVM coming back into uh potentially Porter so I'm comfortable with the NPR uh let me just ask I would love to talk a little bit about the change in charge because I do think that this subsidy to Helen Porter nursing home changes the way I look a little bit at their margin so operating margin currently budgeted to 5.1 if you remove the subsidy I think I believe Porter is really generating about a 3% margin and if we reduce the change in charge down to 4% I think we're in you know into the well I think we are under the 2% operating margin um you know in the one plus range so I guess one of the things that I think about there is that because UVM health network thinks holistically uh all of the subsidiary hospitals or all the affiliated hospitals their margins contribute to the the A rating that the health network needs to the degree that we are uh decreasing margins below 2% in the subsidiary hospitals it's putting more upward pressure on what UVM medical center needs to gain in terms of margin to get that A rating so I'm just wondering if the 4% change in charge might be too low given that need to subsidize Helen Porter nursing home and given the need for all of those hospitals to achieve you know roughly 2% margin to uh maintain their A rating so wondered if the budget team had done those calculations to see what you know what exactly would the operating margin look like if we cut the rate to four and they still had to subsidize at about 2.1 million dollars the Helen Porter nursing home am I about right it's in the 1.5% range Kate I think you provided a number when you were walking through that logic did you not I had a number a dollar value um this would leave them if they did not um make up for the NPR so everything as is and they just took the charge out with a 2.1 million dollar um transfer to Helen Porter would leave them with 2.46 million dollars at Porter okay so I guess hands on whether you just take your calculator and divides that by uh the top line then we can get to what that margin is yeah maybe we can ask Lori to take that figure and divide it into the total operating revenues to find a margin for Porter hospital that reflects the logic that we've discussed Jess you make you make a good point about that however in UV I believe in UVM's presentation they were looking at a weighted average on that contribution um in that medical center would supply the majority of that margin so that the weight of that margin would it be 2.7% if everything falls into order and no expenses are changed or the 3% if they can find the the savings throughout the year it would it probably Porter probably wouldn't move the needle that much on based on their logic around the weighted average of the margin that they need to maintain that A rating if I understood their presentation correctly but still we should still talk about what the margin percentage is um with the reduction in rate and the contribution to Helen Porter do you have that number lori at the 2.46 million I'm working on it um basically you're asking me to take 2.1 million from the current operating margin and also the additional drop in change in charge or not touching that yes both okay the first one we're taking the current operating margin of 5.2 will say million dropping it to 3.2 we're bringing their operating margin to 3% so they originally had 5.1% operating margin and dropping it 2 million one for the Helen Porter brings it to 3% and if we include the rate cut on top of that and the rate cut that we're expecting is worth how much is the rate cut please go back up to the uh it's about 600 000 dollars okay thank you okay so brings the operating margin down to almost 2.5 so then the operating margin that's millions and then the operating margin percent is 2.5 okay and just for me one of the things I'm you know I'm trying to think about is you know looking at um budget and actual and I think you know to me the actual Trump's Trump's budgeted numbers and so for 2021 the budget was 6.5 million for free good free care and bad debt and the actual is coming in at 5 million and now for 2022 the budget is 7 million which is in line with how they were budgeting you know in in 21 um but not understanding why um and the history has been 5 billion in in 20 um now 5 million in 22 and a 7 million budget in uh in 22 so that that's that's where um and and also when we had gone through the commercial rate changes and how they were kind of putting free care a free back in there um it seems to be inflating that number um so if that were reduced even to 6 million or 6.4 million which would be a significant increase over the 5 million expected this year and the prior year um you know that that would offset more than offset um this it's going to be what it is I get that but to me the actual history kind of trumps more the the budget and budgeting what we did last year similarly and that didn't occur so okay can I ask you a quick question can you just go to slide 131 I just want to make sure that I understand because one of the I think I just heard Kate say it was a six hundred thousand dollar impact of a one percent change in charge but I'm just looking at the that um the one percent value of one percent change in charge commercial Medicare Medicaid um how does that line up it's 1.86 I believe I think what Kate was saying was the 1.86 percent reduction oh okay two four percent would be a value of around six hundred thousand dollars yeah okay fine that makes sense sorry just trying to make sure all these things are tying out in my head thank you so I can jump in um I'm comfortable with the staff recommendation um uh on both the MPR and the change in charge I do think to just this point that some of the reduction in change in charge could be made up through pent up demand and redirection of care from UVM um and I think part of the benefits of Porter joining the network has been stronger financial footing for Porter as well as hopefully some continued cost savings from being part of a larger group so I'm comfortable with that and and I think that in in general um given that we're still in a pandemic I am comfortable being a little uh giving us you know more flexibility to hospitals as we've discussed in our previous deliberations um but I do remain concerned about affordability across the board for Vermonters other board members yeah I um I always find Helen Porter a pleasant uh almost island of reprieve to look at their budget while that it was some of the complications of the other um they uh if you look at the four-year trend 2019 to um 2022 budget their npr growth trend has been 3.49 percent and their operating margin operating expenses have been 3.2 percent so they've done well there um the only thing that kind of caught my eye was um in terms of looking at their budget to budget payer uh changes you know they were looking at 8 you know from their uh payer mix 8.9 percent increase for Medicare budget to budget a 16.1 percent increase in Medicaid budget to budget but a zero increase in commercial budget to budget which was they get to by having a 12 percent decrease 2021 budget to um 2021 projected and then a 13 percent increase offsetting from uh 2021 budget to 2022 budget so my sense is I mean these are always difficult to you know have any certainty but that they're you know if there is um you know with the commercial being at zero built into their budget zero growth but to budget that there might be some upside potential there and uh um that would be a good thing other board members robin are you prepared to make a motion sure I move to approve porter medical center's budget with an npr fpp increase of 4.9 percent from fiscal year 21 to fiscal year 22 budget a 4 percent increased overall change in charge subject to the standard budget conditions as outlined in on slide 36 and uh just with the note that um we may come back with another condition after discussion with legal as discussed earlier is there a second second it's been moved and seconded is there board discussion if not I'm going to open it up for public comment does any member of the public wish to comment at this time Mike Fisher um let me take that down um uh uh I want to thank member usifer for um I have heard you recognize the COVID um bump from last year from previous years maybe I didn't make myself clear I think what I hadn't heard was a board decision about the one-time nature of that discussion last year and a decision about whether to do that in future years but I but I um but I was remiss it because um I really do appreciate I think it's important to appreciate that member usifer has has called this out um and I have heard them and thank you so Mike just to be clear because the language was changed last year nothing was one time so legally you can't go back to last year's decisions the way you do any adjustments are in the current um charges and in future charges and so there's there's no legal way to rescind what happened last year which was not a bifurcated rate thank you Mr. Chair I'm I'm fully aware of the dynamics that led to that last year it there was still a discussion and I know this isn't I appreciate the opportunity to say that the discussion last year um of the importance of um though it could not be considered a one time that many board members um recognize the importance of of coming back to it in future years and exactly the right time to do that I think is open for debate I just uh in making the statement that I think it should be done thank you Mike other public comment hearing none the motion before us is to approve Porter Medical Center's budget with uh NPR FPP increase of 4.9 percent from 21 to 22 and a 4 percent um increase to overall change in charge and subject to the standard budget conditions is outlined on slide 36 and um with the recognition that there may be a further um motion later today or on Wednesday um is there any further board discussion hearing none all those in favor of the motion please signify by saying aye aye those opposed please signify by saying nay let the record show that it was unanimous vote Patrick back to you for Central Vermont Medical Center thank you Mr. Chair we will move on to CVMC and Laurie Perry is going to uh walk the board through the hospital profile and staff recommendation Laurie over to you thank you uh Central Vermont's budget to projection variance was a negative 3.8 percent their FY 21 budget was approved at 236 million point one and their projection was 227 million point one and their FY 22 request is 251.5 their um NPR the NPR is 6.5 more than their 21 budget and 10.7 percent more than their 21 projection they are above the uh 3.5 growth rate guidance at 6.5 percent we will be discussing their provider transfer first which um changes this slightly but we'll go to oh it changes it to 4.54 percent and we will um show that in a couple slides their changing charges are commercial at just shy of 5.9 million their Medicaid is uh reduction of shy of 200 000 Medicare is a 1.2 million and self-paying other is a negative 90 000 and they are asking for 7.41 percent for the overall changing charges uh CVMC's um performance versus the 3.5 percent trend shows the budget is 20.9 million more than the trend or 9 percent more the hospital's justifications for their budget are an increase in staffing and capital investments to improve patient access they are seeing an increase in complex care for their excuse me acute admissions and high ed and express care volumes and they are seeing borders residing in the ed they want to have an improvement in their margin and then also they have a lot of inflation pressures the same as all the other hospitals we've been hearing next slide please as i mentioned the and we've approved these is the provider transfers they took effect last year in september and they are worth a negative 2 percent to their npr and these were approved in may on may 19th uh CVMC's drivers of the npr this is their waterfall chart they had a budget growth of 15.5 four million dollars and it is made up of their rate effect of 6.8 million utilization of 6.4 million those provider transfers we mentioned are worth 4.5 million reimbursement pair mix is 2.6 million and their f y 21 rate difference reduces the npr by 5.1 million they also have small drivers such as dish increase of 43 000 and bad debt free care of an increase of 134 000 their expenses they have an increase of 14 million dollars that they're budgeting for of which inflation is worth 6.1 million the provider transfers are worth 5.6 million they have new positions and vacancies combined and those are 1.9 million purchase services are 1.3 million fringe benefits are an increase of 1.2 million provider tax equipment software are both around six a 0.6 million their wages for non-medical and medical staff are half a million the traveling nurses are 233 000 supplies contribute a decrease of 228 000 and drugs are a decrease of 1.6 million and then they are counting for all other expenses have a decrease of 2.2 million cvmc's operating performance this last year for npr they had that they were for the first three quarters have steadily increased from 54.3 million to 56.3 million to 59.4 million as shown in this chart but they are projecting a decline of a negative 3.7 percent or 57.2 million for their fourth quarter their operating margins for the first quarter was a negative 2.4 percent then they reported nearly dealt that with a negative 4.7 percent in the second quarter and then a positive operating margin for the last two quarters of 1 percent and 0.7 percent respectively their historical performance on slide 139 shows that their npr exceeded the budget in fiscal year 16 and 17 but they did not meet their budgets for fiscal years 18, 19, 20 and you also see in the projection 21 for their operating margin performance for 16 they made a two million dollar margin but they reported operating losses for 17, 18, 19 and 20 and they were projecting a loss for 21 at 3.2 million dollars but for 22 they're budgeting a 2.7 million dollar operating margin center Vermont's change in charge is the 7.41 percent and they are having the npr is changed by the change in charge of about 6.8 million dollars the value of 1 percent for commercial is just the eye of 800 thousand dollars or 791 thousand the 1 percent change in charge for Medicare is 700 thousand the change in charge for Medicaid is about 171 thousand they are going to be increasing their service categories for inpatient outpatient and professional services by the 7.41 percent their pair mix for this change in charge as we mentioned on the previous shop excuse me slide is commercial is 5.8 million Medicaid is a negative 178 thousand Medicare is a 1.2 million and then self-paying other is a negative 90 thousand the change in npr is worth 15.4 million and the change in charge as we have been mentioning is worth 6.8 million this hospital's five-year average has been the overall average for their change in charge has been at 2.3 percent approved but the commercial effective weight was 3.7 percent for five-year average the collection rate for central Vermont is was 50 percent for fiscal year 18 and 19 and 49 percent for 20 and projected for 21 but they are budgeting 47 percent this year the budget for commercial is 61 percent Medicaid is 37 percent and Medicare is 38 percent the hospital npr pair mix has shifted a bit the current commercial pairs were about 49 percent in 20 and 21 and Medicaid was about 14 percent and 13 percent for those same years but in 21 and 22 commercial pairs changed to 51 percent Medicaid went to 12 percent Medicare shifted between 36 38 37 percent and back to 36 percent for the 20 through 22 respectively um Patrick if we could go to slide 147 please we thought we would give you a perspective of central Vermont as a pps hospital and the growth that we've seen with that hospital compared to Rutland and southwestern and we see the npr growth for central Vermont for the 2019 through 22 period is great much greater than the other two hospitals and their budget was um higher for all the other years um we've seen the budget growth for them with their kager is at 6.5 percent but the other two hospitals were 1.8 and 2.7 percent for their operating revenue again we're seeing central Vermont is basically like an outlier of those three their kager between the years of 2019 and 22 is 6.3 percent where Rutland is at 1.9 and southwestern is 2.5 at the bottom graph to showing the operating expense growth again center Vermont is the outlier and their um kager for 19 through 22 is 5.2 percent for operating expenses growth where Rutland is 2 percent and southwestern is 2.9 percent we wanted to kind of like put this in perspective for pps hospitals of their size um please go back to our recommendation slide Patrick so we are recommending that um we read first we go to the change in charge that we change in charge from 7.41 percent to 5 percent which equals 1,907,238 reduction to npr or a reduced growth rate of 5.72 percent and then with the provided transfers that is 3.74 percent for the npr mainly we are having these type of reductions or recommendations for this hospital because they hadn't been meeting their budgets through the years and we think they should be concentrating on their expense reductions so they can meet their margins and their rate and utilization are their major drivers of the npr and fpp so we figure they haven't been meeting their utilization and Patrick if you have anything else to add to this particular hospital yes I do so this was a hospital that we took a long look at as it relates to the history and the request which falls under everything that we set out in guidance and so I'll page back to the slides that we're looking at to try to put it into context you know southwestern Vermont from a revenue perspective is slightly smaller than central Vermont and Rutland is slightly larger and we were trying to take a holistic look at why this budget was going over the quarter billion dollar mark from a npr perspective and we've had Rutland and CV and CVMC in here discussing it and certainly a lot of the factors that are driving those budgets are also driving this budget there's a large piece here to be considered is that this hospital has been within the UVM health network for many years and they have advantages to that affiliation that Rutland as a standalone does not and that SVMC may share some relative points with for their relationship with Dartmouth Hitchcock in New Hampshire so when we were looking at this at the npr growth figures in relation to their very close peers in the state and in the operating expense piece we were kind of blown away by that and that is where our concern comes in about the revenue level that is being put forth in this budget is this is a hospital that has had uh rates overall rates that are commensurate with those of Rutland you can see here on slide 149 that what CVMC has been approved for for overall rate increases not effective rate overall rate increases is 2.3 percent and their peer in Rutland is 2.2 percent so they are really neck and neck as it relates to that but yet expense growth is much much higher than it is at Rutland which leads us to believe that there's been issues in controlling those costs now we talked about that during the hearing with UVM and they have a focus on central Vermont as they've stated but when we go back to that topic of Rutland disappear Rutland has controlled costs over this period that we're measuring here and they've produced positive operating margins and CVMC has not and CVMC if it weren't for its affiliation with the network would have the staff very very concerned about its financial future but that said they do have the benefit of being with the network we heard from the network leadership that that is a major factor in being affiliated with it so we hope that there will be some concentrated efforts to get some of that expense growth under wraps and if they can meet their top line revenues then they can produce an operating margin but at least since I've been here we've seen positive margins come in every year of budget season and they don't materialize so like I said that's a big concern for us that the revenue projection going into 22 has an operating expense projection that's mirroring it pretty closely and if they don't hit those numbers we'll be looking at another seven figure loss going through the end of 2022 so I just want to support what Laurie is saying with this recommendation that we do have concerns about the operating expense piece we hope that that will be weighted against the need for services there very very closely I think if anyone has the capacity to really monitor the need to add expenses it will be the network with the resources and the leadership that they have but we still have concerns about that given the very recent history of operating performance at central Vermont so just to recap once we if you were to accept the change in charge reduction to five percent which is still a very high rate increase relative to the other decisions we've made this year that would pull about 1.9 million off of the 251 and then when we back out the contribution from the provider transfers their budget to budget growth falls to 3.74 percent which is where we felt that hospital could achieve the revenue growth from that perspective so with all that said Mr. Chair we'll turn it over to you for a board discussion on central Vermont thank thank you so much Patrick and I'm going to open it up to the board for discussion board members uh sure I'll go this is uh this is a tough one um they've had challenging budgets for several years so if we look at slide um slide 139 um so I guess first my underlying concern is is I agree with the staff on will they be able to hit the 251 that they have for NPR and when we look from 2018 19 and 20 the misses at NPR uh 4 million and 18 3 million and 19 and and quite a bit more um obviously in 20 but just looking at 18 and 19 and then going down operating margin they clearly when they miss the top line have not been able to make any adjustments to their expenses and so they've been running at a loss for many years so so that's obviously a concern and will they be able to show that growth um even if even with the staff recommendation I think it brings it to a 9.8 percent growth from year-end projection to 22 budget um so that to me you know is potentially a challenge whether they'll achieve that or not this this if this weren't a network hospital I agree too that uh there would be a lot more concern on on whether they would be um sustainable um that said a couple things when you go to slide 145 um I think you know relative to comparisons to Rutland and SVMC um and you know this is just one in one indicator and it's it's not an exact science but you know SVMC and Rutland are their commercial to Medicaid rates are double and I'm sorry to Medicare rates are double and SVMC is 142 so they're the lowest um ratio their Medicaid ratio is is a little bit higher so so that may may indicate that you know their Medicare is is a little bit um you know what the reflection that would be to Medicare as well but that's concerning to me there so I know you know all those efficiencies that you just looked at for a CVMC to Rutland and SVMC part of it might be related to this may maybe they're actually you know a little bit underpriced relative to the others so that's one factor um to put in there the other one is if you go to the cash flow page which is um day's cash on hand 153 um and I exclude SVMC obviously has the parent so so that's not a relative comparison but when we look at CVMC they are the lowest except for Copley which we know has a whole bunch of money that's going to come in and increase that when they clear their PPS and some of their CARES Act money uh Springfield which we talked about and then SVMC which has an issue um you know because of their parents so so those things are making me then go look at your the commercial rate um recommendation reduction um which I think may be too hot and um really just because of the financial trouble they've been in and they continue to be in they did have last year a 7% and it was 4% uh base and 3% COVID so I know that's a factor too but I would just be a little concerned with um lowering them you know I'm looking at maybe a 6% rate you know because because of their impacts they've had before on being able to manage their bottom line so not to say they should be relying on rate but you know we have been approving 6% for several of the hospitals and so I would be willing to put forward going to a 6%. The other concern I have when you look at their P&L is exactly what you guys were pushing for before which is the expense increases so in 2020 um their operating expenses were $235 million in 2021 excluding the COVID um one time money for vaccinations it's $246 million and they're projecting $266 million in expenses in uh 22 aligning with that revenue of 251 at NPR and then and then with pharmacy and things like that at 268 so you know I have a concern of them a hitting the top line and b being able to manage those expenses um at the 266 so I think that that's really just pointing forward to the hospitals I'm not saying we can reduce that but certainly this is one that there's going to have to be a really close watch on are they hitting the top line because their history has been they don't hit the top line they don't cut the expenses they lose more money um so so this one you know I just kind of put out a lot of things out there's a challenge to me but um you know it's trying to align that again kind of where their ratios sit where their cash sits which I have been focusing on a lot of the hospitals and uh you know I I think um want them to get on track and hopefully in the future they can be managing that expense to revenue but um I'm concerned that the going down to five is is going to be too much of a challenge for this hospital um who I think still needs has a ways to go before they're able to improve their financials other board members other board members is my mic working yes it is it is we're all thinking Maureen just gave us a lot to digest Kevin okay I guess I'll just start so um you know I share a lot of the concerns around the top line that Maureen outlined even with potential for excess demand potentially from UVM to shift down to CVMC I worry that their submitted budget is again aspirational you know and the you know Laurie went through it Maureen went through it but when I look at the you know 2009 NPR growing at three and a half percent you know it's hard to imagine coming anywhere close to the 251 million um and you know one of the things that the narrative talks about the volumes for all three hospitals generally returning to pre-covid fiscal 19 levels right so they're expecting this this huge increase in NPR but they're also predicting their volume for all three hospitals to return to pre-covid 19 levels and with epic implementation at CVMC I would expect there's got to be some downward adjustment below even potentially you know 19 levels just if we think about depending upon you know I don't know where to think it's so much uncertainty here pent up demand shift of care from UVM but you also have epic implementation in there which we know has an impact on productivity so there's so much unknown here but I still find it hard to imagine them hitting their budget so I support I think the reduction that the staff suggested here that feels better to me with a commensurate reduction in expenses so that they can achieve that margin particularly given their ability to hit their projections which we know they've overestimated their revenues year after year in generated operating losses so the hope would be that if we drop that NPR they drop their expenses they'll have a chance at at making a margin um what I'm thinking about now is the rate request of course is on the high side when compared to other hospitals in Vermont you know and you know they've been affiliated with the UVM network for the longest period of time so I would be hoping that we would start to see some of those gains from affiliation right the benefits of economies of scale translating into lower rate requests so I'm um I guess I'm I'm open to more conversation around the five percent or potentially as Maureen just put out there the six percent but um you know when are we going to start to see you know gains from affiliation leading to lower rate requests than other similar hospitals right we had Southwestern had a 4.8 Rutland had a 3.6 you know you're looking at other hospitals that were able to manage lower rate requests so but I recognize also some of the points that Maureen made about their base their commercial to medicare ratio so I guess I'm I'm fine with the NPR the staff's recommendation on NPR and I'm open to conversation around what that change in charge should be so I'll jump in I am comfortable with the six percent change in charge recognizing that what really I think focus it for me is a factor in looking at all the different comparisons that we've just gone through is the commercial to medicare ratio which um is significantly lower for CVMC than for example Rutland and so that is persuasive to me in terms of being comfortable with the higher rate request I also agree that the NPR is high and seems aspirational so I would be supportive of reducing that I don't I haven't myself landed on a specific number but certainly in the range of what the staff recommendation would be seems reasonable to me and I pretty much agree with you know all the other points that Justin Maureen raised so I'll I don't need to repeat them okay Tom didn't realize my camera was off um I think I I land here supporting basically where the staff is looking at the kind of way I structure these things um you know their NPR trend rate uh from 2019 to 22 budget is 6.5 percent their operating expenses are 5.2 percent um I think they're a little rich in the provider tax in that their 2020 payment was a 5.5 percent payment but they are in for 2021 projected over and uh 2020 budget at 7.03 percent and 6.45 percent so I think there might be some cushion there um and their the revenues I think maybe there's some some upside there they're looking at Medicare going from 2021 budget to 2022 budget from 89.7 million to 91.5 Medicaid from 30.7 million to 30.6 million and commercial a heavier lift from 114 to 128 but that would be with the rate increase but I also keep in mind that they are part of the network and the network has a lot of very talented people working for expensive talented people work for and uh and uh this you know Porter is probably you know not a difficult hospital for them in terms of uh worrying about it and and obviously they've got to worry about UVM Medical Center and and this one but uh because they are part of the network um um I'm not as uh generous in my uh um you're wanting to help them out financially I I think there's obviously some operational issues here and uh uh it's it's up to the network I think to kind of solve this so I I can go with the staff recommendation so I too the staff recommendation the only thing that would um really question me on whether or not it should be a higher rate is knowing that um hopefully by the end of this year we will have um some movement on a CON for the inpatient psych beds and so I get nervous that uh I would not want to do anything that would jeopardize um the financial footing for the institution that we're expecting to move forward on on this project um but as I said coming in today I was prepared to support the staff recommendations but whether it's the five or the six um it's not going to prohibit me from voting for this Robin are you at a point where you think you could make a motion or I would just ask um it sounded Maureen and Jess um what they were thinking about in terms of NPR it sounds like um I'm just not particularly clear on that piece of it for me Robin I support the staff's recommendation on NPR yeah I would regardless of what we do with the change in charge so so if we make it six which would obviously create less of a reduction related to the change in charge I would still look for uh the I still support the staff recommendation up top um and I still think that is a stretch um and you know hopefully with all the analytics that the network has they can be looking at that and and justifying that because um this hospital could have a significant loss the next year if it can't cut expenses corresponding to where the top line may be achieved and they definitely have the history of missing their budgets um and having losses every year so thank you okay that's where I thought you were both were but I just wanted to make sure I was clear so I'm going to move to approve central Vermont Medical Center's budget um with an NPR FPP increase of 5.2 percent from fiscal year 21 to 22 which will be a 3.74 percent increase after factoring in so Robin did you mean 5.72 yes thank you sorry which will be a 3.74 percent increase after factoring in fiscal year 21 physician transfers from UVMMC to CVMC with commensurate reductions in operate to operating expense growth in the aggregate in order to protect margins a 5 percent increase to overall change in charge and subject to the standard budget conditions as outlined on slide 36 with a note that uh we will consider potentially an additional condition as discussed earlier is there a second oh second okay there's been a motion in second board board discussion yeah just to be clear I'm not at five I'm at six but um that's okay yes and actually I'm not at five I'm at six I just got Kevin flustered me with when I misspoke with the 5.72 so I'm going to amend my motion to change the overall chart change in charge to six percent I think I need some lunch I'll second I'll take I'll take uh that uh suggestion Robin and uh it is one minute away from that that 1245 so at this point we're going to go into recess for two hours give the legal team a chance to do some work and give us all a chance to make sure that we're thinking clearly on a nourished body so with that this meeting will be in recess until 245 I'm reconvening the meeting and at this point in time we had left at a point where Robin had made a motion but um had asked to change the language of her motion and so I'm going to go back to Robin and start with her Robin thank you actually now that I'm my blood sugar is back up what I'd like to do is actually withdraw the motion and start over that would be good is the second girl okay with that Tom I think it was me and yes okay great okay so I am going to move that we approve central Vermont medical centers budget with an NPR FPP increase of 5.72 percent from fiscal year 21 to fiscal year 22 budget which will be a 3.74 percent increase after factoring in the fiscal year 21 physician transfers from UDMMC to CVMC with commensurate reductions to operating expense growth in the aggregate in order to protect margins a 6 percent increase to overall change in charge and subject to the standard budget conditions is outlined in slide 36 is there a second yeah I'll second that okay I'll open it up to board discussion hearing none I'm going to open it up for public comment you do see a hand raised and Rick Vinson thank you chair mullen just a few few things I'd like to point out so one just to highlight that earlier we were looking at the the net patient revenue growth for CVMC compared to the expense growth taking a look at that change year over year compared to a couple other hospitals and just to point out that that one of the things that has been increasing expenses at CVMC and it has more of an impact for them than when you look at you know a budget that's that's larger like the UVM medical center is that as the outpatient pharmacy business increases that adds pharmaceutical costs that actually doesn't generate additional net patient revenue it generates additional nonpatient revenue so just to to highlight that that that point particularly when you look back going back to 2019 there's been you know fairly significant growth in that in that expense line the second was just to put some context around what board member Yusuf pointed out in terms of the commercial rate increase as a as a percentage of Medicare if you were to just move you know CVMC 10% up that scale and they were to move a little bit further along the and get a little bit closer to Rutland and some of the other hospitals at the upper end of that that scale that's almost six million dollars for CVMC so it doesn't take much of a change there to start to really change the the outlook and the of the margin for for CVMC and then the last point that I just wanted to make is that certainly going into the first quarter of the new fiscal year I just want to probably set some expectations that we already with what we're having to do in terms of salary adjustments tools that we're putting in place to attract and retain staff and providers are already essentially outstripping the inflation assumptions that we have in our budgets where we're currently at in terms of traveler usage as you probably have seen in some of the exhibits are are well above our 2022 budget and it's going to take time for that to to come down so in the first quarter of the fiscal year at least you know expense reductions with those pressures that are already outstripping the FY 22 budgets will be you know obviously something that will be difficult for CVMC and other hospitals to to tackle while there will certainly be a focus on expense savings a lot of those expense savings could end up being consumed by those inflationary pressures and the fact that we still have a lot of travelers in our in our run rate thank you thank you rick is there other public comment so we'll shift back the motion in front of us is to approve CVMC's budget as modified hereby with an NPR FPP increase of 5.72 percent from 21 to 22 budget which will be a 3.7 increase after factoring in 21 physician transfers from UVMMC to CVMC with commensurate reduction to operating expense growth in the aggregate in order to protect margins a five six percent increase in overall change in charge and subject to the standard budget conditions as outlined on slide 36 and just commensurate with a possible further discussion after the budget is there any further discussion from the board I just wanted to say appreciate rick making his comments and points in terms of clarifying areas it doesn't change my vote but I do appreciate that and I'm I just want to say I'm sympathetic to some of the challenges in the current environment okay is there any other board discussion hearing none all those in favor of the motion please signify by saying aye any opposed please signify by saying nay let the record show that the motion passed unanimously and Tom now I'm going to go to you for an explanation can you or do you want me to go to Russ no you can come to me I lost your sound there for a minute though can you hear me I can yes okay so we had a good little chat it's I think that we all agree that something is pretty much out of balance when you know the the kind of gross amount of a carrier payments to hospitals is around one point six billion and only three tenths of one percent of that is engaged in some kind of healthcare reform program it's a meager four point seven million whereas in Medicare the the participation rate in the FPP is around let's think exactly according to our payer mix tables 33.8 percent and for Medicaid it's 42.9 percent so to have this huge player in in the healthcare market not engaged in the programs that are now getting mature for you know population based or fixed per perspective payments just doesn't make sense on the other hand given the magnitude of it it's also very complicated so I think and this was a you know this was a meeting on the run but I feel comfortable that you know there there there is some sorting that has to happen between our established rate review process and hospital budget review process and maybe others like the sustainability project to make sure that we're not you know stepping on each other's toes and that we have the bandwidth in order to do this stuff well so that's an important consideration um and that that over the coming weeks and so we should or we should be map out a a board process that is consistent with existing rules or integrates or a man's existing rules to to find ways to bring this huge resource that's out there now independent of healthcare reform to bring it in line to some degree and so and also I think there's some hope you know but it's it thinks unfold faster than people anticipate you know that we we might have some idea of where we're going or or or how far we're getting there prior to budget guidance for 2023 so it's you know it's aspirational as marina would say this is as an aspirational you know but to me it's I we just got to get the train on the tracks and start moving down our rulemaking process because 1.6 billion dollars is a lot of money it's bigger than Medicare and bigger than Medicaid and and to have a kind of sitting independent of all the efforts that everybody's making in so many levels in terms of healthcare reform just just doesn't make sense and so in order to kind of end this I think robin has me withdrawing my motion from in the morning which which didn't didn't exist at five o'clock in the morning so that that creation at five o'clock in the morning has had a life that it never expected and but at three o'clock in the afternoon I I would draw that emotion if that's the right way to do it robin it makes sense to me but it is of course up to you tom um I think you've outlined you know that there's definitely some work for us as a board to think about how to move forward across all our processes and make sure that we're supporting the effort to move towards these kinds of payments so I like the idea I hope that we can have a fuller board discussion about that at some point sooner than later but I think that makes sense to me to do it and the holistic approach makes sense and to Jess and Maureen's previous comments since it wasn't in guidance I think for me at least it you know it feels like we're not changing the game in stream but giving people notice that um we're interested in pursuing this line agreed so Tom um since you and Robin were the maker and the seconder I'll consider the uh motion having been withdrawn um that that's what we're doing okay um Ross did you have anything to add no I don't I don't think so I don't want to reiterate what uh board member uh Pelham has said just just now um I think that there will be a next step uh as a presentation to the board of some uh different process options um for the board to consider and and provide some direction on not not necessarily exclusive options but um whether the board wanted to pursue a rulemaking option and or development of some benchmarks for the FY 23 hospital budget guidance okay thank you so Russ Patrick are there any further motions that uh you envision needing or has everything been done that needs to be done in order for the the written um orders to begin I believe you answered everything for this budget process yes I agreed and and there's nothing else I'm uh anticipating um that we wouldn't do additional orders that would be needed here thank you so this would probably be the uh appropriate time for me to uh thank a number of people Kevin before I'm sorry to jump in before you do that did we get a request for reconsideration from Brattleboro and when were we going to talk about that if yes we did receive a request from for reconsideration and does any board member wish to reconsider I wasn't necessarily prepared to bring it up today but um because I did see it late on Friday so I just wasn't sure if we were gonna it seems like we would need to even if we didn't want to reconsider that we'd have to then deny the motion one way or the other but Russ should correct me like we either have to grant it or deny it I think so we'd have to look at it at some point is it a formal request for reconsideration you have not seen it Russ and no I'm sorry I have it here yeah I agree with I agree with Robin that the best course would be for the board to for the board the best course would be for the board to consider whether they want to reconsider the Brattleboro decision and if not to have a motion not to reconsider it should we pull it up I mean I do not want to reconsider it they basically want us to not not do the NPR reduction that we took and they were one of the higher NPR gross over over projection over 10 percent and they have a history of not hitting numbers in quite frankly I didn't see any urgency to this reconsideration because NPR is something that if there are solid reasons why they exceed it during this crazy year that we are in now and coming up into 22 I can't understand why we would seek enforcement if there were valid reasons for it so my opinion was not to reconsider but again I'm just one board member Patrick do you have thoughts I believe the staff would keep the decision as is board members I didn't spend I would keep as is okay I heard Maureen say as is Tom go ahead yeah me too I I you know I I did read the letter and I went back and looked at the material and I couldn't see any reason to to to reconsider Jessica Robin yeah I'm in the same camp thinking that we can leave it as is for the points that you mentioned and obviously if they are running hot I hope that they will come back and talk to us about that but I'm comfortable leaving it as is and Robin I'm comfortable with that approach so why don't I move to not reconsider Brattle borough's budget at this time or to deny the motion for reconsideration I think that would be a cleaner motion all right I move I move that we deny the motion for reconsideration is there a second second it's been moved and seconded to deny the request for reconsideration is there any board discussion I just wanted to chime in and say or maybe I I'm sorry maybe I did say this but I do think if to Jess's point in your point Kevin if there if there does seem to be a need I do hope that they would come back in the future other board comments or questions not I'll open it up for public comment and turn to Mike Del Trucco sorry I was on mute I apologize for that I just wanted to ask a process question if if I know the folks from Brattle borough were on the phone this morning and not of it and aren't available right now is there a situation where this would be noticed as a different meeting to take this up or so they could comment or be available that would be my only thought thank you so if this motion passes Mike that's that's the end of the request for reconsideration at this point in time I understood I just wanted to know where it wasn't on the calendar to be taking up today and they're not on on the call if there was any procedural things where it wasn't on the calendar specifically is let me rephrase this another way Mike are you asking that we postpone action on this motion until the next regularly scheduled board meeting chairman I'm not necessarily asking for postponement I'm asking for consideration where they're not on the call and it wasn't scheduled to be taking up if that's procedurally okay with you you and and and your process there's no there's no way I could sort of require or request a postponement so well Mike I'm inclined to grant your request if that's what you're asking I'll just chime in out of order here I think it probably does make sense to take it we have a meeting scheduled for Wednesday I think to Mike's point the agenda said hospital budget deliberations which is somewhat vague so it it's probably difficult for them to know whether or not we would so to me it's just a little bit cleaner since we already have the meeting scheduled if we push it to Wednesday and that way we can make sure Brattleboro knows that we'll discuss it then and that gives them an opportunity to make comment and Robin and Kevin thank you for hearing me and I've been trying to notify all the hospitals sort of when they're coming up to sort of help with some of that clarity and I know that it's a difficult thing and everything's on the fly but where this was a air quote reconsideration that's why I reached out and and provided comment thank you thank you Mike so unless there's objection from board member we'll put off this discussion until Wednesday morning yeah that's one one request I would have is can we do normal start one o'clock start on Wednesday I don't think we have anything else on the agenda you're pushing me now I got to look at the the the calendar where can we can we do a 10 o'clock start I just have an appointment I can schedule um one one o'clock um would work 10 o'clock uh would work it's for me I don't know about other board members either works for me works for me which works better for you marine now let's do 10 that's fine okay so the meeting will start at 10 o'clock on Wednesday for where the purpose of discussing Brattleboro Memorial's request for reconsideration so I think I will go ahead though and you know make some thank you notes to people at this time and get that out of the way so I don't drag it out on Wednesday and to start I want to thank our hospital budget team Patrick Rooney Laurie Perry Kate Hoffman a lot of work and this was one of the better presentations that I can remember in my years here at the board so thank you for everything that you've done in your analysis but I do want to prepare you because next year I'm going to expect even more and the reason why I'm going to expect even more is the person that I want to thank next um back in May of 2017 um when I was notified that um I was being appointed to this position um the person that came in with me at the same time was Maureen Yusuf and Maureen has been an incredible asset to the board and her financial analysis um has been extremely helpful and is going to be missed so um Patrick we're going to be asking you to even um do a little bit more next year um because we won't have Maureen with us but we're all going to miss you Maureen and I wanted to say that at a public meeting that it has been a pleasure to serve with you and how much we value your contributions to the state of Vermont and your public service so thank you Maureen no thank you as well it wasn't it wasn't prepared for that today but um you know my term in September 30th and um I was not prepared to be able to sign on for another six years but you know really everyone that I've encountered during this process I've been impressed by on you know all sides and um you know I guess as I'm partying out here you know if you're to remember me maybe it's was firm and fair so hopefully uh you know that that will represent and I'm sure I'm going to encounter a lot of people um not leaving Vermont and um you know hope to be able to share stories with all of you on all sides so thank you very much thank you Maureen and I also want to thank everyone at the hospitals who have put in countless hours um preparing budgets reviewing them going back to the drawing board um answering questions and everything that they've done and I know that uh no matter what that in these hospital budget hearings we never please everybody and if we did we probably weren't doing our job so um there is a couple of house keeping items that I do need to take care of first uh Abigail informed me that we have not approved the minutes of nine one or nine three would someone wish to make a motion at this time to approve those minutes so moved second it's been moved and seconded to approve the minutes of nine one and nine three without any additions deletions or corrections is there any discussion hearing none all those in favor of the motion please signify by saying aye aye any opposed so that cleans up um that item is there any old business to come before the board hearing none is there any new business to come before the board hearing none again we will meet at 10 o'clock on Wednesday morning and at this time a motion to adjourn would be appropriate a some move second all those in favor of the motion please signify by saying aye aye aye any opposed thank you everyone enjoy the rest of your day


Hey, this is Brett and this 2021 Ford F-250 Crew Cab Short Box is stock number 12787Z. We are here at Summit Automotive in Fond du Lac, Wisconsin, your new and used heavy duty truck headquarters. This 2021 Ford F-250 has the 6.2 liter V8 gas engine. This truck has been fully-safetyed and inspected by Elmer's Service Shop for the state of Wisconsin inspection process. It has a fresh oil and filter change, all the fluids have been checked and tapped off. And this truck is 100% ready to go, extremely clean all the way around, and we are going to go all the way around in this video, inside, underneath, start up, and take a look under the hood. Race red is the color, and we shoot all of our videos in 4K. So if you have HD capabilities on your computer, tablet, smartphone, or television, I highly recommend turning them on right now, because it is your best way to check out the quality, condition, options, and cleanliness of the truck before seeing it in person. And if you like the video and how we do things here at Summit Automotive, consider clicking the button in the lower right-hand part of the screen, which is a subscribe button to our YouTube channel. And then click the bell notifications and you'll get updates every time we do the videos here at Summit Automotive of our new and used inventory. This one comes with the 18-inch chromed alloy rims, and it has Goodyear Wrangler All-Terrain Adventure tires. These are LT27570R18s, and they have probably about, I'd say, 80% of the tread left on them. Frame and underbody is extremely clean on this truck. This is a one owner out of, I believe it's North Carolina on this truck. See just how nice and clean that frame is. Front fender is in excellent condition. I didn't see any dents or dings on there. Headlight lenses are crystal clear. Front bumper and lower valence are in very nice condition as well. And you do get the chrome tow hooks on there, the chrome trimmed grille. And the hood is in fantastic condition as well. Didn't see any dents or dings. Paint is very glossy. Passenger side front fender, no dents on that, and the passenger side rim, no major scuffs or scrapes. Like I said, this truck is super clean all the way around, and as you go down this side of this 2021, take note of how clean the body is. No dents, no dings, and how reflective and mirror-like the paint is. You take these HD videos, so if you are far away or even if you're close by and just cannot make the trip down, you can still see the truck here, the truck, and have confidence in the vehicle that you're looking at before you even get here. So when you do get here, there's absolutely no surprises, and you can make a smart and informed buying decision from wherever you're at. And if this video helps you make that decision, let your salesman know that you saw the video that it was helpful and that Brett sent you. Frame excellent shape as well, and the back tires have just as much tread as the front tires. Frame and underbody is an exceptionally nice condition, and it is like that all the way underneath. Very, very clean. This is like a brand new truck, almost. Looks like a brand new truck. Factory chrome step bars, get the FX4 Off-Road Suspension Package with the Rancho Shocks, chrome tipped exhaust, rear bumpers in great condition, does have the parking sensors, backup parking sensors, full towing package, which includes the receiver hitch four pin and seven pin wiring, and that tailgate is in fantastic condition. Does have a locking tailgate, has the tailgate step assist, and this one comes with a goose neck hitch. The bed is in very nice condition, very light duty usage back here, just a couple little light scuffs, but overall very, very nice. That tailgate shuts nice and solidly as well, and as you go down the driver's side just as clean as that passenger's side, no dents or dings on the box, and for full disclosure this back rim is in very nice condition as well. Down the rest of the side of the truck looks very, very good, does have the driver's side door code entry, which we do have the code for this truck, and if you ever wanted to figure out what your code is on your 17 to 22 Super Duty in the upper right hand part of screen, I got a video showing you how to find yours on your truck, so click that and check us out there. Blind spot monitoring, built in directional signals, these are the power scope mirrors, so they power telescope out, they power fold in, and I'll show you that just a second. Inside the XLT package gives you the gray cloth interior, there are no rips, there are no tears on the seats, they are in very nice condition.  Power pedals, auto headlamps, tilt, telescopic steering wheel, you get some LED side lights on the mirrors as well, power windows, power locks, and power mirrors. Show you these mirrors, they power fold in like so. I always like showing both sides so that you know that both sides are working properly, and then they power telescope out and in, and once again both sides, working nicely. We'll hop inside, check out the miles, the radio, and everything that this truck has to offer on the interior. You can see that this one has 7,369 miles, you get the nice digital display there, compass display, and obviously you got an off-road with your pitch and roll there. Steering wheel is a nice shape, cruise controls and information center controls on the left, no major wear, scuffs or scrapes on that steering wheel, and Bluetooth and audio controls on the right. This one does have the six-speed automatic transmission with the optional tap shift, and it comes with the sync 8-inch radio. This one does have the factory navigation system on it, as you can see there, that's working nicely, and you have AM, FM, and Sirius XM radio and Bluetooth capabilities on this radio. You also have a Ford Pass Connect, Apple CarPlay, Android Auto, so you can project your cell phone to the screen, that's pretty sweet, and then it does have the cargo cam, which is a nice feature. You can check out your cargo cam there. This is also where your backup camera is going to show up, and that's working nicely too. You do have the downhill assist control, stability control, you can get off that.  The passenger side format and seat are in excellent condition, no rips or tears on there, and the headliner is in fantastic condition.  Map lights right there, and you get two cup holders there, and then my magic trick is now you have four cup holders, so that's pretty sweet. Check out the back seats, and then we'll start it up and take a look under the hood. The back seats are just as clean as the front seats, no rips or tears back here. It does have the latch, child safety system for any child car seats you may have, power sliding rear window with the built-in rear defrost. Those seats are in great condition, all other formats back here. These seats fold up for extra storage.   Child safety locks on the back doors and the bottoms of the doors, of course, all are going to look very, very nice, just like the rest of the truck. We'll start it up and take a look under the hood. No check engine lights or anything like that. I would personally like to thank you for checking out the video today, and my hope is that from this HD video, you will have been able to verify the quality, the condition, the options, and just the overall cleanliness of the trucks that you can make a smart buying decision. And under the hood, we have the 6.2 liter V8 gas engine, engine base, very clean, runs very smooth, and once again, this truck has been fully safety, has a fresh oil and filter change. All the fluids have been checked and topped off by our service shop. And this truck is 100% ready to go. There is your emissions sticker. And I always forget to show the VIN sticker, and tire loading information. There's that. Then there is your VIN sticker with your gross vehicle weight rating and all that good stuff. Like I said, I would personally like to thank you for checking out the video today, and I would highly recommend this 2021 Ford F-250 Crew Cab Short Box XLT FX4 in race red from a quality and condition standpoint. I don't think you'll find a cleaner one than this one. And to see more pictures of this truck, or one of our other 450 new cars, trucks, SUVs, minivans, Wranglers, halftons, recorded tons, one tons, you name it, we've got to go to that website right there, www.summitauto.com, full pictures and descriptions of every single vehicle from two locations all at www.summitauto.com. And if you'd like to check out more HD videos, you can go to www.summitauto.com. Remember to like, subscribe, and share on this video and all the videos that you see there. Click the bell notifications, you'll get updates on the videos that we do each and every day here at Summit Automotive. In fact, in a second, you will see a link to subscribe to our YouTube channel on the upper left. A link to more F-250 videos like this one, the upper right, a link to this vehicle on our website on the lower left, and a link to one of our latest YouTube videos in the lower right. Click those, check us out. And we're super excited to help you with this ultra clean 2021 Ford F-250 Crew Cab Short Box XLT FX4 Gasser in Race Red Clear Coat. Thanks again for checking out the video and remember to like, subscribe, and share.