 All right, well with that, I think it's noon according to my computer. So I think we will kick it off with some board and then staff questions. And I'm gonna ask board member Lunge to lead us off in the questions. Great, thank you very much. Hi everyone, thanks for joining us today. I just wanted to start by saying thank you to Dr. Bromstead for all your work and wish you the best in whatever the next chapter is. So good luck. Thank you so much. You're welcome. I also wanted to just comment that it was very interesting to hear about the access efforts that you've been making and applaud your focus on those efforts. Those are sorely needed and it's great to hear about some of the progress that's being made. So thank you for including that. And similarly, your efforts in the equity space are exciting. I love the synergy with the community health needs assessment and I look forward to seeing how that progresses as we move forward. So I do have a number of questions. I'm gonna start with a couple of just really more comments although you are of course welcome to respond if you'd like about some of the higher level contextual information that you provided which I appreciated. And then just to give you a roadmap of how I'm gonna move forward, I'm gonna ask similar questions on a hospital by hospital basis. As you know, our decisions are required by law to be on a hospital specific basis. And so I feel like we need to drill down a little bit further into each hospital's situation. First of all, I appreciate the context provided by the Dartmouth Atlas and the Medicare statistics and also the low-end analysis that it's interesting and important for us to understand the context surrounding that. But also I would just comment that we also know from the literature that low cost Medicare does not necessarily mean low cost commercial. And as we're looking at commercial price increases, I think we also, in addition to the other context need to think about how that price fits in in the commercial context. So that's just a comment. I do appreciate the information. On the total cost of care, I think as folks know, the board has expressed interest in evolving the regulatory process and moving towards if feasible a total cost of care or per capita outlook. We have, when we've looked into this in the past, face what I would call potential operationalization issues. Not so much obviously with you folks but with some of the smaller or other hospitals in the state. And we of course can't have one regulatory process for the network and a different regulatory process for all the other hospitals. So I look forward to engaging on that work and I hope we can find a solution that works for the other hospitals as well. So that's it for comments. So I'll just jump right in. In terms of the cost inflation materials that you provided both on pages nine and 10 of your narrative, appendix four for each hospital and slide 17 through 20, I had a little bit of trouble reconciling them for all three hospitals between the appendix four of our materials which asks for an inflation only look meaning not an expense growth look but a pure price inflation look. And some of the materials in the binder then specifically in the narratives nine and 10. So I'm wondering if maybe the way to do that is to actually look at slide 17 through 20 and ask you if it's possible to get that look on a hospital by hospital basis. Rick, do you wanna take that? Yeah, absolutely, Robin. We can give you that data for each hospital. Thanks, I think that would be helpful because one of my questions in looking at the cost inflation was really trying to understand what are the assumptions behind the numbers? And that was difficult to tease out for me without that appendix four tying back to the numbers in the narrative. And so I'm just gonna check some of my takeaways from today to see if I took away the right information here and then you can let me know if not. So it sounds like on slide 17 in terms of the salaries payroll taxes fringing benefits as you know it on slide 18 that's not for new positions. So that's existing positions. It wasn't clear to me whether the travelers indicated on slide 20 were in that line or that's separate. No, the travelers are included in those inflationary figures. Okay, great. So that first line is salaries payroll taxes fringe for both employed staff and travelers. Got it. Thank you. I think that really answered that question. Next I wanted to turn to utilization assumptions. So when I was trying to understand I was trying to get an understanding of your net patient revenue growth from budget to budget and projected to budget and how much of that would be coming from your requested effective commercial price and how much was coming from utilization. So the way that I've been doing that for all the hospitals is by looking at appendix one. And so maybe what would be helpful is if we could go through appendix one which you broke the categories out into more detail and then crosswalk that in response to Sarah's questions but could we just walk through appendix one and have you talk through what those assumptions are in a little more detail so I can make sure that I understand it? I don't know if Sarah can maybe pull that up. I don't have that in my materials right here. I might be able to pull it up too, actually. Sarah Lindberg, are you able to pull that up? I am working on it for UVM? Sure. Okay. You can tell I'm gonna, I'm now starting to need bifocals but haven't transitioned yet. So you'll see me doing this a lot. So my apologies for covering my face with my binder. Appendix one is also very small. So would you like me to go down line by line and just highlight which one of these are changes in volume versus rates or? Yeah, I think just explaining to us what sort of what assumptions are leading into each of the lines would be helpful at least for me. So that first line there is the rate increase for the covers, the cost inflation for 23. So this is the October through September cost inflation and how much of our revenue is covering that cost inflation. The next line is the 22 cost inflation that was above and beyond our 22 budget. So that's the revenue rate increase from all sources from commercial Medicare and Medicaid that is covering cost inflation. The next line that's listed adjustment for full year impact of the commercial mid-year rate increase. So this is the revenue that flows forward from the mid-year increase because that increase will continue into FY 23. So that too is a rate increase. The bad debt and free care number that is rate related as we increase gross charges that impacts bad debt and free care, increases that number. Payor administrative write offs that's another rate related change that we're making an assumption that those are going up in terms of increased write offs generated by payer denials and those types of things. This proportionate share that's a small amount. So the next line is really the only real utilization or new volume increase. So that's the $51 million number that's there. The rest of them are all essentially rate changes. The average length of stay initiative that's towards the bottom, that's I would view that as kind of a quasi rate volume. So the assumption that's built into that 9.7 million there is us actually getting some movement and getting patients that don't need acute level care to other sites of service and us filling that bed with a new patient that actually restarts the DRG clock if you will. And so that's kind of a combination, that's kind of a hybrid between rate and volume increase. And you spoke to that in the presentation a little bit as well in terms of that being one of the budget assumptions and initiatives that you have planned. Correct. And I think actually the rest of the CMI, the EPIC, the GME and all of those were all, you also did speak to those in your presentation. So that's great. So for UVM Medical Center, could you give me a little bit more color comm or someone on the team if they could give me a little bit more color commentary on utilization? I imagine some of that, what's feeding that dollar amount and the assumptions behind it are some of the access initiatives that you're pursuing, but could you connect those dots for me? There's also, which in our packet, we also get from adaptive, the a chart that has some utilization information like average daily census, total admissions, those sorts of things. So I was trying to understand the data that we have from that chart in relationship to that 51 million and now also in relationship to the access initiatives. Absolutely, and I'll start and there may be others on the team that want to chime in. Dr. Sanders might want to add a few things to what I'm about to say. But yeah, those are all driven by either access initiatives where we're trying to reduce backlogs in areas or just new patients. So our market area is continuing to grow pretty rapidly, actually, which is part of the reason that we're struggling to keep up and that growth is even when we make some headway in a particular area, we're having a hard time keeping up with the demand just because of the ever increasing population that we're serving. But that volume is spread across multiple areas. So it results in increases in clinic visits. If you go back to our FTE chart in our presentation, we are adding physician FTEs. So part of that will generate new clinic volumes, new surgeries, new endoscopies, all aimed at providing appropriate level of access for our patients. But that's all of those different components of what factor into that increase, that $51 million increase that you have there. Dr. Sanders, I don't know if you want to add anything to that. I would just underscore that in this model, as we look at fiscal year 23, this is predominantly driven by backlogs of requests we're getting from our own primary care physicians, those in the community and patients. We outlined some earlier, we are working to reduce utilization through e-consults. We certainly hope that some of our earlier screening programs can detect illnesses earlier to reduce the need for more significant treatments and interventions. But really, as Rick said, this is still very reactive, which is our challenge of, and you've seen it with our access needs, it's trying to meet backlog reduction in all those areas. Yeah, I think, sorry, go ahead. Sorry, Robin, I was just going to turn to Steve Leffler to close out the answer if that's okay. Of course. Thank you, Alan, Robin. So really, Robin is very focused on access. So we are expecting our ORs to be at full capacity for the whole year. We haven't had that for a while, but we have the FANY fully functional right now. We've done a lot of work to get our ORs back to normal capacity. We're expecting radiology. We've added an MRI and a CT scanner, which would greatly reduce backlogs. We expect them to be at full functional through 23. Pharmacy, we expect to be busy, clinical volumes in our outpatient clinics. Also, which drives orders for CTs, MRIs, and OR cases. So all those tied together to increase, basically though, it's access. It's getting people the care they need that have both either been waiting or new patients coming into the system. Great, thank you. And that jives with what I had seen in your numbers, but I wanted to make sure that I was understanding what was happening on the ground. And it looked like in the utilization numbers also that what I would call more the inpatient stuff is flat, which is consistent with what you've been talking about in terms of being full. Obviously you can't grow from being full. So thank you. That's very helpful in understanding the data. So I'd like to do that for each hospital. Would you want to just jump into, I can either go through all my questions for UVMMC and then switch, or we can do each question for each hospital, whatever you would all prefer to do. If it's Robin, it's really up to you. If you prefer to do one hospital at a time, if that would help with your focus, or if you want to jump around either way. I think it's actually probably keeping the topic areas is a little bit easier, so I'm not repeating questions. So yeah, so I'd like to do something. I don't think we necessarily need to go through the appendix because the categories were consistent unless there's anything that stands out in particular for CVMC and Porter, but it would be helpful to kind of highlight the utilization assumption in dollars and then talk as we just did for UVMMC what the assumptions are behind it. Great, so we'll go back to Rick first and go from there. Thank you. Sarah, do you mind pulling up the CVMC chart? I should have anticipated this. Forgive my sluggishness. Sorry, Sarah. No, no, I'm just only got 27 spreadsheets open. I want to make sure I have the right one for you. Here we go. Sarah knows I love my binder, so she's probably not surprised by me. Yeah, so the categories on here are essentially identical. There's a few that are not on here that were on the Medical Center, the Medical Center chart. So the utilization impact, and this is, just want to make sure this is CVMC here. So for CVMC, the utilization assumption is actually a small decline in the patient volume. That's what that $2.6 million figure is there. So given the size of the overall budget, that means that essentially volumes are pretty, are anticipated to be pretty flat there from budget to budget. The rest of the items that are on here are all rate-related changes. Yeah, and Rick, I would just note for CVMC in the projected to budget, it is an increase. It's a 5.2 million, so Sarah, that's later on the same page, I think. So I think maybe what would make sense is to speak to, obviously 22 budgets were hard to do, right? Everybody was sort of trying to figure out where the world would be, and that was tough. So it may actually make sense to speak in this particular case to the projection to budget because it does seem like CVMC isn't exceeding its budget like we're seeing in many other budgets this year. I don't know if Anna or perhaps Kim Patton or the CFO could probably give you a little bit more detail on some of the volume numbers. I assume it's similar to the UVM Medical Center that it's increases in clinic visits or our cases because they too on the inpatient side have been flat just because things are full, but Anna, I don't know if you wanna add anything more specific than that. Yeah, happy to Rick, thanks. So we do, we are projecting slight increases. I alluded to this in my comments, we did increase capacity in two of our areas, both IPP and MedSurge by utilizing bed capacity in our women's service to increase our MedSurge capacity. We also have a slight increase in our surgical volumes. We're collaborating with the network to bring appropriate volumes here where again, where appropriate, so you're seeing an increase there when we also see a slight increase in our visit volumes. So we really did use the FY22 actuals to project FY23. And we are seeing certainly a higher than expected census than what we budgeted for FY22 consistently. So, and as I mentioned, we do also have about 25% of our capacity that's tied up with long-stay patients, despite the fact that we have woodritch in our care continuum. Thank you, thank you, Anna. I was curious about, I think that's a terrific idea that you all are working towards as a network where you're using all of your facilities to their highest capacity. And it's good to hear that CVMC has been able to get some referrals through that process. I would love to hear a little bit more about that in terms of if you have other areas that you're focusing on, particularly for CVMC in this particular conversation. Yeah, so Jason, do you wanna start off CVMC but also what we're thinking as a network? Yeah, underscore Anna's comment about surgical procedures. We're looking at all of our operating rooms, particularly in addition to UVM Medical Center, those at CVMC, I know outside the jurisdiction of Green Mountain Care Board, but at CVPH. So we're with Epic again in April, we can standardize our measures for each operating room from the beginning of the day, first case all the way through. And so very explicitly that goes into our recruitment. We've been challenged to recruit anesthesiologist. We do have a new chair of anesthesiology who's starting September 1st from Stanford. And we're excited about her arrival through recruitment. That will be something we'll need to work on next year, but ORs across the network, we've worked a lot on call across our sites which enables us to plan better for our elective and non-elective surgeries. I would say imaging in general. And then for clinics, I shared the urology example earlier. We think there's more clinics. Now we do, it's an option. So as we have that centralized scheduling, we can offer the option of patients. Some patients may want to wait a bit longer to stay in a geography, but for others to travel. An example I didn't mention earlier was neurology, actually we're offering patients coming from our region in upstate New York over to the UVM Medical Center. So it's comprehensive. But for CVMC particularly, as Anna highlighted, we really want to be able to schedule operator room cases. Also she highlighted, one of our challenges is for cases that can't be a same day procedure and discharge to be able to plan for an inpatient mission. It is really challenging, but does longer stay patients in the hospital beds. Yeah, yeah, I appreciate that. Thank you. Oh, go ahead. Is that good Robin or if Anna wanted to add anything from CVMC's perspective again? The only thing I would add to Dr. Sanders comments is that we're also doing similar things in the practice space. So using leveraging departmental network departments and bringing volumes here where appropriate. If our clinicians here providers have space to Dr. Sanders point, we're offering, they're now being offered the opportunity to come to CVMC and be seen. We're also doing that in radiology, physical therapy, et cetera. So we're trying to really look at us as a network, if you will, and wherever there's the quickest access, we're working together to get patients in to be seen. Great. Thank you. Okay, I'm good with CVMC, unless anybody else had anything to add there. Maybe we could switch to Porter and talk about the utilization assumptions. Thank you. So our utilization assumptions in our budget are really a matter of what our capacity is. We've been at steadily high volumes throughout this year relative to the inpatient capacity that we have and the types of patients we can mix in our organization at any one time. We of course have both acute and observation patients at any one time, as well as a balance of swing bed patients in our care settings. And that's a balancing act because we are always evaluating how what's the disposition status of those patients relative to when our acute volume is bump up. And that is a juggling act. We've come quite good at it. And we do have the, of course, the ability to use Helen Porter rehabilitation and nursing, our skilled nursing facility to support both post-acute and sometimes long-term care cares for patients and residents. All of our facilities have returned to levels of capacity that are challenged every day. The thing that's a little different about our utilization right now is with the increased length of stay and acuity of patients and throughput issues with our emergency department, as I mentioned in the narrative earlier this morning, our ability to move patients through our system has been challenging. Our volumes haven't been driven so much by surgical patients as medical patients. And in one organization of our scale, if we're down a surgeon or two, that's very material relative to our business. And of course, like Anna, we're mostly an outpatient business. But it really does, if we were at our full complement of surgical providers, it would be very challenging for us to manage any other capacity. And but at the same time, I would echo the comments of Dr. Sanders and Anna about our distribution of our active strategy to distribute patients throughout our care system in a manner that can be very patient-centric and get them seen when they wanna be seen. It's a great, I think, very proactive strategy we're using to manage care in our organization. Anything else? Yeah, that's great. Thank you very much. I could just highlight one specific example for a Porter. We are working to increase capacity for colorectal cancer screening with endoscopy at Porter Medical Center, which is also part of our population health initiative. That's all I mentioned on there. Great, thank you. Thank you. So the other question I wanted to talk about a little bit is the cost savings that you highlighted on slide 28 and also in your narrative on pages 34 to 35. I think, let me just double check that. I think it's 34 to 35 in the, yes, narrative. Hold on, that's not the right page, but that's the right. Let me go to slide. I'm juggling many materials as well. Slide 28. I was wondering if we could talk through those initiatives. Actually, it's pages 14 to 15 in your narrative. You've mentioned a number of initiatives that are resulting in the 50 million. And I'm wondering if we can talk through those a little bit on more of a hospital by hospital basis. We have talked about, I think already, managing the use of acute care patient beds and post-acute beds and expansion of surgical capacity across the network. And Anna spoke quite a bit to improving the talent pipeline programs, employee recruitment and retention. The other items you listed here were organized in expanding pharmacy services, moving to hybrid and remote work for, as a workforce strategy and the access issues. So could we talk a little bit more about how the cost savings is flowing through to each individual hospital? Absolutely, Robin. Rick, do you wanna go first? Yes. I'll start with just a little bit higher level before we get down to the individual hospitals and just point out that really, by far the biggest impact here in terms of those cost savings and the number that we've essentially decreased from when we were in front of you for the mid-year rate increase is workforce. It's our traveler utilization. So what Anna was mentioning in terms of talent pipeline, our investment in housing, our investment in increasing salaries, working on our culture, all of those things are all aimed at decreasing that utilization and that cost. To be honest, we're on a, just to put this in context, it's certainly in the context of the commercial rate increase, which you asked earlier, which of those inflationary factors, do travelers factor into that number in the first question you asked? Yep. We're a bit on a limb on this assumption that we've made in terms of being able to reduce that number. And so just to put that, I realize our commercial rate increases is very high, but just to put some context to that number that if we were to build our budget today with the amount of travelers we have in our budget, the number would be even higher than it is in our budget. So most of our efforts are aimed at reducing that number and probably the place that really highlights that Robin is in our presentation on slide 20. You can see there where we've made assumptions for each one of the hospitals in terms of the, the decrease in the FTEs that we've built in, both FTE and also the rate increase that, but to achieve those, we have to do all these other things that, so pipelines, trying to address housing to try to get to those numbers, but that'll give you a flavor at least on how that has trickled down into the, for that piece. The hybrid remote work, the, where that gets a one that helps, that helps with recruitment and retention as well because flowers are not just in the nursing areas, they're essentially, we're using, contract labor throughout our workforce. So hybrid work helps in that regard as well. The other place that it helps is it allows us to decrease our physical footprint. So being able to decrease the number of buildings that we lease for staff has a very direct impact in terms of cost reductions. I don't have the number right at my fingertips in terms of what that translates for each one of the organizations, but we can certainly follow up and give you that detail on the assumptions we've made in our budget in terms of decreasing our physical footprint. Just looking through these other categories. Was there another category that you were interested in kind of learning a little bit more about how it impacts the individual hospitals? No, I did see that on pages 34 and 35, you did break it down in more detail. Sorry, it's juggling the binder sometimes is difficult, but I did find it eventually where you broke it down by hospital to talk a little bit more about the cost savings impacts for each. So that, and there are some dollar values there, which is very helpful. That's certainly, it's an area that I've been asking each of the hospitals to speak to as we go through the hearings is where are they targeting cost impact, cost reduction, expense reductions and just trying to understand how that's playing into the budget because sometimes that can be hidden if it's an existing ongoing effort. So that's great. I would now say I'm down to some random questions from your narrative that I'm just gonna do chronologically through your narrative. So I apologize for skipping around. On page 31 of the narrative, CVMC in the answer to the question about other operating and non-operating revenue changes noted that there's a budget to budget increase of a million due to anticipated increase in value-based program. And I was just curious to learn a little bit more about that. Rick, do you have that? I'll start and Dr. Sanders can probably hit cleanup. So in our budget, we have assumed that as a result of our investment that we're making in our value-based infrastructure, so our population health team where we're investing in care management, additional coding assets, we believe that investment will generate additional revenue in a couple of areas. So one is that it will improve our likelihood of being able to achieve our spend targets related to our ACO programs. So generate shared savings from those programs that it will allow us to tap into quality incentives that every year we do unfortunately leave money on the table in those areas of our contractual arrangements that with the investments we've made in our population health infrastructure that we'll be able to capture. Those investments, so that's what the million dollars is tied to is our belief that between essentially shared savings and quality add-ons, if you will, that we'll be able to recoup those opportunities. Dr. Sanders, anything you want to add? I just say for CVMC in particular, all the practices at CVMC benefit from what Rick mentioned of centralized capabilities and the example would be an annual wellness visit. That's for the over 65 population for younger, just thinking about care gaps and identifying them working in the clinic or working now more remotely, working with care management to close those. And then another thing that you might hear about is particularly in our primary care clinics, we're referring to it as test and learn, utilize what we have now available in Epic to assign a risk score from one to six for each patient in a primary care clinic, a patient with a risk score of one, lower risk, maybe no chronic conditions, generally healthy, someone risk scores multiple chronic conditions and the higher risk. In addition to closing care gaps, testing, whether scheduling more frequently in the outpatient setting can reduce ER visits and inpatient emissions. Great, thank you. There's some like very exciting initiatives and really the direction that we hope we're all going as a state. In answer to, so we have a question in the guidance about support for subsidiaries which is, let's see if I can, I think it's question, it's under operating margin and total margin B. And I think perhaps you answered the question more generically, but I would just invite that if there's anything we should know in looking at your budget related to your margin and subsidiaries, I think probably that's more applicable to the CVMC importer with the nursing home situation. So I would invite you to speak to that. Yeah, so Robin, I'll take the first crack at that and then I'll turn to others if they want to comment. So that's a, because of the way we're structured, that's a very interesting question and tough for us to, maybe for next year we could work on the wording of that. Sure. You know, Helen Porter is obviously a separate entity from PMC and so that kind of is how the question comes at us. But then the medical group is also a separate entity with a separate board and we're just trying to be transparent here. There's, when I show the health network margin, that's everything. When I show health network days cash on hand, that's everything. The medical group is part of each affiliate in the P&L and so, and in the FTEs and, you know, so you, we really don't have any of that of what you're trying to ask us other than we're just really complicated. Yeah. That fair. Got it, yep. Thank you. Yeah, I think that it just makes it a little tough for apples to apples comparisons for the CVMC importer in terms of their other peers around the state. But I hear you. Totally understand. And CVMC is different than Porter. So even that gets confusing up for us, so. Sure. Okay. Just give me one moment to flip through my little sticky notes and see if I've gotten everything. So one question that I have been asking each of the critical access hospitals. And you've touched on this in your fiscal year 22 cost inflation table description. But I've been asking each of the critical access hospitals to just talk with us a little bit about how expenses in fiscal year 22, how and when those will hit the cost report and what kind of impact you're expecting to see. Rick, do you want to start that one? Yeah, I think the, to get to do that question justice, I think we'll wanna get back to you on that with the exact number that we've built into the budget related to cost inflation. Very quickly, when you look at the chart on slide 32, which is the commercial, which is the order commercial rate increase, the increases that you see there are in part what we've assumed, but for 22, we'll have to get you the exact number that will roll into that 22 cost report. Thank you. And I am almost done, I promise. So two, I just have, I think two more questions. One is related to sort of higher level utilization patterns you may see or may not see. You've had a lot going on, particularly at the medical center during COVID. So this may not hold true, but I've been asking most of the hospitals to comment on sort of patterns in respect to COVID surges. We heard in the Qualified Health Plan Rate Review process that there seems to be some sort of a correlation of a drop in ED and urgent care utilization with COVID spikes with that care not necessarily returning and with other areas that often the care would return within the calendar year, but although obviously not necessarily exactly, but just kind of roughly. I don't know if that's easy to tease out quite frankly and in your utilization patterns, given the complexity of particularly at the medical center, but I just thought I'd consistently ask you that question as well and see if you had any observations or thoughts. Yeah, so Robin, I'll turn to Dr. Leffler in a second here, but if you'll recall at our presentation last August, I presented volume charts that were red, yellow, and green. Yes, I had forgotten that. What's that? I had forgotten that, but thank you. And we have those, could we use those monthly? We could send you those up to date till now. Basically, every time we were hit with a surge, which seemed like it happened pretty frequently, we went from green to red. And so I would agree, but what I'd also say is some of our volumes are down because our admissions are down, but our census isn't down, so the numbers get weird on the inpatient side. Steve, do you wanna add some texture to that? Yeah, Robin, so when there was a lot of publicity about a big surge of COVID, less people went to the ED in urgent care. It was clear every time, but our ED through since about April has been at very normal volumes. Our inpatient census has been high. I told you that it's mainly been driven by more complicated medical patients that we can't discharge and a little less surgical patients who get something done and go home right on time. So our volume is slanted now towards more complex medical patients who take longer, take a lot of resources. That's why I told you our hospital service has been so busy. So our fundamental volume and what we're admitting has changed somewhat, which actually is a pattern across the United States and academic medical centers. Everywhere from UCLA to other big, large metropolitan academic medical centers are seeing an increase in complex medical care staying longer and less of the surgical volume that oftentimes comes in. You know, it's going home on Thursday, goes home Thursday morning. And Robin, just from the community hospital perspective, that trend is also apparent here. The only shift that I would say that I wanna offer is that we're seeing increases. Some of our highest census days in our ED have been in the last month in my five year tenure. So we've had 110, 105 patients coming through a day in our ED and that was unheard of certainly a year ago, but even six months ago. So we are seeing higher utilization, but to Steve's point, they're complex medical. And I think you're familiar with the demographics in central Vermont. We are the only population. Demographic that's increasing unfortunately is 65 and older and they have a tendency to have more complex medical needs. Is that enough Robin or would you like to hear from Porter? I'd love to hear from Porter. I don't wanna give Porter short shrift. No, that's thank you. I would just say that we have a similarly scaled response. I mean, this is the same sort of experience. The other thing, the only thing I would add is that on the express care ambulatory clinic and ER fronts were all above 2019 volumes. Great. Thank you. And then my last question was about the UVM health network PHSO and the relationship with one care. Let me find that question. So you had, thank you for answering the question that we had asked about providing more detail about the relationship between the two and anticipated timeline for transition. One of the questions I had was how you, what you're thinking about in terms of this relationship moving forward with the rest of the one care network. Jason, do you wanna take that first? Yeah, thanks, I'm happy to start and Ania may have some comments as well. So, as you mentioned, we think there's an opportunity with the unification of resources and informatics and analytics in particular, moving from a health catalyst to Arcadia to take data feeds across all the claim sources and match it with clinicals. So just you get a scale and scope benefit. At the same time, we very much think it's important that we function as one care is assigned as a network of providers, community providers, private practice providers, affiliated providers, employee providers. So the goal would be certainly over next year and going forward for everyone to see more clearly the analytics and as we mentioned, more health equity analytics and then go through our typical processes with all the participants in one care about which measures we're gonna target and what thresholds to set. I do think that we have an opportunity to increase the coordination from the experience providers in the health network, not uncommon for those in communities as well, depending on the pair of contracts is you can have 150 easily quality measures at one point. As this has started, as you're familiar, each payer with good intentions wanted to target this area or another and they're not entirely dissimilar, but it's a wide range. And I think it just gives more data for us to say, here's where with our time and capacity we're really gonna focus and I would underscore health equity. The other thing and on in my comment more is I think it gives us more insights into what's next for the all payer model. We're nearing the conclusion initial five year period. There's more learnings from that discussions about what's next. And I think this combination of resources will provide insights for what the provider community feels would be areas to really target and to set accountability for. Anya, do you wanna add? Jason covered also the substance. So I just say I'm really excited about this. I can geek out on this because I think it's a better product. Certainly a better product than what our network has had and a better product than what OneCare has had in the past and the fact that we'll have the same platform and that we and the network will be learning how best to use this and can share that with other providers in the OneCare network. To me, it's just a tremendous opportunity and will be fun to see over the next few years. Thanks, Anya. Great. Okay, that's all I have. Thank you very much for bearing with me. Thank you, Robin. Thanks, Robin. I think with that, I'll turn it over to your board member, Pelham. Well, thank you all. And again, I wanna applaud you for your energy and efforts over the last two or three years. It's just from this purchase is daunting to understand all the pressures and nuances and changes and hopefully we are slowly emerging at a faster rate from all of that. It's also daunting for me to sit here and look on the screen and see you all knowing that you live in that world and it's like they know so much, but I'll try. I'm finding it hard to read my notes here, which I thought I very carefully crafted over the last couple of days and then I start drawing the arrows around and stuff and it gets difficult to read. So I'll do the best I can. I wanna start by just saying that I fully understand the need for rate increases to address 20, 22 deficiencies and 2023 anticipated demands. But already asking already burden remoders in the current economy to right now absorb commercial rate increases of 19.9%, 14.5% and 11.4% may be too much in my mind too fast. And so I have this little birdie sitting on my shoulder as I'm kind of reading this stuff and saying, but what about this? But what about that? So my questions are kind of in that vein. One, the first one, and I think good Mr. Gobe hit on this a little bit early on, it has to do with the cost shift. And it's during the last legislative session, the Medicaid global commitment appropriation was reduced for fiscal year 2023, the current fiscal year by $18.5 million. And you can follow that reduction from the emergency board to the governor's office and through the house and Senate. And I think probably it occurred with a on a good basis to some extent because it's caseload reduction. You know, as we came out of the pandemic, caseloads and recertifications go down and they just kind of ran that through their numbers at Tiva, there might be more to it, but that's my interpretation. So I'm just wondering if the network as the global commitment appropriation and one more context thing is that if the JFO publishes a five year trend on every appropriation and for global commitment going back to 2017, the annual trend is four tenths of 1%. So clearly Medicaid I don't think is keeping pace with the real world that you folks are facing. But so my question was is that during the legislative process, did you testify at all on the global commitment appropriation for 2023? So member Pelham, I'm gonna take the broader question here and I'm gonna turn to John Bromstead to talk about our Medicaid strategy, if that's okay, and we'll start there and we'll make sure that we answer every nuance to your question before we move on. But John, do you wanna start from here? Sure, I'll start and emphasize what I'll just said. I can speak to our strategy and our work with the Scott administration and the agency of human services. But when we get down into the very specifics, Tom of your question, I'm really gonna have to pitch it to Al and Anya and others that have lived in that world. There are federal revenue streams that many academic health systems tap into that for a whole host of reasons we have not been able to because of CAPS and the 1115 waiver and headroom and other things. And as some of those CAPS have been renegotiated, we've engaged directly with the Scott administration and have found our interactions with Secretary Samuelson incredibly helpful. Those are the streams that are pretty esoteric, some would even say Byzantine to actually tap into and we certainly can have an aside with our finance staff and your staff to go through some details of that. But we're working really, really hard to get those streams tapped into and solidified to the place where literally and figuratively we can take them to the bank and the commitment that we've come back to several times during the presentation today is that as we can really nail those down with assuredness, we certainly want to use those to impact the cost shift in the reverse fashion which you've been speaking to loudly and consistently every time we've gotten together and we appreciate that. So those conversations we're having, some of those will require good conversations with legislative leaders that are in the appropriate places and we're starting to think through when we have those conversations and how and again, it's really working very, very closely with Secretary Samuelson and I just can't, you know, again, I've been around many, many blocks, many, many times and this is right up there with the most productive conversations we've had on these funding streams in my entire experience. So, and then Al and Anya, I'll pitch it to you to get more specific with Tom's questions around the trends and whatnot that have been in the budget the last year or two. Anya, do you want to start? Sure, so to answer your question, Tom, about test-define, I don't believe that we offered formal testimony during the legislative session, but we certainly talked with lots of legislators about the challenge of lack of rate increases from Medicaid and I believe we also signed on to a letter with lots of other healthcare providers making a plea for Medicaid rate increases toward the beginning of the session. There was a shift, I want to say about four to six weeks ago with the renewal of the 1115 waiver. We had been told many times over by Secretary Samuelson that there was no room for rate increases under the 1115 and that all of the headroom under the global commitment was used up. Quite impressively, she was able to at the last minute negotiate for some relief from that and so the tune changed. And I think that's why you saw that message being delivered during the legislative session and now there actually is some flexibility to increase provider rates. And so she with that new headroom has been working with us on, as Dr. Bromsted said, a variety of potential mechanisms for providing rate increases, not just to us, but to other providers as well. So that's been great. I agree, it's very difficult to follow the bouncing ball. I've looked on the Diva website for their quarterly reports relative to the budget neutrality cap and I can't find one more recent than 2021. So, flying blind in that regard. I'm not quite sure I fully understand your reconciliation approach against government payers. So just a hypothetical question. Say we do hit a get a double or a home run under the new 1115 waiver and there is more Medicaid and play. Can you maybe just at a practical level explain how those revenues would relate to your reconciliation idea? Yeah, absolutely, Tom. So pretty straightforward and transparent idea. On, if you look at Rick's slides on 30, 31 and 32, we put down Medicare rate increase, Medicare, ACO rate increase, Medicaid rate increase, and we put a dollar amount. And then it comes down and then it says required funding from the commercial rate. And under UVMMC, it's 125.8 million dollars. And so right now, Medicaid rate increase is $150,000. If that number was to, if something strong was to happen with Medicaid and we got $20 million on that line item, we would deduct it from the 125 and lower the commercial rate accordingly through the rest of the waterfall of that document. It would be dollar for dollar. So basically we're saying we need a certain amount of money. Unfortunately, we get everything we can from the government payers. The rest goes to commercial. If the government payers, which we've already said, Medicare will be higher than we forecasted, whatever we get from them will lower the commercial rate by. And we want, we pick November 15th because we think that that's enough time for the Medicare rules to be done and to negotiate with Medicaid. So it'd be a direct relief. So that means that that Delta would be deducted from the estimate for commercial. And when you file your rates in January, they will be lower than say the 19.9%, et cetera. Dollar for dollar. And we'll tell you exactly, we'll give you an exact schedule and tell you exactly how that comes off of the rate we were approved for. Al, if I could just reiterate something that you mentioned earlier, that that reconciliation is predicated on recognition that we really do need all of those funds to come into the system to cover our inflation. Irrespective of the source, we still need that top number. Yeah, and Tom, I'll also say to your earlier comment, like I said, none of us wanna be here with a double digit rate increase. And the expenses that we're seeing and the result on our finances, I mean, we're so close right now to breaking a bond covenant. And there's a big difference between a bond rating and a bond covenant. Ones like your credit score, the other is going south on your home mortgage. So, we're at a point right now where we don't have the wiggle room to not ask for what we've asked for. This is what, and not that we ever have, but this is what we truly need. And it's an imperative at this time. I really appreciate you being straight with your thoughts like that. Thank you. Yeah. So my next question might be a softball for Dr. Brumsted. But last year during the hearing, there was this issue about willing partners, Blue Cross Blue Shield saying it didn't have willing partners to do fixed perspective payments with hospitals. And Dr. Brumsted upset for us and saying I'll be first in line. And I love that quote. It was just something out of a movie. I'll be first in line. So, here we are a year later. I have here a letter or an email from Don George from Blue Cross Blue Shield where he was opposing your mid-year rate increase. But in that email, he says, we must turn determinedly toward value-based payments and global hospital budgets to think more holistically about patient health rather than incentivizing volume by paying for each service individually. And it just seems to me that my guess is, and maybe I'm wrong, that nothing has really happened in terms of fixed perspective payments and your hospitals in the last year. And that we're still probably at a less than 1% engagement but by the commercial carriers. And I'm just checking in with you to see if that's still the situation. Yeah, so, Tom, this is where I get to pick who answers the question. And if I wanna have a job at five o'clock tonight, I'm gonna turn to John Bromstead now. I'm still first in line, Tom, and I'm waiting. And it's not just Blue Cross Blue Shield of Vermont. Other commercial payers are digging their heels in. Their reason for existence is to bear risk and to modify that risk so that they continue to exist as a company. And so our push to bring accountability to the provider community through taking that risk is not being met with a whole lot of willing participation. And it's one of the reasons why we're working really, really hard to craft a partnership with a regional New York and Vermont, not-for-profit healthcare insurance partner in MVP because we are having those conversations with those folks. Just to be specific, and I think you were specific last year when you asked this question, we, through OneCare Vermont and our folks there, I was board chair as we pushed this, have really, really, really tried very, very hard to come to a methodology with Blue Cross Blue Shield, which is very, very much like the prospective payment methodology that we use with DEBA, which has worked incredibly well. They need to put some more money into the method, but the method itself on a total cost of care process that is a target that we all shoot for is one that we really tried hard with Blue Cross Blue Shield to get to. We've had actuaries involved. We even most recently agreed to use one actuary Milliman to help us craft that model. And we didn't get to a place that was close to what we have with DEBA. Rick is chair of the finance committee and he can give you the up to the minute on that. Anya is now chair of the OneCare Board. Dr. Sanders is very much in the loop on this, but maybe Al, I'll jump in and just Rick is finance chair. Can you give any further color commentary to that negotiation? We're still at the same place in terms of the spend target, if you will, for this coming year. The other important thing to highlight in those discussions is I think there's a difference of opinion of what a fixed perspective payment should be. And so for us, what we're pushing for and what the arrangement that we have with DEBA is a true fixed payment. So to start the year, you know that you're gonna get X amount per member per month and you can count on that revenue and it allows you all the flexibility in terms of creativity, in terms of how you keep that population healthy and look to decrease utilization. That is a true population health fixed payment. Fixed payment that you get at the beginning of the year and that at the end of the year gets reconciled to what you would have earned through the fee for service mechanism is not a fixed payment. And so that's another area that we just, we haven't been able to get any engagement on and we're kind of stuck in this position of trying to move our efforts forward and really not having willing partners in that space. Well, you can see, I mean, this is no question but you can see how this might be some frustration looking at the size of these rate increases and having these ideas in play, like more Medicaid money, at least to kind of grow with some kind of economic indicator and fixed perspective payments which is one of the pillars of healthcare reform in Vermont. And there's nothing happening but except these rates are gonna are going up and so that's what a little bird on my shoulder says is like, we got to get unstuck here. So my next question has to do with not just travelers specifically but I use them as an example that I think that during our hearings we're getting some minor sense not to take to the bank but getting some minor sense that the need for travelers is easing up out there. And so one thought was, obviously if the need for travelers eases up is a substantial area of the hospital's budget and obviously there's more demand for that money than the risks apply but I'm just wondering if in consideration that one of the refrains we hear from the healthcare advocate is that these higher rates are gonna cause people not to get insurance. And I'm just wondering is if you have any kind of thought about moving if things do lighten up and there is more flexibility in the budget of pushing some of this money into free care so those that are kind of priced out of the commercial market have some support to purchase their healthcare. Yeah, so Tom, I'll go first and then Rick you can correct the record for everything I get wrong here but so let's first talk about travelers and how we estimated them and where we think it's gonna go and what we're seeing now. There's not a president or a CFO listening to this call that believes we need less travelers today than we did a little while ago or a few months ago. We're still struggling with the traveler burden that we have. The chart that I brought up, chart 20 which has the traveler FTEs on it you can see that we have a very ambitious target and we are out on a limb here to quote my good friend Rick Vincent because right now we're pretty much at the 530 to 540 range maybe a little higher and October 1st we have to be at 295. Our budget is a function of the number of travelers and the rate. So we have seen the rate come down somewhat that we pay them but we have not been able to get off of the traveler need yet. Now we have a lot of good work that we're doing to try to get there for our budget start of October 1 but that's just not the case yet for us and with our volumes and the system frozen the way it is we don't have any choice but to hire folks to care for the people that we have. So that's the traveler piece. Rick, do you wanna comment on that? So it is a big risk in our budget because we do have a month and a half to go before that number becomes our number for the year. But as we started the presentation we feel like we're fully transparent with the board every year in terms of the data that we present that we're putting a lot of trust in the board to look at that data in an objective way. If this number does decrease below that 295 number or the $135,000 annual salary during the year you will clearly see that in our budget requests next year and unlike the numbers you're seeing this year where you're seeing the inflationary costs adding a significant amount to that commercial rate increase if we're before you next year and that traveler number is 150 or 200 you're gonna clearly see that you're gonna clearly see the cost inflation impact of that and that will result in essentially you'll see a negative number on our cost inflation meaning cost inflation has gone backwards which taken all together with everything else that's in the budget at that point in time will drive the revenue that we need next year. So I still think that. Yeah, so Steve do you wanna add anything from UVMMC's perspective? Yeah, first off, Rick my dream is that we only need 200 travelers for the budget for 24 that would be unbelievable. So Tom for the medical center our reduction in travelers from the 22 budget to where we are right now today is 156 travelers which is I will say a significant risk when our census is running at 440. Offsetting some of that risk is we hired more than 150 new grad nurses this year that's the most ever at the medical center we typically hire around 50. Since we've hired them as they're rolling on board we they need preceptors typically for the first six to eight to 12 weeks before they get up to speed completely and we're managing local preceptors by having travelers backfill that so we do expect our traveler numbers to start coming down some in October and November other slightly encouraging trends are in January our clinical nurse turnover rates was 17% we were losing 17% of the workforce that's down to 12% right now which still is high but is trending in the right direction so we have a plan here we're working very hard and I'm assuming you'll see us hire a lot of new grad nurses again this year and next year as another way to offset the number of travelers that we need but we are heavily budgeting that our traveler number starts to decrease significantly October November and going forward that our retention rate stays lower so we're not losing so many nurses well the thing that caught my eye this isn't a question it's just let you know what caught my eye which was the statement in the narrative on page 48 where it says the fiscal 23 budget figure is an 86 million dollar decrease from the fiscal year 22 projected that was for non-precision travelers and so I'm thinking about all the money that like Ina Bacchus's workforce report effort and the legislature there's been a lot of effort on time workforce and you know maybe none of this will pay off but maybe it will maybe it won't pay off in fiscal 23 but at some point down the line there's a lot of what I would call one time money this is kind of fresh money that's been put into the system for something that we hope is temporary and as we wean ourselves from it that fresh money is going to be available for something and you know I thought that free care might be a nice place to put some of it if it's available just because those folks you know many of them and the healthcare advocates making the point you know that people would be just are going to be squeezed out of commercial insurance and this is a way to mitigate that to some degree my this is an issue that I was not close to other members of the board were much closer to it than I was but I did notice some you know tensions as the sustainability bill went through the legislature this year and I'm just wondering you know all the benefits of S285 are yet to be revealed do you have any concerns about engaging in this process because I noticed in your narrative that you referenced that project and it's an effort that's going to unfold in the next year and just you know trying to get a sense of what you anticipate your engagement will be John do you want to start sure you know with my tenure my organizational commitment comes through my knowledge of the type of people that are being recruited as my replacement and the wonderful people that are the clinical and administrative leadership of our organization right now and it goes back to thanking chair Holmes and member lunge for engaging with us around the integration of Ticonderoga campus into Elizabeth Town there are solutions that drive a sustainable health care delivery system in a rural environment there are there can be cataclysmic happenings which disrupt and displace and are terrible awful Springfield E.J. Noble over in Governor New York those are to be avoided so as an organization it's really at the foundation of why we're developing a system of care through the UBM health network that we want a sustainable delivery system for our rural region um and it's really hard try going to the community of Malone New York and say we can no longer have obstetrical deliveries in your campus and then go to a town meeting with 250 people and explain that to them it's really really hard work to get to a sustainable system but we all have to do it and it gets back to um in a rural region with sort of the small scale that we have even if you're big relatively like us the only way to get there is through collaboration so I can commit our organization to be at the table to have these conversations and um to share our experiences and to listen to what others have I really hope that my successor won't have a meeting like we had last month in Malone New York and that she he will be able to navigate that but so we want to learn and we also want to help people learn from our experiences so we're committed to that it's it's at the core of population health and the value-based approach anybody on the team want to speak to that yeah so Anya do you want to jump in here I know you've been involved sure um yeah I mean I think just to summarize what John said this is too important to not be involved and we have some experience and some some experience to share and some scars to show from work we've already done this arena and already I've been engaged thanks to um Robin and Jessica I've they've shared initial thoughts about contracting and the scope of work for your contractor I'm gathering input from our team and fully expect to have that back within the next week or so to your team and um absolutely will be will be engaged as you move forward thanks Anya so um two more questions one is has to do with free care and bad debt and you kind of describe the methodology that you employ which is a percent of gross revenues and so I'm just the kind of and looking at the present free care and bad debt relative to gross revenue for 2021 budget the amount is a negative 1.81 percent dropping to negative 1.45 percent for 2021 projected and finally settling at a negative 1.25 percent for 2021 actual the resulting decrease in deductions from revenues was 20.6 million dollars that's what that the downward slope entails for 2022 budget the starting amount again is high not that it's relatively high but it's a it's a large large number at 1.7 negative 1.78 percent falling to a negative 1.51 percent projected and that's all we have for 2022 and the FY 2023 number in your proposed budget is again 1.75 percent so my question is when was the last time actual bad debt and free care combined hit 1.75 percent or more just oh sorry y'all no go ahead Rick you you anticipated well up then there too early so just look at I have a chart here Tom that looks like in FY 21 it only goes sorry FY 20 it only goes back to to that year we can look further back from that but in FY 21 the actual percentage was 1.71 and then you know when you get into FY 2021 in 2022 obviously there's been dramatic shifts in terms of the mix of services changes in utilization changes in gross fees as well so that you know when you change every time you change your your rate structure that changes that that number as well but it looks like in FY 20 which is the furthest back that I have who is at 1.71 actual actual yep okay I mean I know it's a small number that bounce around a little bit but it's a huge leverage in terms of of the dollar amounts that that are affected and so my final question is one I probably can answer myself but you know my experience is in the early 90s with the state budget was that it took us five or six years to dig out of the hole that was left after the 1990 1991 recession and the double-digit increases of the prior administration prior to Dick Snelling coming along and I'm just wondering you know what your thoughts would be if if someone was to take the attitude well maybe this shouldn't be a one-year strategy that you can't go from a negative operating margin in one year to a positive operating margin the next year and that that's just too optimistic an expectation so what if the thought was to get your network to a positive operating margin in 2023 but not at the 1.9% that I think I've seen as the collective projected number but to something like 0.5% or some something less and just to just to kind of let lessen the pressure you know on revenues I mean going clearly you've got to get to a positive operating margin but to do it in one year could be a stretch I don't know I'm just kind of probing your thoughts about that yeah so so Tom I'll give you a few of my thoughts and then I'll I'll turn to Rick so you know if you remember the margin chart that I showed at the beginning of the meeting this morning that's a trend and and that won't reverse itself easily we have a 24.1 million dollar risk in our model moving from Medicaid to commercial in the redeterminations we have a huge risk in the traveler area and I can go on about the other risks that we have in our budget but you know if basically you have to reverse that that margin decline and you have to we have to get to a place where we're producing cash because of our days cash on hand which was my second slide we are not state government in that you know we are regulated but we also are financed and we have a relationship with our banks and with our you know with the larger lending community that you know when when we think about our public debt that we have to perform in order to maintain you know who we are and the last point I'll make is the thing that disturbs me the most in all of our numbers which is proof I'm boring is the average age of plant number because that's whether or not we're modern and whether or not we're ready for our patients to come through the door in the long term and it's it's getting to the point it's getting up there and if we don't get a margin and don't have enough money for capital that will grow substantially and then we're then we're just struggling to be modern and so you know the time to fix our budget is now we can't wait and I will also say that every conversation I've been a part of with rates over the last few years this is the question that's asked why do you need this now can't we just wait and the answer is well we've kind of pushed this off now for a period of years through rate cuts we need our budget as presented because we don't have you know I guess the way to say it is the potatoes in the in the cellar to get through the winter anymore but Rick I you know you can add to that or to track from that whatever you want to the only thing I would add is that we are taking a multi-year approach to this you know the operating margin that we have in our budget which is what I tried to highlight on slide 25 is that the very low end of where we need to be to be financially solid to be able to start to generate the cash that we need to invest in all of the infrastructure needs replacing equipment investing in our people we're not keeping up with demand now and it's only going to get it's only going to get worse when you look at where our operating margin needs to grow it really isn't until 2026 where that operating margin is back into the three plus range where we need to start be heading so my answer is we already have taken an incremental approach to what to the budget and what you have in front of you you know certainly can't be scaled back from from where it is well thank you all for the conversation and I'll pass the ball back to Jess thank you Tom thank you Tom and so I'm going to pass the ball over to our other Tom Tom Walsh thank you chair Holmes and good afternoon you know meeting like this through through teams is difficult but I can get a sense from it I I believe you all when you're saying that you're committed to building a system that delivers high quality evidence based care that helps to slow the rate of growth Vermonters deserve it I think Vermonters also deserve evidence based regulation right and so it's it's worth thinking about I think I want to applaud the as chair as a member lunch did your efforts with justice equity diversity and inclusion it's really at the forefront of anything that I've seen anywhere similarly I want to applaud your use of the of the Atlas data I've been teaching that how to use that to non researchers since 2010 and usually I'm trying to convince people to look at it so your use of it is great at the same time it it's it feels a little weird to me like I want to talk for a moment about over generalizing with it that it's Medicare data and low cost Medicare regions or facilities are not necessarily low cost commercial or Medicaid and Dartmouth has been worried about this for a long time that it is just Medicare data and so um there's a partnership now with Yale and the healthcare pricing project that is something to really try to dig into there's no correlation between across the country between high spending or low spending medic Medicare and what gets spent commercial or Medicaid and so the what comes out of that the interpretation out of that is for policy and regulation standpoint we need specific approaches that deal with Medicare Medicaid and private private payers addressing unwarranted variation in the quantity of of Medicare care is something that regulators need to to look at and that's something that you all have worked on really well as far as I can see but the the evidence base is that policy makers and regulators for private markets have to look at price caps and that's different we've been talking about so far today that pricing project and others have repeatedly shown a low correlation between Medicaid and private payers which has really started us to shift our thinking about what we mean when we say cost shift the older model more and more disproven suggests that if Medicaid payments low private payments would need to be high but when we look across the country we don't see that relationship similarly if Medicaid payments went up we'd expect that commercial payments could go down like you were offering to do but we don't see that across the country that correlation doesn't exist there are many areas with low Medicaid reimbursement who also have low private pay reimbursement so I think we need to try to work together to further interpret these these newer findings and integrate them into our processes as regulators and as healthcare delivery systems so I was also I was interested in your the number of improvement and savings programs as I read through the narrative that you submitted I'm wondering if I'd like to know more about how you calculate the cost of care for a service line for example for a patient who was seeking a knee replacement what's the how do you determine the cost of care for doing that and you're there's an approach and value-based care but I'm wondering how you're all doing it currently Tom are you good you want to is that a question or do you want to yes yeah so yeah so Jason you can jump in here if you want but we we basically have a care delivery optimization team that works under Jason that does that kind of work do you want to describe the work Jason yeah be happy to and this has been a place for a few years I think the foundational elements are the integration of our hospitals and our physicians working together to approach more of a care pathway and certainly know if you build up the parts of the cost if you look at more central supply chain but in terms of the you know the work itself in the patient triage and the number of expected post-operative inpatient days or if it needs an inpatient stay there has been a lot of work we call it CDO and exactly unwarranted variation is the discussion and that's something that our board of trustees and board quality committee really highlights which to your point it's an internal benchmark I mean there's an external one as well but to look for that internally so that has been done a number of surgical procedures it's been done for cardiology I would refer to Epic again because it's not just clinicals it's revenue cycle and even with for Epic I didn't mention this earlier but you know as you go through an Epic implementation well it takes you a few years to do it they're upgrading the system so we have like literally an Epic upgrade again in September so this is a lot of progress that we want to keep doing and then it you know brings together physicians and with our value-based goals it's the right discussion to have we would combine with that I know your question was on on cost variation but if you look at episodes of care you know procedural 30 days 60 days 90 days we do want to add our health equity lens to it so so CDO is a specific area we probably haven't mentioned it much today but just a term that we use internally or network clinical department so if you're in general surgery at Porter or if you're general surgery at CBMC if you're general surgery at UVMC and so forth to really more formally have those clinical leaders come together and develop these pathways and there are just steps to get to the point but I think Dr. Brum says highlighted word real inflection point and we have the data feeds I might just say one thing to highlight what you mentioned earlier we're really interested in getting at those correlations and we think that our ability now to really combine our clinical data which we can see ourselves better with claims data that will be a good partner and understanding our own variation so hopefully that helps I know it's a little bit more high level but you know that's the process as I'll describe in our commitment and so Tom sorry Tom I also want to turn to Anya Yeah sorry I just wanted to mention because it came up both in your remarks Shannon Robbins I did not explain the use of the Dartmouth Atlas data as thoroughly as I should have obviously I did not mean to indicate that that was a representation of costs across the border across all payers I do however think it's a representation of the generally conservative practice style in Vermont generally and particularly in this area and any doctor you talk to will tell you they don't change their practice style based on who's paying the bill when a patient walks through the door and I think that's a legit claim we I don't think there's anyone more interested in understanding our own costs and how we benchmark against peers than the team you see on this screen and we've actually gone through an internal exercise recently of trying to call all the possible data sets and some of what I showed you came from that exercise including the NASHP data and the cost data which are more representative of all payers but as you probably know there's real challenges in doing that there aren't a whole lot of all payer data sources the ones that exist have real problems they're not fully representative and there are differences I went through an exercise recently in Rhode Island for example of trying to use their all payer claims data set to do analysis across the entire system and there's real differences between the self-insured employers who are in that data set and those who are not and so making generalizations from that data set is really difficult and I imagine that the same might be true here also in Vermont we suffer from a particular problem around Medicaid because of how we've constructed the global commitment and sort of put lots of things under the Medicaid roof that wouldn't be in other states our Medicaid costs look higher than really aren't comparable to other states in many ways so there's challenges in all that we'd be happy to share the full range of stuff that we've looked at but I think that even though the Dartmouth Atlas has its limitations and is only truly generalizable to the Medicare population it still has some real value as a benchmark I agree use it a lot so I think there's yeah I appreciate the explanation and agree and I think these are hard things and being committed to bringing high quality evidence-based care for regulation trying to figure these things out together to build a system that nobody's going broke not the patients who need care or the people who are delivering it right we want a sustainable affordable system and I sense that you all are committed to that as our I am and I'm the rest of the board Jason I appreciate you kind of walking me through some of the steps that you're taking and the use of Epic the use of software to do it there's a big commitment toward value-based care in your in the organization something that hasn't gotten a lot of attention as part of value-based care yet across the country is really learning the cost allocation methods that are inherent in that approach a time-driven activity-based cost allocation can help you identify what it does cost to deliver a knee replacement to a patient so then when you get reimbursed for that you can better sense does that reimbursement pay for that procedure without that type of detail in the service line cost allocation it's really hard to know whether you're losing money each time you do it it's it's it's hard work but it's something that I think we need to do to get there in the narrative there were a lot of programs and improvements and savings programs that were outlined and I appreciate those efforts right when I was a clinician and first got started into research and policy and regulation projects those were the type of things that I that I got started with they're important they're and you mentioned operational changes to improve efficiency reduce costs improve staff satisfaction and improve patient care there was however no data to show where that whether you found efficiency with that or whether staff did become more satisfied or whether outcomes were improved or whether there was greater efficiency so it'd be helpful to think about here's the project and here are the results in a in a narrative it just make it easier to follow all right and I'm sure that's being done somewhere just our guidance doesn't ask for it to be laid out that way and and now one year of reading submissions I think I want that in the guidance it's just a cleaner way to do it I want to talk a little bit and and ask some questions about utilization assumptions Robin touched on this Tom touched on it the health care advocate and prior meetings has touched on it from an evidence-based standpoint from the Oregon experiments through numerous other places we see over and over again that if the price the out-of-pocket expense for a patient goes up they use less care a $15 increase in the price of a medicine patients will stop taking it over 40% of patient of citizens in Vermont private commercial payers are considered under insured and with the price increases that we're talking about this budget cycle I have yet to see any organization model decreased utilization because people have been priced out and I think that that's a legitimate worry when people don't go to the doctors for routine care or they become uninsured or under insured they still get sick they still have accidents and so that leads to more unplanned and unreimbursed complex medical admissions and we have a logjam system where they can't go out which increases costs even more and I worry about these these things and that the increased prices that we're talking about across the system may exacerbate some of this logjam for that reason and finally each facility that we've talked to and you've talked about market adjustments to compensation packages and things to help with retention and recruitment I'm wondering if there are other areas of the organization where you've looked at market adjustments either up or down with providers, administrators, leadership in order to help with this budget so we'll answer that that question Tom or do you want to not sure okay so so I think you're making an overall point here about affordability and I hear you and that's my point about how we feel you know coming in with a double digit increase but there's a point at which we don't have other options if you look at all of the market data that we have for our employees from environmental services to medical technologists to to docs to nurses you know there's you know this elevators in terms of the workforce crisis is just going up you know we don't we don't see we don't see there's not a lot of down on the horizon and there hasn't been for quite a while and so I don't see savings there to be gained to offset the affordability that you're talking about I mean and and at some point a business and we are a business you know you can't you can only think of one thing when you're a couple thousand dollars away from a bond covenant and that's the bond covenant you know and so I I guess my point is I totally hear you but we don't have any alternatives right now and you know we you know affordability is certainly something that we are concerned with you know but we have to balance it with the real need to be here for our patients Steve do you want to weigh in on this about retention or you know the workforce crisis or people or anything that that Tom has mentioned that would be helpful yeah Tom I couldn't agree more that we're very focused on trying to figure out how to keep our costs as low as possible so with the medical center for the rest of 22 and for 23 we've taken a bunch of steps probably the most important one we've already mentioned is trying to get our traveler numbers down but we've also done a lot of work around every single person that we're we replace we have a meeting now every single week to decide should we replace that person or not should we bring them back should we delay it we've decreased our capital spending for small equipment 20% in the 23 budget for professional development 38% which is not a satisfactor for your staff I'll tell you but we feel it's important to do in this budget other supplies everything else 20% reduction in the 23 budget external food catering 61% reduction in our budget what I will tell you is we've been trying really hard to gradually roll out staff increases but what we're finding is as soon as we ignore an area or say it's going to come in four months they start leaving like crazy EBS food services security there are just options out there where they can make more money now and they're leaving and so we have an absolute freeze on any further wage increases until after October 1st because of the bond risk but the number of people building up into this next bucket to try and figure out how to do in 23 is going to be a big number and it's in our budget but it's not exactly in our budget either we already mentioned that you know that we have to make sure we have enough food service workers to feed everybody here over the in 22 at times we had to close down our employee cafeteria to make sure we could serve meals to all of our patients right now we don't have enough EBS workers to actually clean the executive hallways we all I vacuum my own floor now I take my own garbage out which is fine so we're going to have to pay wages to cover that and we're trying to stage as best we can but we're under this pressure to make sure that the patient rooms are clean and yeah just I hear you and and I've I've been in organizations with those types of pressures and and done similar things and and and just to be clear I wasn't asking if you had looked to to cut wages for for cafeteria workers is looking to see if you had considered other wage freezes or temporary decreases among senior leadership to see if we can get through this over a longer horizon the way that member Pelham talked about yeah Tom we have done senior leader reductions during the pandemic we have done variable pay reductions we've even done contributions to retirement deductions I mean in in the last couple of years we've taken a lot of steps if you look at the nine nineties I think you'll see even beginning in 2020 that they're very different than they were in 2019 and so I mean we you know we have you know I mean we all ate lunch today I bought lunch Tom you know so you know that's where we're at and I do think people have been in these circumstances before but I but I can't you know I I can't um like I mean yeah this is something gang this is not norm this is not like oh the recession in 91 nope went through it owned a business then like this is a uniquely extraordinary time we are in the stabilization phase of a pandemic with historic inflations England just broke 10 percent inflation I mean this is this is something and and uh we're fighting right now we're fighting this is an existential threat to our organization and and we are needed you you you are and and I I understand that and I you're fighting you mentioned earlier like if you're if you're very close to breaking your a bond covenant that's all you can think about I'm just trying to fight too for people who are really focused on what they're going to be able to eat it's hard to think about anything else when you don't know how you're going to pay for food and how you're going to pay for health care so I appreciate the fight brother and I'm just trying to do the other side and with yeah it's it's going to be a shared sacrifice I think that's the only way we've got to get through it is I appreciate the fight and thank you back to you share homes thank you Tom thank you Al I appreciate it yeah great so the last one up so thank you all for the presentation I really just want to acknowledge and appreciate your emphasis on the transparency particularly related to your methodology coming up with the commercial rate and willingness to share information as you get it about unexpected revenues from public payers so I would just ask my first request would be as you get that information if you'd be willing to share it with us when you get it that would be helpful but you know I do want to acknowledge that it's clear that a lot of time is an effort has gone into building these budgets and preparing these materials and I have absolutely no doubt that building this budget during these challenging times uncertainty and strains is a daunting task I mean I just it's want to acknowledge that so there's a couple topics I did want to touch on I don't think I have nearly as many questions as everybody else the first one actually was the wait times and this is again a thank you for the detail that you provided on the wait times you know the expanded look that we asked for on both the referral lag and the visit lag the networks analysis was one of the most comprehensive and I think frankly the most important given the networks role in delivering you know specialty care so I just want to say given the initiatives you know underway with you know the patient access center the reliance on e-consults the hiring of new providers I'm actually really optimistic I think I share your optimism that maybe these wait times will fall by next year and you know I thank you for giving us a baseline that will hopefully be the peak and we'll be you know moving forward with that but I know it was a lot to ask in March to get that data together and I appreciate it you're a model for other hospitals in the state and I'm hoping that you know we can learn from this experience what you all gathered and we can perhaps boss can work with other hospitals to get similar data you know we didn't get the same level of comprehensiveness on those access points but I also recognize you have a bigger team and in some cases you know maybe easier way to do that with your systems we've been hearing a lot from hospitals you all today but then the hospitals this week about these growing costs of throughput right these log jams in the system I think you said the system is stuck and this is again sort of a parking lot request not for this process but I'm wondering if you all would be willing to work with boss and some of the other hospitals to try and roll up these annual costs the direct costs of patient care for these patients who are boarding right who should be in different places for mental health issues or should be in post-acute settings but are not because there's no post-acute setting that's that are willing to take them at that point in time you know if we can start to add up across the system the annual costs of the direct care costs and the lost revenue that's not coming in because that's a bed that's being used that could have been used to generate some revenue and then translate that into these commercial rate asks what is that cost rolling into in terms of the burden that we're placing on on the privately insured I think those numbers would be really alarming if we added them up across the entire system if we started to quantify it I suspect it would be shocking and I think if we don't quantify the magnitude of the problem we're actually never going to start to really make inroads in that throughput issue so it's a request we've been talking about this for years I have no doubt the pandemic and the workforce pressures probably have amplified this existing problem but I think you all are probably experiencing more than most and if we can start quantifying that and adding it up might be helpful yeah and we've we've done that and so we would be happy to participate with Vaz you know I mean we'd want to standardize what we're counting and how we're counting it and make sure it's all apples to apples but we've done a lot of work on that that was part of our budget work to try to figure out what's driving you know that's sort of the average link the stay work where we said if we could get people out there's 10 million in revenue there that we can use to buy down commercial rates there's one way to look at it exactly so and I think your point about standardizing it isn't really important so that's where I feel like Vaz could take a role here I've already mentioned this at least in the public hearings with shout out to Mike Del Treco hoping that he can facilitate some of that I wanted to talk a little bit about capacity and I recognize the challenges you all have been facing I have no doubt the daily struggle of trying to you know meet the needs of your patients in both New York and in Vermont given the workforce shortages have been tremendous I think my question is specifically at first for EVM MC wondering about the impact of Dartmouth-Hitchcock's expanded inpatient capacity and how that will impact you know your capacity issues as we're adding a 65 new beds right across the border it looked like you budgeted your average daily census for 23 to be about the same as your fiscal year 22 maybe a 1% drop I think I saw there but roughly flatlined and I'm thinking about you know the degree that your demand for inpatient beds and you know these days on red and even super red has exacerbated these shortages and staffing and need for travelers is it possible that those 65 new beds will allow you to you know drop down to levels lower than fiscal year 22 given that they're supposed to be online next year those beds yeah so Steve in a second I'll come to you I just want to make a really quick comment you know Jessica last year I showed the chart that showed Chittenden County growing and growing older and I made the comment under oath we don't have enough of anything that's exactly what I said I stand by that you know we have a model that says we need 140 new inpatient beds at UVMMC you know there's modeling with our surgery needs you know mental health needs et cetera you know we don't have enough of anything right now and I'll let Steve you know put some some context to that but anyway go ahead Steve just Jessica it's a great question I would say that across our region we don't have tertiary care capacity if you look at every single day and you join one of our calls for our transfer center every single day Dartmouth can't accept anyone base states full typically Albany is quite full and there's the medical center and so every day there's people out there waiting and my belief is that any additional capacity at Dartmouth will instantly get sucked up so my belief is strongly that we'll stay about as busy as we are I'd love us to get back under 440 back down to 410 it would help many many things here but we're a long long ways from there right now and as dark those beds come on I'm wondering will they be able to staff them will they be able to have all this it's not just the nurses it's support services it's EBS it's security there's a lot of other pieces that have to come into place so I would welcome getting our census back down a little bit and not having those 15 beds open for there's a lot of good to that I think we're a ways out okay no and you actually you know you've led me right into my follow-up question which is I don't know if they're going to be able to staff that but my suspicion is they're going to staff it with health care workers on the southeastern part of our state potentially drawing them over to Dartmouth-Hitchcock and I just wondered if with respect to CVMC whether there's any concern about as they get online in their capacity whether that's going to exacerbate the workforce shortage you know particularly at CVMC which is a little bit closer in proximity to Dartmouth-Hitchcock yeah Anna do you want to take that or so Jessica I would tell you that Steve's point where he's hired the most new grads that he's ever hired we've hired the fewest new grads that we've ever hired in the last five years they're not coming to CVMC they're following the money no matter where that money is we've always been very successful in retaining the students that we educate here absent our own programs those folks stay thankfully but from our feeder schools they're they're not staying locally they're traveling they're going and they really truly are following the money so I just want to amplify the notion that staffing is absolutely critical again the only budget line we're over is in salary everything else is under in fiscal year to date so I think that is there's a potential for that possibly that that there will we'll see some leakage to those new vets but I think there's so much demand right now I mean twice this week we had healthcare notifications that that's organizations have closed and are done diversion so the the numbers that we're seeing are reflective of the aging demographic of our state and the complexity of the individuals that we're trying to treat and serve in our communities so I agree with Steve we may see a slight dip but with higher numbers than I've seen in my tenure here in our ED and our express care and our acute care settings it is definitely a challenge no question yeah I'm always just looking for silver lining and hope on the horizon so that was my was my reason for those questions we'll take a couple of those yeah we'd love them my next question is you know you present a compelling argument I think about the need for the board to rely on objective financial metrics in our budget review because it's to some degree how rating agencies are going to judge your financial health it's how your cost of capital will be determined actually I think that's a reasonable request and one that we should be considering as we start to reimagine our hospital budget process you also share multiple slides and in your narrative overall metrics for the system and performance goals related to you know margin and debt service and days cash on hand and all that I guess my my request of you is if if you would like us to consider the entire network's financial health and our decision for the three hospitals what I think is a reasonable request to think about the network it would be really helpful if we could see for each of those hospitals how you're performing I recognize we only regulate three hospitals but would you be willing to recreate or create slide 25 for each of the New York and Vermont hospitals and the network along with what you're asking for in terms of change in charge and an effective commercial rate for each of those hospitals so that we could have a complete picture of the overall financial health and bond rating risk we're willing to be transparent about about anything the reason that I started with the UVM health network the two slides was because you know we hear you know whispers that you know people are like oh well you know days cash on days cash on hand here but they have money somewhere else it's like no here's the whole thing you know right and by the way UVMMC is below that number CVMC is below that number Porter is actually above the number just as an example and Elizabeth Town is our highest days cash on hand so when John talks about it being a success it truly is a success so yeah totally happy to share and and and aligning with you here Madam Chair we were we were trying to be totally transparent so there was no doubt you know what where the money is so to speak no no no I appreciate that and I recognize the transparency I just think it'd be really helpful to see the whole you know you know how it's functioning we only regulate three not trying to regulate anything else so but and actually along those lines I think for me slides 40 and 41 we're really helpful those are the ones that outlined expense per day and costs per discharge per day for UVMMC is it possible for you to share that same data for PMC and CVMC or is that something that's not available benchmarking wise so everything that's available for the academic medical center is not available for all of our hospitals Anna whenever I have a question about this kind of stuff I typically go to Anna so and do you want to explain kind of the whole though what's going on with all this yeah so to the point that's already made most of the benchmarks are available for academic medical centers there are some data sets and benchmarking that we utilize through an organization called Visiant that does have some community hospital benchmarks but they're mostly in the arena of length of stay mortality rates those sorts of things again happy to be transparent with with that and we are comparing against like sized community hospitals favorably but those other benchmarks unfortunately are usually academic centers to academic centers okay thank you I appreciate that my next question is just help us understand a little bit the pharmacy so there's so much going on in pharmacy right and it's clear that this is where some really big swings are showing up and there's a lot of uncertainty and I recognize that I'm just wondering if you have any insights or intel it looks like there's maybe 40 million at stake here with 340b revenues and federal litigation that might claw back some of these loss revenues is there any updates since your budget submission about any of that and what some of those what some of the potential opportunities seem new in this particular budget for revenue so yeah so I'm going to try to she asked a bunch of questions let me try to see if hit on all of them so so if you look at slide 14 this is this is our attempt to show the margin from our pharmacy now when I say our pharmacy that's air quotes as if it's one thing one place and one mission but from our pharmacy it doesn't have every cost so that is not pure margin I don't want to leave it like epics not in here pixus is in here there's a bunch of shared costs that are not in here because to Tom's good point earlier doing you know cost accounting to this level on this on this part of our of our business is is really hard to do at some level but we're trying to be transparent here and say here's the the gross margin so to speak this is not revenue this is gross margin so revenues obviously much bigger than this number with contract pharmacy what we think of is 340 b where we contract with pharmacies to sell our our pharmaceuticals that's a 340 b federal program it's designed to help us do free care it's designed to help us offset the care of payers that don't cover cost you know we've seen manufacturers pull out we've been negotiating to get them back in so you know it was declining it's now growing again because of our work with manufacturers so we're estimating it to you know be at 43 million the the annualized number from 22 was I think 38 million but I might be I might be off I wouldn't want to be quoted on that but the point is it was going down we think it's coming back with specialty pharmacy that was the CON that we put in with you with the with the two robots that are marching here from somewhere across America that's my joke with our pharmacy people but the two robots that'll help us build a stronger specialty pharmacy program you know that's work that's happening out at hollycourt and then for retail you know I'm looking at Anna right now because you know you look at CVMC and you look at Porter and they don't have any retail or specialty retail is also a big part of what we do and that's really important because you know we have programs like meds to beds where we literally prescribe to people before they leave the hospital so they you know this is all about readmission rates and drug compliance and you know a whole bunch of things that helps keep people you know headed in the right direction you know so that's that's what we're talking about here we see this growing and helping to offset some of our costs but but yes there's a whole bunch of noise every year about all of this and but this is our estimate of what's happening in 23 okay great my last question was have you do you think you've recovered all that you're going to recover from the insurance carrier with the cyber attack that all that's it yes yep okay great that is it actually for me with questions again I appreciate your willingness to be transparent about any known or likely changes and in anything federal and state relief funds Medicaid Medicare reimbursements all of that so I know you'll be in contact with Sarah Lindberg and the team as you as you learn more absolutely I think with that you know we have we're going to turn it over to the health care advocate but I'm going to use my chairs prerogative unless there's no other objections and give us all a 10 minute bio break and we'll be back here in 10 minutes so let's call it 225 225 thank you before I kick it over to the health care advocate I just wanted to make sure that our team our staff Sarah Lindberg team have any questions they have the opportunity to ask them so Sarah Lindberg hey I'll try to be efficient here Sarah Lindberg GMCB finance team so in your request you mentioned that between the mid-year request and the current request that you were able to you realize a 50 million dollar reduction in kind of the perceived carry forward needs related to the current fiscal year I understand that some of that is still at risk and some of that may have been realized so at a high level kind of what what does that sugar out to for risk versus realized savings Rick do you want to take that yep so I would say Sarah the probably you know maybe half of that essentially has been realized we definitely turned we definitely changed the trajectory of where the traveler usage was compared to the the mid-year break increase discussion but where with where we're at at least half of that is at risk if if if not more at this point but roughly I would say about 50 50 I won't I won't hold you to any decimals here thank you so and then that would leave you know about 52.7 million kind of in this additional unrealized inflation for fiscal year 22 and that's obviously built into your request for fiscal year 23 and can you help me understand why how you're thinking about these costs and why they should kind of be included on an ongoing or evergreen basis for your rates let me keep going yep yep so the so the traveler expense for example as I as I shared I think when it might have been when Tom asked that question this may not be evergreen our hope actually is that it's not evergreen but that's the situation we're we're in today if next year our traveling numbers we can budget something that's less than what we have in our budget today we'll clearly identify that and we'll it'll actually be a reverse cost inflation if you will that will will be very transparent about so for the traveler piece there's a chance that you know that it you know that it not all of at least will be evergreen all the other expenses really are evergreen I mean all the salary increases that we've given to recruit and retain staff you know those are not you know those are not going away those are now part of our you know our base expenses which is why we line up our rate increases to match our cost inflation increase so you know if the system from our perspective works perfectly you get the rate increase from whatever source that is Medicare or Medicaid to match your cost inflation then that's then the following year that's kind of in the rear you know the rear view mirror and you you kind of move on from from there and when you consider making adjustments based on maybe work that's still ahead and funds to be realized I just want to make sure I understand so some of these may in fact be kind of one time expenses and if some payments are maybe one time say like a dish payment or something is that the sort of thing that would be balanced out for the 19.9 or is that limited to you know rate or reimbursement increases so yes so Sarah certainly dish payments if they were increased those have been you know they change that when we say evergreen we mean you know you know sort of reliable you know you know Medicare rates have been cut before dish payments have been cut before but if if we were given dish enhanced dish that would be that would go into the calculation and and and you know we want we want this to feel good between you know you Sarah and us so that you know what we're calling evergreen what we would identify as one time and we'll be transparent with Vermont about it what we're trying to say here is 19.9 is a big number we already know it came down a little bit because of the Medicare inpatient and anything else that we that we get we want to bring that down you know because that's because we think that's important work I mean being transparent about it is important as well understood and so I certainly picked up on a theme of you know approving this as submitted and I just want to make sure that that the reason that is being asked so if you could just help me understand why it's critical that it's approved as submitted from your perspective yeah so you know when you when you develop a budget like this there's all sorts of assumptions you know not everything will go the way we're planning we all know that I mean look at the last three years of our lives but you know our budget right now is allowing us to begin to move to a better place in terms of financial sustainability so that we can invest in our people in our communities in our facilities that this begins to move us there Rick did a great job of explaining our multi-year plan that you know that's the whole idea behind this is we need to get we need to take the first step forward on that plan and begin to get out of the hole we're in and that's why we needed approved as it is and that way this money wouldn't go toward you know if we're you know if our budget was cut you know you know by a huge amount of money and then this was you know they make this adjustment where are we at you know copy that so my last inquiry is going to be around mental health obviously no surprise that we're having a lot of stress there I was just curious about an update on your work with particularly the Vermont Department of Mental Health related the self-restricted funds and if you're having any attraction there so we have you know we talk to them we talk to them every day you know and we've had conversations with them about the issues that we're facing we have not done any major work on that dollar amount you know and how we would look at that in terms of what we're spending every day to you know to try to deal with it with the current headwinds in mental health so we have work to do there that we need to get back to you on I understood and any other kind of activity to help address some of these issues on a systemic level you mean mental health issues on a yeah yeah yeah yeah yeah um you know I'm trying to I'm trying to think on the fly here I mean we do we have so many different things going on you know I will uh I'll open it up to any of my colleagues that want to give an update on anything Al maybe Jason can talk about the primary care mental health integration project that'd be great yeah thanks Dr. Bromstad Sarah that's something we would like to highlight we have seen that that is effective so collating co-locating behavioral health professionals with primary care that's both at the same time in the visit and also at different times to maximize our capacity which is another benefit e-consults otherwise our emergency departments as you're familiar with we have significant numbers you've heard earlier at UVMC and then CBMC in particular patients with behavioral needs in our emergency rooms so increasing our psychiatrist and mental health professionals who are seeing patients in those settings we know the model works I mean I you know short answer we know that integration model works is a resource issue transparently and that's a lot of our limitation we've had actually unfortunately one of our highest turnovers among our physicians is actually in our psychiatry group it's well over 20% this year and turnover so but we're fully committed to it we do hope that some of the investments that you heard about for identifying patients earlier and as you know the partnership with designated agencies is critical thank you thank you one other comment and this is early work and I'm not sure it'll actually come to fruition in 23 but it would be a dream we've been having some meetings with key players in Burlington about possibly being able to divert some of the patients out of the ED so go to another location get services there be able to have their care needs met without waiting in the ED for care there these programs are really well run in other states we're trying to learn from that and so there has been three or four meetings they haven't actually come to but we have a possible spot in mind and some ideas about how to run it it just needs a little jump start but we are focused on that because getting some of those people that will help them will help our ED will help the other people that we're trying to get seen through the emergency department that's very exciting those are all the questions I had just thanks for all your partnership in these tough times and look forward to continuing to kind of evolve this process to be as streamlined and focused as possible thank you Sarah great thank you Sarah I am going to turn it over now to the health care advocate I'm not sure I saw Sam on there I also saw Mike Fisher so I'm not sure who's leading these questions I think we're going to have Sam yeah Sam's back go ahead Sam great thanks Chair Holmes and thanks UVM and members of the board members of the public that are listening just want to start off so I'm Sam Paich health policy analyst with the Office of the health care advocate or the HCA I wanted to start off by recognizing UVM's commitments that you've made around DEI and the number of hires you've made and financial commitments in that area particularly want to commend Dr. Hunter and our team for your work so far and really look forward to hearing what's planned for the future years and I particularly want to acknowledge the focus on language access and community engagement in that area so I appreciate it so our first question follows up a bit on the focus area that both member Lunge and member Walsh touched on written regard to UVM's low cost for Medicare presentation and I want to focus a bit more specifically on hospital pricing recently Rand published findings from their employer led transparency initiative which looked at hospital prices from more than 4,000 hospitals in every state and it found that UVM Medical Center was one of the more expensive the second and third highest SIL for outpatient and impatient so I just wanted to see if you could respond to that in the context of the presentation you made around costs so on you do you want me to start or do you want to go first you can start if you want well you might have to correct me so I might go to the doctor first why don't you okay that's fine yet Sam actually we were intrigued by that ourselves and did a little digging into it Steve Capello I mentioned earlier and and who has been doing some work for us actually got in touch with the lead researcher at Rand to understand a little bit more behind their methodology and they admitted and I can actually share an email that we got from them on this subject they admitted that it's hard to make direct comparisons between institutions because of how they count Medicare costs and it has to do with some institutions getting a lot more of sort of outside of the regular rate flow or revenue flow Medicare dollars for things like graduate medical education and so there's there's sort of a fundamental fault in their methodology and as I said I'd be happy to share more details but I think it's it's not nearly as straightforward as it seemed at first thank you yeah that'd be great to share and happy to chat more about that second question is I'm wondering if you could quantify how many if any primary care and or independent practice clinics in the state have been purchased or incorporated by UVM health network in the past year Jason do you want to take a crack at that or or Rick I yeah we have any none no we've been none yeah it's nice yeah okay yeah I agree okay thank you actually it's it's been it's been none for quite some time okay thank you just want to clarify that this is a bit of a detailed question but I think it's important and it's specific to CVMC on page three of the budget submission I'm hoping you can elaborate a bit on what accounts for what looks like a 69.7 percent increase in consulting costs from FY 22 to FY 23 yeah less yeah unless Anna or Kim have and they answer that Sam we'll have to get back to you with that with that increase is Anna do you have any sense on what with that yeah to wait to my knowledge we haven't engaged any consultants in the last year or planning on engaging consultants but I'm happy to look into that Sam and and we'll get back to you okay thanks I'll turn over to Mike thank you Sam oh thank you everyone good to see everyone Mike Fisher healthcare advocate and hey let's do this in person next year I agree please I've been sort of mulling over for the last little bit whether to start with the tough question or end with the tough tough comment or end with the tough comment and I think I'll start with it so I I'm not this is a comment that doesn't require response we've all been a part of conversations over the years about executive compensation and I fully understand that the overall costs of executive compensate compensation at a hospital looks small in comparison to patient care dollars and I also fully know and understand the discussion about the need to compete with a national talent pool per hospital hospital executives yet I still feel the need to raise the issue it's a concern about how many Vermonters understand this as understand this issue as a statement of values your most recent available 990 lists the top 10 highest employees of UVM health network make a total of 8.3 million dollars that's for the year 2020 by the way this breaks down to an average salary of 836,000 it's over 10 times higher than an average Vermonters so I feel like as a health care advocate it would be a miss if I didn't recognize this and again I don't need a response thank you Mike so um patient care financial assistance policies we've we've been asking hospitals about coming into compliance with the new law that was passed last year we recognize that it will well it's not required of you for a couple of years and I think rather than asking a question about it I think I'm going to just turn it into a statement we will be happy to partner with the three hospitals represent here in the task of coming into compliance and look forward to engaging that work we've done some of it already with both UVM and CVMC around plain language and look forward to working on that we we may be accused of being a little impatient looking for movement towards that before it's required of you thank you Mike and we uh we support what you're doing and you know we'll work together on that so today represents the one opportunity I have to compare hospitals you know I can't ask Rutland to comment on Springfield or something like that but I can hear today look at three hospitals in how they're doing around free care and bad debt and and and I I want to do it because I'm trying to understand it trying to learn what it is that leads to one hospital having giving more free care as compared to bad debt than another hospital and and I'll just say and I've said this in the earlier hearings I believe the ratio of free care to bad debt is provides for a measure of the functioning of the system not only the quality of the free care policy but also the delivery of that policy how well a hospital make sure people know about it and helps them with it so you have a range in the three hospitals before us today from UVM that that for every dollar of free care has $1.9 of bad debt CVMC it's one to 2.6 and for Porter it's one to 3.8 and so I I would love to hear some discussion about what you think is going on that leads to that difference Rick do you want to yeah I mean I think we can definitely get you a little bit I actually haven't asked been asked that question in that kind of that that exact context it's got an interesting way to kind of look at that kind of the ratio between between the two my yes but we'll want to to validate this with actual data is that we definitely have different air mixes across the three hospitals we have in terms of commercial Medicare Medicaid and and uninsured that may be what's driving that because yet we have to remember the bad debt is is a combination of true if somebody doesn't have insurance and it's been written off and it's also somebody does have insurance and they don't they don't fully pay their co-pays or they're deductible so bad debt is a combination of those two things so it could be that the pair mix you know that there's there's a little bit more high deductible plan potentially patients that go to the UVM Medical Center compared to the other two organization that's driving that you know that second component of bad debt a little bit higher there but again that's that's just kind of guesses at this point but we definitely it's an interesting question and it's interesting way to kind of look at those two and can certainly provide follow up for you in the in the board yeah I I've been mulling over this question as to whether pair mix what what impact pair mix would have on this I mean we we are after all here comparing the set of people who haven't paid their bills at one hospital with the set of people who haven't paid their bills at another hospital so for instance a higher rate of Medicaid would actually bring down these numbers right so I think the right thing to say is I I would welcome that conversation again we're trying to understand it yeah you know there there is quite a range across the Vermont hospital now system you know from from one from one to one at the best and Mike I'd want to look at where the patient originated from you know does where they go like if they go to UVMMC but they're from far away does that impact any you know there's probably factors here we you know this it's a good conversation to have so when follow up on the same topic page 58 of your budget narrative about free care financial assistance policies you mentioned that there will be an expanded exclusion list for non-medically necessary services I'd love to hear if you have any description of what you're contemplating moving into that excluded category and and in follow-up if there's a list of of what's already excluded and what you're contemplating moving that would be great yeah we can definitely I don't have the list with me so we'll definitely follow up on that as well Mike okay so about one care it's been noteworthy to me this week that how little the discussion there's been about one care and about the all-pair model and and so and on top of that I think you know I'll just recognize that in health care policy wonk circles there's always a lot of whispering it's always hard to know exactly what that whispering means but that's sort of the backdrop of our question today about about the all-pair model is is sort of what is the future of it from your perspective from what you can say out loud we see in budget in page 40 of oh and I also want to recognize that I think Rob and ask a question like this question about this earlier and and I have to admit that I don't think I have a clear understanding after your answer and that might just be because I'm just not smart enough but on page 40 of your budget narrative you you talk about making a sizable investment in the creation of this population health services organization can you tell us more about that quantify the size of it and and what the what the what's the relationship of this effort with one care so Mike there's a few questions there let's start with the question about the future of the all-pair model and you know what's going on with one care on you I'm gonna turn to you if if you want to take that and I can kind of add to the future of the all-pair model after you're done sure happy to so we remain committed to one care we remain committed to the all-pair model but we're all sort of in limbo right now waiting to find out what will the next version be and unfortunately as I think you're aware you know the feds have not been very quick to respond to our requests for changes in the model which is a big disappointment for us for all the reasons that rick talked about you know it is not truly a fixed prospective payment model and in some ways is is more of an annoyance than an advance in terms of value-based payment because while we go through the exercise of of getting this advanced payment we then have to reconcile back to fee for service and there's burden associated with that and time lag uh which makes it really hard to predict what the outcome is going to be from a financial perspective and also I think dilutes the financial incentive that should be inherent in an alternative payment model so there's lots of ways in which well there's there's a couple of big ways in which we'd like to improve the model but at this point we're waiting on the feds having capacity to enter into those discussions with the state in the meantime we've made clear to members of the board and the secretary of AHS that we feel an obligation due diligence on other potential models including Medicare advantage and expanding our footprint there because we are committed to value-based contracting and alternative payments we're looking at what are the other things what are the off-the-shelf models that CMMI has for example that we could pursue if the all-pair model ends up not being improved upon in any major way so we're sort of in a holding pattern exploring other options but still hoping that that will materialize and still working actively through one care with other providers I think Dr. Bromstead can probably say more than me about sort of the advances that we've seen through one care in terms of that network of providers really coming together to be a group that's able to work through value-based contracting together because of the special arrangement that we have under the all-pair model and do and make meaningful advances but on the other side as was discussed earlier we've only been able to advance so much with with certain payers most notably Medicare and commercial payers thanks Anya and I'm going to go to Jason in a second and possibly Rick but with the population health initiative Mike you know we've been really aligned by program if you want to think about it that way like we had one care that was focused on the all-pair model we had care management and care coordination through the blueprint and then we were trying to do analytics and in two different places for two different for for the same need so we've tried to you know reshuffle one care so it's just what it needs to be and then have the things that one care was doing and that we were doing come back to the population health area so that we can keep those all together so it's not done by program but it's what we do every day and so Jason do you want to comment on any of that yeah thanks Alex actually we get economies of scale with pulling together areas that were individually working on informatics analytics and then now if you look just simplistically at the population health services organization I think you're familiar with how it works with our payer contracting but really connecting population health services with our care delivery teams you know to the point about the narrative we just wanted to highlight our commitment even in a challenging budget environment to investing in the now with tangible goals next year we talked about some of them and the future care management is in the population health services organization we're really trying to target care manager some of the work we've talked about you know earlier in the process in the hospital getting more care managers in the emergency department to see if there's a way to safely discharge sooner or at least set up the plan if they go inpatient as much as possible you know we've made capital investments in what sits on top of Epic because really if you look at it two views I think you're probably most familiar with the care manager or someone who's in our analytics team you know going through our performance on human alone when a one C measure or blood pressure control measure and then now with health equity commitment to seeing it by social determinant of health we really need that to be translated our point of care and that's a lot of the primary care test and learn work so those are a few functional examples and I'll turn it over to Rick for any other comments he made thank you for the question yeah that work of pulling together the the PSHO is a combination of centralizing all of those efforts so centralizing between one care and health network but also within the UVM health network with care management and analytics spread throughout pulling that all together after the after that the incremental investment that we've made to try to capture some of those value-based incentive dollars that we spoke about earlier to try to increase our opportunity to generate shared shared savings through our one care arrangements the incremental investment that we're making is in the the $3 million range okay thanks so I have a a clinical health equity question and and you should all brace yourselves when a social worker starts to ask a clinical question I'm sure there's any number of people on here who know more about this than I do but interested about the the the practice of race correction metrics on medical devices an example of that I think is spirometers you know in our research there's a long history of well there's a long history of racism in health care and and here's one where you know many many years ago there was a determination somebody believed that that Africans that African-Americans or Black people had smaller lungs and that we should correct for that when we're measuring how much how much lung capacity they have it's a current issue because of COVID and so the question really is is there is there a race correction used today in UVM health network hospitals with the use of spirometers and I'm not asking this question because I want to call anybody out as not doing the work I'm asking the question because I want to ask how are we challenging ourselves on issues like this and or how do we best challenge ourselves on issues like this Thanks Mike Jason do you want to weigh in on that? Yes, sure Mike we'd be happy to follow up on how we adjust the serometry values as you know they're used in patients with asthma to measure peak flow and a targeted asthma action plan a lot of it historically is by age and weight but we'll follow up on exactly what we're doing I would highlight something else that we've talked about I know Dr Hunter and I mentioned this but I think the study that really stood out to me recently was the oxygen sensors during COVID that there was disproportionate measurements and discrepant based on skin color that affected COVID outcomes but in your spirometry question if it's all right we'd like to follow up exactly how we adjusted in our pulmonary function testing and it's both there's formal pulmonary function testing as you know and also just in primary care settings we're just a handheld and see how our teams are using it but that's all right and Dr. Hunter any comments you have? Yeah I think that's a great comment and similar to what Dr. Sanders referenced as we continue to navigate through health equity there's going to be a lot of different things that we have to unravel because as you reference racism has been a part of the healthcare system and delivery system for quite some time so we definitely are committed as we think about health equity to really start to tackle some of those areas and what partnership with my team and the presence as well that is something that we are very committed to doing Yeah thank you and again thank you for your work this is just a little bit of a different angle because it's a clinical question and it sounds like there's quite a few like it so thank you thank you for engaging One thing I'll add is that the medical center for our safe reports we've added DEI question to every single safe report that comes in right now so was DEI was the race an issue in this event and we're tracking those now and capturing those and we have actually made some changes to some of our reference ranges because the exact issue raised I know that renal function has been corrected I wasn't aware of the spirometer when I saw a lot of people in the ED in my lifetime so it's a good question we'll have to track that down Great you know similar closely related our people screen for sickle cell traits when patients come through your EDD and again you know I'm just adding it to the list these are the kinds of things that as we research it that makes sense to have have current for us maybe not okay so and then I think lastly I'll wait into the public payer potential for increases in public payer reimbursment topic and and I want to recognize that's been talked about quite a bit today and I appreciate the discussion Al about a dollar for dollar recognition of increase in public payer reimbursement on the commercial rates but I also want to recognize the you know your need to make the statement about the you know that you're willing to make this commitment if your entire budget is is funded and I don't know what the green mountain care board is going to decide for you I don't know whether you'll get trimmed by a couple of percent but I want to I just want I guess I just want to call out if we're going to do this it's not going to be easy the state share of money doesn't come from you know out of thin air we're going to have to raise it and and and I just make it as a as a statement I'm not I'm not expecting that your budget ask will go down by whatever we can increase through increased federal participation in Medicaid I fully understand that areas of your budget will continue to grow faster but nonetheless I think if we are able to assure that there's a dollar for dollar transfer from increased monies through Medicaid I'll say in this example to commercial it will make the conversation the public policy conversation significantly easier in my opinion yeah thank you Mike and we are making that commitment so okay thank you thank you for a really fun day good to see you Mr. Fisher good to see you Mr. Gobey Mr. Fisher I do have to question your definition of fun but I will I will move on from there the actually the next part of our agenda is actually to open it up for public comment and so is there anybody from the public that wishes to comment on this budget if you do have a comment please just use the the team's raise your hand function and I will see you and acknowledge you yes Mike Del Treco can you see me and can you hear me I can perfect so Chair Holmes I've taken notes of areas where you want Vaz to engage and we're more than willing to to do that work with the hospital so first comment and my comments not specific to the health network's budget but but just just a general comment on the week that we just went through so I'll just start by saying my name is Mike Del Treco I represent the Vermont Association of hospitals and health systems and all our members so thanks Chair Holmes board members Green Mountain Care Board staff and members of the public I know this process is complicated and taxing and thanks for your commitment to this important work I think it's important to pause and acknowledge what we've heard midway through this hearing process this week we've heard from critical access hospitals PPS hospitals and today the academic medical center each leadership team has outlined the deep challenges they are managing you've heard a great amount of detail about workforce challenges wage pressures shortages and travelers multiple years of steep health care inflation supply chain issues a trend of declining margins capacity issues related to sicker patients and patient flow hurdles because of broken mental health and long-term care delivery systems I said this before but I want to be very clear there's nothing normal about what our hospitals are managing today what what is particularly inspiring though is what we've heard from these hospitals about how they're managing through these difficult times for every challenge whether it's in their control or not our Vermont hospitals have created plans develop collaborations and have put policies or strategies into place to be able to continue to care for their patient support their staff and strengthen their communities our hospitals are creative they lean in when there's a crisis and they're not sitting idly by waiting for others to act they are leading and they are committed to progress but their teams are tired and stressed and in some cases really burned out and they need your help right now our delivery system is challenged and in very precarious situation we are at a major inflection point you heard about it today you heard about it all week and there are great consequences of not approving these budgets no matter what type of hospital critical access PPS or academic medical center in Vermont they are all community hospitals that bring care and hope to patients and their families as well as vitality to their communities we need strong critical access and PPS hospitals in every corner of Vermont and of equal importance we need a strong academic medical center to teach future doctors healthcare leaders care and treat the most complicated patients and to be a resource for all hospitals and every Vermonner any suggestion otherwise would be dangerous so again my ask is simple and with complete respect please approve these budgets as submitted I want to thank you for your dedication to this process and I look forward to hearing from the remaining hospitals next week and I will continue to take notes on where you want of us to engage and happy to do so and thank you for allowing me to speak today yeah thank you I appreciate it and you're willing us to follow up on some of those initiatives I think they're really important is there any other public comment again you can use the raise your hand function if you're on the phone just let me know and you can start speaking okay I'm not hearing anybody I'm not seeing anybody else so thank you to everybody I think there's really we do have sorry hi Robert Hoffman just briefly wanted to make a couple points in 2019 I wrote to this board and alerted you all that the failure of the all payer model to unlock greater value based care would ultimately come collide with bondholders at hospitals and here we are an existential request is being made against the best backdrop of a possible markdown to bonds and at that same time in 2019 I alerted you all to the widely understood economic law of Stein's law that what must end will end as Alan Rick Vincent shared the systemic issues facing these hospitals began long before COVID and current inflationary pressures patient access has been in decline since the APM commenced in 2017 it's data that for whatever reason your board doesn't share often or publicly but it's data that's well collated for those who are interested in looking at it in 2019 or 2018 nurses at the medical center decried both culture and wages executive to FTE wage ratio amongst pure academic medical centers in the region has been packed back of the pack for years lumber copper auto all inflation indicators as we speak many of them are in decline have corrected by more than 50% inflation is transitory UVM HN culture and management failures are not transitory and yet this C-suite is staffed and paid like they are batting a thousand what value did Ms. Wallach's $500,000 salary bring to today's discussions that Mr. Broomstead could not have handled what value did Algo Bay's $500,000 salary bring to the discussion today that Dr. Broomstead could not have fielded why does a $2 million a year CEO need $5 million worth of a C-suite to run a mere $1.3 billion organization I've worked at organizations four times that size with much smaller C-suites we are here because of long-standing mismanagement not transitory secular trends member Walsh highlighted this network's exercise and confirmation bias to pick and choose evidence to support its presentation other data points not shared are that they're 15% higher FTE than average 47% more beds than average 36% fewer discharges per employee than average personnel expenses 42% higher as percentage of operating revenue than average whether you fulfill this request or not Stein's law will prevail Walsh is right this rate increase will break the price elasticity demand in Vermont for consumers the whack-a-mole game that this network engages in may achieve their aim today to knock the head down in one area and the head will pop up somewhere else concurrently groups like Dartmouth-Hitchcock Blue Cross Blue Shield Vermont Clover Health and even the startup that I performed advisory work for revive healthcare where we deliver comprehensive primary care pharma and labs for $25 per member per month if our startup can do that at 25 what will Amazon's recent acquisition do in the same space whatever happens today is transitory irrespective of what decision you make UVMHN is an overly aspirational aged rural academic medical center trying to exceed the region's need whether UVMHN next year or in five years whether by market forces or Act 167 will return in time to its humble $500 million rural academic medical center in a state of 600,000 people who are struggling to make ends meet thank you okay thank you for your comments Mr. Hoffman is there anybody else who has a public comment they would like to make all right well this has been a long day I would say it's been an important day a productive day we've heard a lot of important information some exciting initiatives potentially but also a lot of work to do and I just want to thank everybody for coming for being here with us today and sharing your insights it was actually really lovely to meet some of your new team members at the health network and you know Dr. Brumsted again my best wishes to you as you move on to the best you know the next chapter of your life I hope you have a wonderful retirement I'm a bit envious um with that I would say the UVM health network you are off the proverbial hook for today there is some follow-up that Sarah will connect with you on I think there were some questions in there and hopefully the team has pulled some of those together for some questions that we needed a little follow-up on board members I would say not so much off the proverbial hook we'll be back online Monday morning at 8 30 we're going to be hearing from Rutland and Mount Ascotney so with that is there a motion to adjourn I move to adjourn okay I hear Tom motioning and I hear Robin seconding I'll take it that way all those in favor hi hi and you posed I would hope not we are adjourned thank you very much to everybody at the UVM health network for coming in today and spending the day with us online maybe next year in person hopefully next year in person thank you team Green Mountain Care Board