 I'll call the order of the Green Mountain Care Board's hearing of Wednesday, December 20th 2023. We have a few agenda items today. We have the Brattleboro retreat fiscal year 24 budget. Which will be presented by the folks for Brattleboro retreat together with Jeff Batista and Russ McCracken. And we have a potential vote noticed. Around to have the Medicare, I'm sorry. Around to 30, we'll have the Medicare benchmark proposal and a potential vote. And then around 3 o'clock, we'll start a presentation on the 1 care Vermont fiscal year 24 budget. I'll turn to Susan Barrett for the executive director's report. Thank you, Mr. Chair. Just to brief 1 today, 1st, happy holidays to everyone on the board. With that in mind, we will not have a board meeting next week. So we look forward to seeing you in 2024 and our schedule for January will be posted shortly. Just a couple of ongoing public comment periods, as folks may have known, we finished up our community engagement work per fall. We're continuing to take public comments and those comments are posted on our website. That work will continue with some visits by our consultant in person in the spring. So, information can be found on that work on our website. In addition, we have an ongoing public comment regarding a next potential. All payer model with the federal government. We take any of the comments we receive and share them with the agency of human services as they are leading the current model as well as the negotiations for any potential next model. Thank you. We have minutes from December, 13th, 2023. Is there a motion to approve the minutes? 2nd, all those in favor, say aye. And the minutes from December, 13th are approved. I'll turn it over to Mr. Batista. Should I turn it to you or directly to the Brattle borough folks? Yeah, um, Brattle Borough will be presenting first. So let's turn it over to them. Great, thanks. Miss Rossi, thank you for being here that you're the chief executive. If you would mind introducing everybody and then we'll we'll hear your presentation. And thank you for coming today. Miss Rossi here. I've received an email saying they're setting up the passcode now. Great, okay. It occurs to me that since this is a, you know, a hospital budget hearing. That might should also swear the witnesses and I guess for the Brattle borough folks, when you're all here, just let us know and Mr. McCracken can can swear you in. And then you can turn to your presentation and share faster. This is there is a court reporter with us today. Her name is for your knowledge. Thank you, Susan. Well, we wait. Do you have any holiday songs you want to share? Oh, oh God, no, you would not want to hear anything. But thank you for asking. Go for it. Oh, and I bet you have one for us. I do have a guitar sitting next to me. I'll spare you all. Sure. How do I have another message? It said that the retreat is having a hard time signing on. There seems to be a problem with the computer blocking them from signing in. So, do you should should we have Christian and I maybe reach out to them to help them? And what would you like to do? Why don't we take a 12 minute break and just come back at 1 20? So they have sufficient time and Kristen and Susan, I think there'd been a problem historically once with like, whether you're logging through an Apple or something, I believe was maybe that's the issue. We'll see. Maybe they have some kind of a firewall at their institution. So, let's, um, Christian, I will work on it. All right, we'll adjourn to 1 20 if we need more time. Just send me a message. Thank you. Thank you. We can resume and I'll turn to Mr. McCracken to swear in the folks from better Brattleboro retreat. Thank you for the Brattleboro retreat team. If you're going to be testifying or answering questions today, if you could raise your right hands and I'll swear you in. Do you solemnly swear that the evidence you shall give relative to the cause? No under consideration shall be the whole truth in nothing but the truth. So, help you God. Thanks very much. And we will turn it over to you. Good afternoon. I'm Linda Rossi here in the middle. I want to apologize for those the technical difficulties at the beginning of the presentation. Thank you for your patience. Um, I am the CEO of the Brattleboro retreat and I have a number of the executive team here with me today to participate in this budget review before I begin. I would like to thank the Green Mountain care board for including us in this process. Although we deal with a variety of state entities. This is our first time with the Green Mountain care board. I want to acknowledge the support and guidance that we've received from the staff. It's been very helpful. We've learned a lot over the past couple of months in particular and have made some adjustments on our end to be a better organization. So thank you to the Green Mountain care board. With me today to my right is Jill Meschke. Jill is the chief financial officer. On the other side is Elizabeth Wall. She is a member of the executive team and in-house council. On my left, which may be your right. I'm not sure how this looks. I have Dr. Kyle Jeffries, our chief medical officer, and on the other side is Amelia Schillingford, our chief nursing officer. I'm going to begin our presentation and I'll introduce Tom Uvner. Tom is joining us by Zoom. I think many of you know Tom. Due to Tom's recent surgery, he has asked that I read his opening statement. So I'm on Tom's behalf. This is Tom speaking. I joined the retreat board in 2018 because as a retired CEO, I know how vital the retreat is to the functioning of the health care system in Vermont. The retreat provides all of the acute child and adolescent psychiatric beds in the state and about 50% of the adult beds. The retreat was hit particularly hard by the COVID pandemic. The rules for isolating patients in a psychiatric setting are particularly challenging. Staffing, which has always been difficult in mental health, has become extraordinarily difficult. By March of 2022, the retreat census had dropped to 45 beds. This led to many problems throughout the entire health system in Vermont. Notably, it significantly contributed to the backup of psychiatric patients in the emergency room statewide. It was at that time that we worked with the agency of human services to create a way forward and to turn things around. The retreat changed leadership. It committed to getting the census back to 100. The retreat created and improved a statewide transportation option for mental health patients. In turn, AHS provided the funding needed to help us accomplish these tasks. Very clearly, the retreat could not have accomplished its goals without AHS support. And most importantly, we could not have done it without the hard work of the entire staff of the retreat. The retreat is once again meeting the acute psychiatric needs of Vermont patients and looks forward to doing so in the years ahead. Okay, so I am going to talk about where we've gone over the past couple of years and give an update on our current operations. So we began a turnaround and a baseline for this purpose is 2022. In January 2022, the Brattle Bar Retreat was an organization in crisis. We had just concluded 2021 with a loss of $20 million, which was significant for the retreat. In partnership with AHS, Secretary Samuelson, Rich Donahue, we developed six sustainability strategies. The first was to create increase in patient capacity. We needed to move from 45 open beds to 100 open beds. We needed to do that to be able to respond to the needs of the acute care hospitals and people of Vermont, as well as to become financially viable. We needed to grow outpatient services. We needed new revenue streams. We needed and we need an EMR replacement, electronic medical record replacement. The current medical record system that we have electronic medical record doesn't work. And it has created issues for us for a long time, but we didn't have the funds to be able to replace it. We began a new APM alternative payer model arrangement with the state that I'll talk about a little bit with regards to our Medicaid reimbursement. We looked to increase. We actually had a director from AHS to enhance our payer mix. Our commercial contracts needed attention. Some of them had been dormant for quite a long time, and we took a fresh look at those contracts. And we needed to improve revenue cycle management. The first thing we did there was to hire an expert consultant who we subsequently hired as a vice president of revenue management. The APM contract was restructured and that contract governs Medicaid reimbursement. That contract has a daily per diem that is capped. So, and I was looking at some of our staffing this morning where we're running, you know, each staff member might have two patients. Sometimes they have one patient. And that reflects the acuity of our current patient population. So regardless of our staffing needs on a daily basis, we have a flat amount of money that does not change. So we moved away from fee for service to this model. It also includes risk corridors on two points. We have a risk corridor on the number of level one, which are involuntary patients. We have a no refusal rate that we need to abide by. And we also have utilization risk corridors and that affects the amount of reimbursement we get. It's rather complicated, so I won't get into details, but those were two new parameters that were incorporated into the contract and are there to this, to this date and I think we're going into round four. The 2024 contract with the state for Medicaid is in the approval process. So we should have that done by the end of the year. We had a directive from AHS to grow capacity and we had timelines, deadlines that were set. We were asked to grow our capacity from 45 beds to 80 beds in a six month period of time and we did that. Then we were asked to grow our 80 bed census to 100 within another six months and we actually hit 100 within three months of that. That was the good news. The not so good news was that in order to do that, we had to hire contract labor to double our capacity in that kind of timeframe by the infusion of funds, which we received for some portion of time from AHS. But it allowed us to increase our capacity quickly. We've been holding steady at 120 to 130 travelers since that time. Right now, a traveler contract population comprises 50% of our direct patient care staff. The pandemic changed the labor market. It was already a strained labor market in terms of health care talent. But after the pandemic, we saw major changes in terms of the talent pool. Psych is generally about 10% of the health care workers and we continue to see the impact of that. Telehealth changed a lot for us. It changed in terms of provider talent. It changed in terms of social worker talent that was available. We also experienced wage pressures around the Massachusetts border. That makes it very challenging for us to be able to compete in the mass market. And we do draw some of our staff from Massachusetts as well as New Hampshire and New Hampshire not having state tax presents its own challenges in terms of attracting individuals to work in Vermont. We also have a housing shortage in Brattleboro as many communities have. It was particularly challenging when you have 130 travelers that need a place to stay. So what the retreat did is we refitted at least an empty nursing home for three years. We had to get that approved by the Housing Authority. And that has provided housing for our contract labor population and we're hoping for an employee population as well. Given the wait times in the EDs, we did our best at the retreat to provide relief both to the patients that were waiting and to the acute care hospitals to move those patients as quickly as we could into the right setting. We improved our admissions process. We reduced our cycle times. We created a unique transportation solution and we worked hard to improve responsiveness and customer service. Transportation was a solution that we worked with one care to open access and we contracted with Rescue Inc. and Ambulance Service on March 1st of 2022 to transport patients from any acute care hospital in the state of Vermont needing mental health care to the retreat. The retreat is funding that contract, 100% of that contract. We're hoping to renew the contract in 2023 and we're hoping to do so in partnership with UVM who will provide some funding to expand transportation later into the evening and on the weekends. Again, this is available to all hospitals in the state. I think it's worth highlighting the fact that in early 22, we had some leadership changes. The CEO and the CMO. And your representative will be with you shortly. The CEO and the CMO both left the retreat in early 2022. At that time, we did not have a chief financial officer. I was performing that role. We also did not have a chief information officer. I was trying to manage IT. In late 2022, our CNO and our director of quality left the retreat. So we had to rebuild the executive team. So I came on board in roughly April May of 2022. Dr. Jeffries was there a month before myself. Jill, our CFO, joined the organization just this past May. Amelia has been in the position for a year. Our CIO joined in the summer of this year. VP of revenue cycle management joined about three quarters of a year ago and we hired a new controller and a director of quality. So it's taken some time for this leadership team to become a team. And I think now we have all our key positions filled and the team is working in a very unified fashion and doing well. We also had a turnaround in labor relations. Anyone that has been following the retreat for some time knows that we were not in a good place with our union. We spent a considerable amount of time and energy in 2021 to rebuild that relationship. We opened communications. We've been very transparent with the union. We have frequent communications. We meet every month in labor management meetings. As of today, we have no grievances and no arbitrations and I can tell you that's a dramatic change from 2020 and 2019. We also renegotiated a three-year contract in June of 2022, which was several months early and it was done very quickly. We have very constructive and productive relations with our union. I'm happy and proud to say. The last item I just want to mention is the electronic medical record. This is an AHS, Agency of Health Human Services, Sustainability Deliverable. It was in our sustainability plan provided to them in January 2022. We have been working for the past year looking at various solutions and vendors and we are currently evaluating the need to file for a CON with the Green Mountain Care Board so we can hopefully move forward with that soon. So that is my overview of our operational status. I'm going to turn it over to Jill Meschke, our CFO, to talk about the financial turnaround. Good afternoon. I'm Jill Meschke, Chief Financial Officer at the Red Arrow Retreat and I will be providing a financial update. 2023 has been a turnaround year for the retreat financially. However, the recovery remains fragile. As of today, the retreat is experiencing 105 days cash on hand, but we project that to slightly decline throughout 2024. Banking relationships are positive. In 2023, the retreat was released from forbearance. We are in compliance with our covenants and both the liquidity ratio and the debt service cover ratio are well above the required targets. Like many other hospitals, labor costs are the primary financial challenge for the retreat. Year to date 2023 labor costs have exceeded plan by 12%. Contract labor is planned to continue to drive expenses into 2024. Nursing leadership actively manages staffing daily to ensure the right staff are on the units at the right time and staff and management at the retreat do a very good job controlling other operating expenses. Administrative costs represent under 20% of the costs of the retreat. Despite growing hospital occupancy, the number of administrative staff has only increased slightly. This increase in capacity and flat administrative expenses has helped the retreat control overall costs of care. The retreat is an old institution with aging infrastructure. We make strategic capital investments focused on clinical units and spaces to improve buildings and care. More investment is planned and infrastructure for 2024. The retreat is investing in personnel resources to bolster the financial acumen of the organization. There has been a turnover in some of the key financial rules, including that of the controller and the chief financial officer. Efforts continue to build a strong finance team. Within the last year I was hired into the CFO role and Eric Bergen was hired as controller. Our additions in partnership with the experience of the other team members have stabilized the finance function. Additionally, Valerie Ostrander's hiring into the VP of revenue cycle has brought added leadership and knowledge to a hardworking revenue cycle and HIM team. She is leading key projects to improve revenue performance. Finally, thanks to the insights by the health care advocates office, we have decided to make some immediate changes to our financial assistance policy. Effective January 1, we are expanding both eligibility for financial assistance and discounts being offered based on the federal poverty guidelines. And our policy updates will bring us into compliance with Act 119. Thank you. Thank you. I'll turn this over to Dr. Carl Jeffries, our chief medical officer. Thank you. I'm Dr. Carl Jeffries. I'm the chief medical officer at Brattle Bar Retreat and I'll be providing some information on clinical care that's provided at Brattle Bar Retreat, which spans a broad range of levels of care. We provide outpatient level of care. We have partial hospital level of care. We have residential treatment options and then we have inpatient hospitalization care. I'm going to start with the inpatient hospital. Volume data through the year so far 2023 is that we've been able to maintain an average daily census in the low 90s thus far. As Linda pointed out, we started the year with a capacity of 84. We were able to grow that capacity throughout the year. And one of the challenges with growing that capacity is that we also wanted to work very hard to maintain the capacity percentage that we had our census that was filling those beds. That was very difficult along the way because in order to do that we had to make many facilities adjustments as well as staffing arrangements to accommodate that so we've moved units around and along the way we've had to make adjustments to in order to maintain that capacity. Right now we are at a capacity of 99 but and by the end of the year we will be at a capacity of 101 beds. The breakdown of those beds. Following an adjustment last week that we were able to make in order to expand the number of adolescent inpatient beds is that we have a total of 68 beds out of those 101 that are adult beds. Currently, 26 of those beds are designated level one beds for high acuity patients on one of our two high acuity units and the remaining 42 beds are general adults. 33 of those 101 beds are now designated child and adolescent beds. The care will be provided on three different units. Two of those units will be adolescent units and one of them will be designated as a child unit providing care for patients 12 and under. The adolescent units will be primarily 13 and above though that 12 to 13 year age there's there's some mix over sometimes. In support of maintaining this high occupancy rate that we that we were ever striving for we needed to make some improvements in our admissions process. Obstacles to admissions prior to the work that we were doing were both in the efficiency and communication of our internal communication admissions process as well as communications with outside referral agencies. And so we made improvements in both of those. We looked at early communications with the outs outside referral agencies. And so right now we have a process in place where we are contacting those referral sources as early and as quickly as often in order to ensure a seamless admission process as much as able. Additionally, we brought in providers who were really accepting providers in the admissions process much earlier in the process than we had previously. So very early in the morning we have a provider who's involved and communicating with outside hospitals and referral sources. Additionally, we as Linda noted we wanted to pay attention to transportation issues because there were very often times that we had patients who are waiting in emergency rooms. We were ready to accept them and there were transportation issues that were preventing that from happening. We entered into that contract with Rescue Inc. to which Linda previously referred. And as of December 11th year today we've had 234 transfers that were able to take place to facilitate those admissions. Next year we expect that to be higher because we've only had a rescuing for 10 out of the 12 months this year. And I'm happy to report that these changes did contribute to an improvement overall. This year nearly 70% of our admissions thus far have been referrals that were made within the previous day of the admission, which is an improvement over previous years and it is always our target to try to get somebody admitted within a 24-hour period after the referral process. And anytime that you expand we are highly attentive to quality issues along the way. We want to make sure that we are maintaining quality of care when we are bringing in a large number of new travelers and new staff and expanding spaces and expanding programming. Early in 2023 we were able to hire a new director of quality. At the same time we are also able to hire a new patient safety officer. The two of those staff members were able to oversee and navigate a successful joint commission survey which took place in May of 2023 with recertification being granted at that point. And then since that time we've had two impromptu licensing and protection CMS surveys that came to us following complaints or events that occurred and both of those were wrapped up very quickly and both of those had no findings at the end of the survey. In addition we needed to make sure that we had appropriate staffing in place and one of the tools that we do utilize here is telehealth to provide the care at all levels of care, both inpatient and outpatient. There are many advantages to this capability. There's this help with both recruitment and retention of our high quality core staff. It provides rapid access to providers and off hours whenever our patients need a provider. We can get them quickly just getting the patient in front of the tele screen. And we built tele units on every single one of our units and by doing so what we were able to do is provide access to that technology in a safe manner. So we have built in technology that meets the safety standards of inpatient psych units. Currently our general adult units have core staff who are telehealth providers so that has helped us with core staff providing core staff on those units. We don't have any telehealth core staff providers on the adult intensive units or on the child or adolescent units. And then in the outpatient setting we provide telehealth for individual psychotherapy, individual psychiatry visits, and our partial hospital. It's an entirely virtual program with every bit of its care, both individual and group being provided by telehealth. And an additional advantage to this program is that it increases access of care and widens our catchment area for patients who can participate in that level of care. And then finally I want to just touch on the expansion of our outpatient care. We have in the past two years been able to add two new specialty clinics to our outpatient setting. First is transcranial magnetic stimulation or our TMS clinic. And the second is our S ketamine clinic. Both of these clinics are evidence based treatments for patients diagnosed with treatment resistant depression. They are treatment protocols that are delivered over a defined period of time. And also both of them are procedure based treatments and so the care is delivered to patients while they are in the office. TMS is a non-invasive procedure where a device is placed on near the skull. It's used to deliver very brief magnetic pulses in a rapid succession over a defined period of time and sometimes that period of time is as quick as four minutes. And then the defined treatment course is 30 sessions delivered daily Monday through Friday. And then S ketamine is a medication based treatment and it is self administered intranasally by the patients. And then it requires a two hour monitoring, safety monitoring session afterwards and that's performed in our clinics. And the initial treatment course for that is eight week timeframe with twice weekly sessions that then transitions gradually to one week. And then there is the possibility for S ketamine to transition into maintenance therapies. And that's a broad overview of what we're doing now. Thank you. And Amelia Schillingford will speak to some of the staffing challenges we have and strategies on our inpatient unit. Good afternoon. My name is Amelia Schillingford. I am the chief nursing officer here at the Battleborough retreat. Linda has a lot in me five minutes and I'm going to do my darkest time frame. But anyone who knows me knows that that's going to be a bit of a challenge as a board member chair. Tom humor mentioned our census in March of 2022 was 45. And then a year later in 2023 it was 95. And the only way we could do that as Linda mentioned was the rapid expansion of our staffing needs and hiring on travel staff. And so what we've spent this year doing 2023 is figuring out how to run a hospital with effectively having 50 percent of the frontline staff as travel staff. Currently we have 42 travel nurses 12 travel LPN's 53 behavioral health checks whom we refer to as BHTs and 11 social workers. We that means that about 60 percent of our licensed staff so RNs and LPNs are travels while about 30 percent of our BHTs are travel staff. In the social work domain the need is for 19 social workers by the end of February they expect to have 12 core. So they are on trend to becoming more majority core staff. The focus again as I said for the 2023 has been how to run a hospital with 50 percent staff while maintaining patients quality of patient care and safety. And we've done this through a variety of ways. The first was to establish a nursing leadership team when we started off the year in 2023 about 30 percent of the nursing leaders were themselves travel staff. And now it is 90 percent core staff. The second was to improve our communication process across departments. So improving communication between the clinical nurse managers the nursing leadership the schedulers and our recruitment folks to again make that process of recruitment to interview to hiring a lot faster. We realize that our in order to be successful our travel staff needed two weeks of orientation. Anyone will tell you that it's a much longer period of orientation than most hospitals offer. But we feel that it is imperative to set the travel staff up for success to deliver quality care that they receive two weeks of orientation. Travelers were placed on teams to work with a unit and have a clinical nurse manager instead of floating around the hospital. This was to decrease the burden on core staff and help travel staff feel like they are authentic members of the team which they are. We have scheduled weekly reviews so we could identify skilled travel staff and provide extensions trying to maintain continuity of staffing and care as well as early identification of staff that were not working out. And finally identification of travel staff who would be interested in coming on core. And we were able to convert several staff from travel staff to core staff including several people in the position of nursing leadership. So that was 2023 and 2024 we're going to be focusing on growing our core staff. We're going to be doing that in two different ways. One will be recruiting and the other will be growing our own talent. And the recruiting aspects we do not want to be poaching nurses from other hospitals in Vermont. All of the CMOs have spoken together and that is something that we agree is not fair playing and not the kind of organization and state we want to be. So we are working with a recruitment company to recruit nurses from other states particularly states where there is low satisfaction for nursing work. So we have targeted developed a campaign to target nurses working in Texas and Florida. And we are looking at creating an advertising campaign that really highlights the strengths of our hospital including our union relations are nursing to staffing ratios as well as the state of Vermont itself. We have two recruiters in our HR department who in fact have worked the very positions they are recruiting for. So Grace Albert Gardner is herself an RN. She recruits the RNs and she has worked here as an RN and as a clinical nurse manager Jessica Tully recruits our BHTs and she herself has been a BHT here in the hospital. So that will be recruiting staff from other states and then growing our own talents. Right now we partner with multiple nursing schools five nursing schools across three different states before RNs they come here for their clinical rotations with their own faculty. We also partner with six different schools across five different states for nurse practitioners and we've had several several medically trained nurse practitioners come to the retreat work here in a medical capacity while enrolled in school performing their clinicals here. Graduating and then going on to become psychiatric nurse practitioners as part of the medical team. And we have two people currently pursuing that path right now. We have a tuition reimbursement program for our for our staff one is a tuition reimbursement for all staff that speaks generally to current job skills that prepare staff for further career in behavioral health field. And then we have a second program that is specifically dedicated to employees who wish to pursue nursing degrees whether that is an associates degree bachelors or masters. The employees who qualify can receive five thousand per semester thirty thousand for the degree. Sorry that's thirty thousand a year for the degree is prorated based on part time work. And the agreement is that for every year of tuition assistance the employee agrees to work at the retreat for a year. In twenty twenty four we will be developing our own nursing apprenticeship and residency program. We last had an internship program in 2003 and we recognize that along with the other hospitals in the states we want to create our own pipeline program as well. So we will be developing this apprenticeship program partnering with Vermont colleges that offer nursing degrees. We're also looking to partner with the MH to provide a wider range of learning opportunities. And then we would like to develop a we plan to develop a residency phase to help nurses transfer from being students into being novice nurses. And we hope that both of those things will contribute to your staff retention separately on a separate side note we have a psychology intern program that is approved by the American Psychological Association that provides pre doctoral psychology internships. One of the primary goals is to increase the number of psychologists in the state of Vermont. There have been thirty five candidates who have completed the program eleven of them have went on to work at the retreat in some capacity and seven of them continue to do so. We currently have eight trainees and then an additional three former interns who have returned to the retreat to do a book post doctoral fellowships. I think we're good. Okay. Yeah. Thank you. Amelia. Okay. I'm just going to be interested time. I won't repeat anything. So I'm just going to close this presentation with a couple of points. One we know that the amount of money being spent on travel labor is not sustainable. It's not sustainable from a morale perspective or the burden administratively on the organization. We will develop a plan and we will submit that as the Green Mountain Care Board is requesting in the time frame. It's our biggest strategic challenge and impediment to success. So it's a priority for us. We're going to continue to expand our service offerings for children and adolescents through the outpatient area. So we're looking at PHP and IOP for adolescents. We are hoping to move forward on the the bid that we submitted to DCF and other agencies to reopen adolescent residential services and to be able to have 15 adolescent PRTF beds by the end of 2024. We're looking to expand our shared services arrangement with Brattle Bar Memorial Hospital. It's been a fabulous partnership. They're wonderful and we will continue to work with them to see where we can consolidate administrative functions and resources so that both of us can stay focused on cost control. And last, we are working and looking at a potential partnership with North Star, the FQHC in Springfield to see if we can bring some FQHC services into the Brattle Bar Memorial area through a partnership again with BMH, the Retreat, HCRS, and the Dental Clinic in Brattle Bar. So those are our key points. You know, the Brattle Bar Retreat remains a key statewide resource for mental health services. We work every hard to deliver on our collective commitment to be there for the people that need intense and outpatient mental health services. We respect that the funding for the retreat comes primarily from the Vermonters, and we will spend their hard-earned money as efficiently and responsibly as we can. So thank you for giving us this opportunity. We do appreciate this chance to talk about the retreat and the turnaround that it's had. It remains fragile. I mean, we're not out of the woods. We've got to keep our eye on the ball all the time, and we will do that. So thank you and thank you to the staff of the Green Mountain Care Board for their support and help. Thank you all for your presentation, and I hadn't appreciated that a number of you were new. So thank you for signing up for this work and taking you on these important roles. I'll turn it to Mr. Batista. Jeff, do you have any information for us to share? Yes, I'd like to run through the staff presentation with an eye to time. Thank you. So just confirming that everyone can see the slide on the screen. Yes. Wonderful. So welcome everyone. My name is Jeff Batista. I am associate director of the health systems finance team. And I'll be presenting the hospital budget with Russ McCracken, staff attorney. And an acknowledgement to the remaining members of the hospital finance team, Matt, Flora, Elena, for their assistance in making this presentation. So I'll turn it over to Russ for the first legal slides. Thanks, Jeff. So just briefly, the. As you all know, the Green Mountain Care Board reviews has reviewed historically the hospital budgets per Vermont's 14 community hospitals. There was a change in 2020 under Act 140 that modified the hospital budget review statute and extended the board's review to all hospitals, not just general hospitals. So that now includes psychiatric care hospitals, although it excludes psychiatric care hospitals run by the state of Vermont. So effectively that leaves one additional hospital and that's the Brattleboro retreat that falls under the board's hospital budget review. It's the board's review is based on several statutory factors and the guidance that the board puts out annually. That includes a number of factors, labor expenses, utilization, pharmaceutical cost inflation. Some other factors in here, which I think everyone is familiar with from our extensive review of the other 14 hospitals this summer. So we can go to the next slide, Jeff. This is the first review the first year that the Brattleboro retreats budget is subject to a full review. There was some provision in Act 140 when it was passed that allowed the board to kind of gradually scale up the scope of the review from 2020. As long as a full review is conducted for the FY 24 budget. So that's where we are now at this point. And that's what we're doing. We think it's important to know from the staff perspective and for the board's review that the Brattleboro retreat is quite different than a community hospital. And that comes through in the Brattleboro retreats budget. It has a different scope of operations. It has a different role in the state's health care system. I think it's clear, but I do also want to note that the Brattleboro retreat has a different fiscal year than the other hospitals that it's a January 1. Start day, which is why we're conducting this review now and not over the summer with the other hospitals. And the way we think about things like patient migration and service areas are different for the retreat than they are for a community hospital. So, and Jeff will run through the analysis here in more detail, but in reviewing the retreats budget. We're interpreting and thinking about the board's FY 24 guidance with these differences with these differences in mind. And I think that, you know, come through and how their views presented and also, you know, a couple of specific areas like the comparisons between the Brattleboro retreat. I think are more apt other psychiatric hospitals. We tried to look at, I think inflation. Not for general hospitals, but for psychiatric hospitals. And I think there are some other factors in the review that are tailored more specifically to the retreat. So, I think with that, I am going to turn it back to you, Jeff. Awesome. Thank you, Russ. So, I am to a certain extent preaching to the choir right now. So, I'm going to run through the the introductory information of it quickly. But all this is saying is that the Vermont legislator has made legislature has made it clear that mental healthcare investment is a critical part of our healthcare strategy. The act 167 does help. Does state that support. Equal access to appropriate mental healthcare that means the standards of quality access and affordability equivalent to other components of the healthcare system. Namely physical health as part of an integrated and holistic system of care. Some broader trends and additional context. Mental healthcare is in high demand. There is also a shortage of inpatient healthcare. Particularly for adolescents, the retreat is the only facility in the state that works with children or does inpatient child and adolescent care. Also, the healthcare workforce is stretched as alluded to by the retreat. This is imparted a demographic change, both shaping the workforce and the people seeking care. Increasing demand for that housing costs and just the general shortage of housing, no matter what you're willing to pay. And in the retreats case, in particular, there's regional competition among several hospitals within, let's say, community distance 3045 minutes. And that creates some fierce competition for nurses, behavioral health technicians and social workers. He members of the healthcare workforce. Moving into the basics of the budget, the board or the retreat has requested an NPR increase of 6.6%. Up to 97.4 million dollars in fiscal year 2024. However, it's given the high public payer percentage here. 80% or 81% coming from Medicaid and Medicare. The commercial rate change is not that significant, both in its magnitude and its absolute amount. Only 154 dollars in additional net revenue expected there. What does this mean for revenue at the retreat? So given that public payers fund most of the revenue utilization is really what is raising NPR. You'll note the in this chart, it's orange or the the color above the bottom. And that's contributing to about 87% of the total revenue increases. Budget to budget 22 to 24. An additional 9% is from rate. This is generally linked to the Medicaid per diem increase from. About 2,500 to 3,100 in fiscal year 2022. That is constant through the remainder of fiscal year 24. And the third category, payer mix. There was an agreement whereby commercial and Medicare admissions who lose coverage during their care at the retreat are now treated as Medicaid. So that explains the gray bump at the top of the Medicaid bar chart there. How does this all boil down to net patient revenue? So overall growth patient revenues at 47% that's driven by an increase in the utilization of inpatient care. Primarily. The, the outpatient share is growing at a slightly faster rate with that 56.7% there. Deductions are up as well, which comes to a net. If 1 were to take all of the blue bars and subtract the yellow colored bars. You come up with a dark blue line, which is NPR. Take that same blue line and turn into the blue bars here. You're looking at a income statement that is very heavily driven by inpatient or. By patient care rather than other sources of operating revenues such as grants. Whether that's the coven relief funds you see in the light blue in 2022 in this graph. Or the other grant sources are starting to drop as well. That said, as noted during the presentation by the retreats, the operating expenses are quite a bit and that is largely driven by traveler expenses. I've color coded the non MD staff in dark red. And the traveler staff increase in dark yellow. So you can see that non MD staff that spending is about constant. Going up slightly, but the 75% ish increase in traveler expenses. Between 22 actuals and 24 budget are quite large. All this means that operating margin is down as the operating expenses rise faster than that operating revenue. Currently the margin for the operating margin is about 1.3%. Moving to the balance sheet, the retreat is, let's say, leaner and meaner. With a far few liabilities, the liabilities have gone down at a faster rate than gross assets. Yielding a net asset increase of about 18.6%. To compare to some other hospitals in Vermont. The retreat has a slightly lower operating margin and total margin. It stays cash on hand have gone down over time. And the age of plant, though not favorable compared to the from a hospital median is improving. Some of the narrative responses. The admission rates are inpatient admissions are improving both in the rate that people are admitted. And the timing it takes for them to get transferred from the other eds to the retreat. So, at this point, about 40% of people who are referred to the retreat are admitted. Main reasons for not admission include just patients declining treatment. Being placed in alternate facility and other reasons though. I do want to point to the 25.6% out of state insurance coverage concerns and legal status. As well as the 14.4% being placed in alternate facility due to age or treatment. Wait times are down as you see on the graph to the right. With more people being admitted within 2 days and fewer and more than 2 days. Moving to outpatient wait times. There is a 10 week wait for psychotherapy at the. And a marsh clinic. There are is quick turnaround for the virtual intensive outpatient care as mentioned by the retreat. And their testimony as well as the health care professionals program. Where health care professionals can seek outpatient care for issues related to their job. In addition, the outpatient specialty medicine clinic with the ischemic. And the trans cranial. Procedure those post wait times are posted and take wait times are up. Or are relatively high in large part due to physician availability and scheduling. I felt it was important to break down 1 component of. The operating expenses here at the retreat that being traveler expenses and. Going through a little exercise, I just want to know that the map is on the next slide. So. The financial sustainability of the retreat depends on 2 things. Maxing out their census and minimizing their expenses, primarily labor expenses. So, there is some room to improve. If you look at this from a strictly accounting exercise, no trade offs, no externalities. At present, they are spending approximately 85. Or 38.5 million dollars combined nurse and behavioral health technician fte's. And that relies on a large component of travelers that you see in the red and the bar graph. If 1 were to assume that they staffed all of these positions as staff rather than travelers. That would be 21.2 million. And assuming that everyone who was staff got a 25% combined salary and fringe raise. That would only rise to 26.5 million. Given that so much of the revenue for the retreat comes from public payers, particularly Medicaid. Travelers are being paid by the public purse and. Should assuming a 1 to 1 net patient revenue to operation expenses ratio, which is pretty close to where the retreat stands today. You're looking at anywhere, saving anywhere from 8.9 million. 12.7 million in the. The 2 scenarios after the status quo in this graph. Just breaking down the math here, you know, changes to the. Number of fte's that are travelers versus staff as well as changes to. The cost per fte, assuming a 25% raise in salary and fringe. So, with all this information in mind, the staff recommendation is to approve the budget as submitted with the following conditions. Proven NPR fpp plus deductions growth as submitted at 6.6%. Approved with a commercial change in charge as submitted at 1.9%. And an additional condition, which I drew from. Other budget orders earlier this year is to include an additional condition for monthly reporting and to submit within 3 months and improvement plan to address traveler expenses. The rationale behind this is utilization not rate is driving the NPR growth at the bread bowl retreat, given its public payer mix. Traveler expenses are rising faster than staff expenses and patient revenue in general. And most of the traveler expenses are paid by Medicaid, assuming a 1 to 1 NPR at operation expenses ratio. So, I will pass it on to Russ for some standard budget conditions lights. Thanks, Jeff. These are the same standard budget conditions that the board had approved. For hospitals over the summer. For consistency, we were recommending that we continue to use the same conditions here for the retreat. There are a couple of instances where I changed some dates. So that it kind of made more sense with a January 1 fiscal year. So I'll just run through them. We're approving an NPR growth rate and NPR for FY 24. We're approving an overall change in charge and commercial rate increase at not more than a percentage increase over FY 23. That has no commercial payer or no commercial rate increase for any payer more than that amount. And the commercial rate increases can be less as negotiated between the hospital and the payer. Next conditions, there's a commercial rate cap as a maximum and subject to negotiation. It's not to be represented as an amount guaranteed by the GMCB. Next condition is the retreat expected commercial NPR based on his order is an amount that we will take from their budget submission. If it's approved without modification, they'll report back their actual expected commercial NPR. Clearly given the different payer mix of the retreat, the commercial rate is less impactful for the spreadable retreat than it is for other hospitals. Condition E, we have some reporting conditions in here. The Broward retreat will file its actual up year to date FY 24 results. I think I think I need to update the dates here too, but we'll just push those out kind of appropriately for a January 1 fiscal year. I'm going to go on to the next slide. There's some more reporting requirements here. I think we may need to fix these dates as well. But there will be reporting for the FY 23 actuals kind of when those are available. The retreat report is FY 23 audited financials. Again at a date that's sort of appropriate for when those are finished. Requirement that the retreat participate in telephonic check-ins at the discretion of the board chair to discuss their FY 24 year to date performance. And any retreat will advise the board of any material changes to its 24 budget revenues or expenses. Go on to the next slide. This is the same wait times requirement that we've had for other hospitals that Broward retreat would develop a system to be able to measure and report. For a lag and visit lag kind of as appropriate I think for the Broward retreat. I'm not sure if we have more to say about that. We can go on to the next slide. Broward retreat will participate with the board's Act 167 work again to the extent that's applicable. The Broward retreat shall timely file all forms of information and data requested by the board. And then just some boilerplate conditions here at the end. Thanks. So they suggest in motion language is outlined here. Move to approve the Broward retreats budget as submitted with an approximately 97.4 fiscal year 2024 budgeted NPR MVP a 1.9% rate in commercial rate increase. Between fiscal year 23 and 24 and subject to the standard hospital budget conditions as previously approved by the board with additional conditions as follows. That reporting for the travelers within 3 months. The vote is scheduled for today. I understand that. Timing is a bit compressed and perhaps we'd like to move this to next week. It is the earliest that we were able to do the presentation, but happy to adjust the schedule as requested. So, I'll turn it back the chair. Thank you. Thank you very much. I'll open up to board member questions and comments for our staff or for the Brattleboro leadership. I would say at the outset that I would like to get to a vote today if it's possible and let everyone go home and not have to worry about this. We're extending out, but if we can't, we can't. So we can see where the board members are and take it from there. I'll open it up to the other board members. Hi, this is Robin. I'll go ahead and jump in. I just had a couple questions related to the EMR upgrade. I was noticing in your submission that you didn't necessarily assume that the EMR upgrade would impact your revenue, which is certainly something we've seen with the general hospitals. So I wondered if you could just touch a little bit on that and talk a little bit to how the EMR upgrade may or may not affect your patient care or your administrative burden, those sorts of things. Yeah, this is Linda Rossi. I'll take a stab at that. We're looking, assuming we get the proper approvals, we'd be looking to start the transition to a new EMR mid-year 2024. So I'm not really sure we're going to see any revenue impact in 2024. I think it'll hit in 2025. It's an 18 month project. We have done some upgrades to our current NetSmart system and we are seeing improvements in terms of cycle times, but no major impact on revenue at this time. So that'll be a 2025 impact projection for us. Thank you. That makes sense. That was really the only question I had. Thank you very much. Good afternoon. This is Tom Walsh. Thanks for presenting to us and thank you for the work that you do. It's hard. It's needed and it's personally valued. I'm ready to approve the budget as submitted. I did. I did want to comment on the analysis that was shown about salaries. That paying for travelers is very expensive and can be a short term means to get through. But in my experience with other healthcare organizations around the country, it's a bit like paying loans. Once it started, it's hard to stop. It's hard to dig out. And what Mr. Batista's analysis showed was that increasing the salary for your existing staff or any oncoming staff by 25% would be less expensive for Vermont taxpayers than what's currently being paid for travelers. I know you can't recruit as fast to get people to move to Vermont. So I'm not asking Jeff to do this, but I imagine we could do a similar calculation that had a 15% increase in wages plus a voucher for a year's rent in the Browboro region. And it may still be less expensive than paying travelers. So I'm really trying to do what you can to retain staff and recruit. I think is really important. And I heard your concern about being perceived as poaching staff from other places. And I wonder if you could just say a little bit more about the agreement that you've reached with other healthcare systems about not poaching. Sure, Dr. Welsh, I attend the VAZ CNO monthly meeting. And during those meetings, we primarily talk about the nursing shortage in the states and what we are doing for recruiting. And in a sort of offhand manner, we spoke with each other about the agreement to basically not try to steal each other's staff that the main issue was that we needed to create new nurses, new LPNs through the pipeline program and or other parts of the country. And so there was no sort of official agreements. It was really a collegial, conversational, collaborative conversation about how we can all work together to address the state's needs. Yeah, just expand on that for a second. I mean, my background is human resources. And I think it's an unspoken commitment to our hospital colleagues that we will not directly solicit any of their staff. I mean, certainly if they were interested in a career change or wanted to come to the broader bar retreat, we would consider them, but we would never, you know, have a job here across the street from one of our acute care hospitals. So, you know, we honor that commitment as HR professionals and we'll continue to do so. Thank you. I can. I can pop in. Thank you, Miss Rossi and team. I appreciate the submission the candor the conversation. Like everyone else I and and Jeff's comments. I'm fully in agreement that the mental health care provide that you provide at Brattleboro. And others pride around the state is is one of the very most important resources we have for for monitors in the health care system. So I applaud applaud the work and appreciate the dedication and I know you've your team has done some amazing work over the last few years, you know, with work with diva and and the Medicaid support to become financially sustainable and be the resource that you've become as you know, I work as an emergency physician and I've noted, noticed the speed of which we can get patients transferred down to Brattleboro the impact that is it's not that we're not boarding still but it's what it was two years ago and now is substantially different. So thank you so much for that and for for all of us. I support the budget is submitted. I just want to ask a few questions that came up during during the hearing it so one is I think I just want to like note the exposure. I mean, this isn't like this is clearly something you all know that you that Brattleboro has more so than a lot of the rest of the state to swings in contract labor costs. So if if next year was a high cost year as opposed to the sort of subtle downtrend that we have right now. I would imagine that would be a big challenge for the treat is there any any thoughts on that on how that would be managed if that occurred. Yeah, that would be probably devastating for the retreat should there be a major shift on the cost of travelers, you know, we're aware of it every single day and we are recruiting as aggressively as we can. We have some ideas. I mean, we've been working together with, you know, Amelia in terms of what can we do to train resources, our biggest population here are behavioral health techs that's our biggest employee population. Those individuals that have a lot of options in the area. We have to train them. I mean they don't come licensed to the retreat. So I think expanding our investments in developing that talent pool so that we can pull them in and offer them a career opportunity here is something we're going to focus on. I mean, as Amelia said, we'd like to create a nurse residency program so we have to grow our own. It's not easy to do that I've done that in other places where I've worked it's challenging but that's one area we need to focus we're going to look are going to expand our recruitment focus out of the region. And start recruiting nationally. We do a fortune and enough to have a housing option that if we were to bring in out of the regional, you know, area resources to work here we can offer them housing and we can make that free. I've also been working on some wage possibilities for frontline staff to get creative with that all of our frontline staff are unionized. So that requires collaboration with the union. So it's delicate it's it's hard and it's delicate it's very challenging to manage turnover 50% of your direct patient care staff every 13 weeks. It is hard on our numbers, certainly but it's also very challenging from a morale perspective, and it stretches our infrastructure resources training, education, recruitment, I mean this constant turnover. We don't want to have this long term for the retreat, and we're going to do our absolute best it's a difficult labor market as you know in healthcare in general. But if you look at the number of healthcare workers interested in working in psych. It's even more narrow. The attention is really important to us. I think morale has come a long way in the past two years in the workforce union relations labor relations have improved considerably and that's, you know, that's also helpful so we're trying to attack this from various perspectives. Thank you for that. Another question that's not related to that is just a quick question that came up and maybe Jeff is the better person to answer this but how does one lose their Medicare coverage during a hospitalization. Is that ticket that right if someone loses Medicare coverage they become Medicaid. Correct yes I mean so you know they have a certain you know if you're a Medicare when you exhaust your Medicare coverage, then you, you know the patient can apply for Medicaid and we help with that process. It's like a length of hospitalization. Yeah, correct. Yes. Okay. All right. Thank you. I'll pass on to whoever's next. Great. Thank you. I just have actually just a couple of quick questions. One was what percentage of your average daily census is Vermonters versus out of state patients off the top of your head would you say. The Medicaid pretty much 90 90% 90% is Vermonters. Okay. Yes. Okay. At least 90 90. Okay. No, I was just curious. I also just wondering, what do you use as we're thinking about, you know, reviewing your budget in the future years, you know, and building a process that's more, you know, relatable to, you know, your facility. What do you use as a benchmark, a comparable group to sort of benchmark your own costs, your access to your quality productivity turnover days cash on hand things like that like what is your comparison group that you all use. That's very challenging because we looked at the organizations that had been identified by the Green Mountain Care Board and went through them one by one and honestly trying to find a match was very difficult. Some of them are part of health systems, some of them are for profit organizations. You know, some of them don't have the patient population that we have so it's, it's, we're, we're challenged trying to find a benchmark that we feel is appropriate. We look forward to, you know, refining our search and hopefully coming up with some information. I, you know, I've done some Google searches myself to find some metrics. So, you know, the staffing ratios as an example, and, you know, I couldn't find anything that was current that or actually fit our population. I mean, we a third of our patients roughly are involuntary patients, they're more, they're on the level of a state hospital. So, you know, we certainly can look at the state hospital in terms of those benchmarks but the other two thirds. are just different. So we're struggling with finding an appropriate benchmark and we will continue to look to see where there might be some information. I looked at the behavioral health organizations under AHA, the American Hospital Association. I didn't find a lot there either. So, you know, I welcome any insight the Mountain Care Board may have. Okay, so I guess that that means that in the past, the Broward retreat has not done its own benchmarking for performance. No, not that I'm aware, not that I'm aware. Okay. And the last is really just a clarifying question I think for the record. Just to the word, I think this is probably a typo but I wanted to check. You know, as I would read through the narrative on the on page two of the narrative, there's a description of fiscal year 22 being, you know, abysmal and experiencing an operating loss of $582,000. And then later in the narrative on page seven, there's a description of an operating margin positive of 10.6%. And when I looked at the income statement, it was a $8 million gain. So I just wanted to clarify for the record that it's in fact an $8 million gain for fiscal year 22 and not the negative 500, 600,000 that was listed in the narrative. That's correct. Okay. Okay, thank you that those are my questions. Thank you for for answering and I, you know, I echo my colleague on the board's comments about, you know, your efforts to turn around the Broward retreat and the battle asset that you provide for our community. So we really appreciate all your work. Thank you. Just out of curiosity. What EMR were you on and which one do you think you're moving to? Yeah, we're currently on avatar through net smart is the vendor and we're planning hoping to move to meta tech. And then the revenue impact that you may see from that change, you thought it might be 25. Before you see that and are you anticipating that being to the positive or negative? Sometimes with these EMR implementations, there's a lag in getting it going and getting the claims right. But there's also an upside opportunity to capture more of the work. Did you mean upside or downside for 25? Well, we're hoping for an upside. That's, you know, really good. Yeah, we have a broken EMR right now. And although we're working to improve it, this should, I mean, I think we'll see a little bit of a dip as we, you know, ramp up that system, but then I, we should be operating far more efficiently on the revenue management side. So yes, positive impact is the plan. And then on the salaries, like for the, for the nursing for the nursing staff. How do those compare to other hospitals? I thought there might have been a slide on that here. Yeah. So am I reading this correctly for RNs staff? It's about $101,000 cost per FTE. That's total costs, including benefits and healthcare and all that. Yeah, that and over time and premium pay and all the other things that we give. Yes. I didn't do those calculations, but they sound reasonably correct. Great. I had no questions. Thank you very much for your work and getting Brattleboro in a really good place. And for the service that you all do provide, it's obviously critically important in so many different ways. So it sounds like the board's prepared to vote and I would be as well. So I will make a motion. I'll see if there's a second and then I'll open up to the healthcare advocate and the public comment and then we'll see if we can have a vote. So I moved to approve Brattleboro retreats budget as submitted with a $97,379,571 fiscal year 24 budget NPR FPP, a 1.9% rate increase from fiscal year 2023 to 2024 and subject to the standard hospital budget conditions as previously approved by the board. And an additional condition that Brattleboro retreat shall submit to the board within 3 months a plan addressing Brattleboro retreats efforts to reduce expenses and reliance on traveling staff. Could I make a I wonder if I could make a friendly amendment, which would be to add that the standard budget condition dates could be amended by staff to reflect the retreats. Fiscal year because I interpreted what Russ is saying right. The staff need to make some tweaks there. Yeah, I think the friend. Yes, I think that that is what Russ had said. With that friendly amendment, I will second. Any other board discussion on the motion and the healthcare advocate. Do you have any comments? Just a brief comment. Thank you chair fosters want to thank all the board staff for a great presentation and all your hard work on this and also thanks to the retreat for the great presentation and for your willingness to address the concerns that we raised. Related to the patient financial assistance policies and we look forward to continuing to support you coming into clients compliance with act 119. Thank you. And I'll open it up to public comment via the raise, raise the hand function. All right, seeing none. All those in favor of the motion, please say aye. Aye. Aye. I remember homes I didn't hear you did. Did you vote? I think I couldn't get my mute off fast enough. So yes, I. The motion carries unanimously and we'll work on getting out in order for you folks. And this was a really nice presentation. So thank you to our staff and to the brought up or retreat folks. This is really. This is enjoyable and a good presentation. So thank you. Thank you. Thank you very much. Merry Christmas and happy holiday and happy holiday everyone. Thank you. Next on our agenda, we have the Medicare benchmark proposal and a potential vote noticed. So I'll turn it over to Michelle degree, our health policy project director and Lindsay kill our data analytic and information chief. I believe I've unmuted myself and I confirm that you all can hear me. Yes. I will just see myself today. Check off there. I have a relatively brief presentation for you after last week. Let me share my screen. I do want to start by noting that we did not receive any public comment. I'm going to stop talking. Maybe not. Okay. I want to first start off by saying we did not receive any public comment directly related to the Medicare benchmark for 2024. So with that, I'm going to just review a couple of points that we made last week and then I've put some suggested motion language together for you all. And I'm here for any outstanding questions you may have. So with that. Again, the staff recommendation was to use the maximum allowable trend for one care for months Medicare benchmarks. Those as you see on the screen are 4.3% for non ESRD population and 6.7% for the ESRD population. That translates to a request of advanced shared savings of $9.9 million and that is used to fund statewide blueprint for health programs and the breakout is there. If you wish to see it. Again, just highlighting the tradeoffs for using that maximum trend I'll focus here on the con, which is the maximum trend may endure the ability of the state to fulfill its financial target from the APM agreement. Current modeling does not put us in within that threshold or kind of have any concerns for staff on on going over that limit. Even though it's listed as a con, we don't foresee that actually becoming an issue with the 2024 benchmark. Again, highlighting the previous trend limits. I know there was some conversation about this last week that Lindsay was able to really helpfully answer for us. I just wanted to show this again. For the past performance years of the all pair model including our first extension year of 2023. That's it. Are there any other questions before I move to the motion language for you? None from for myself. I see lots of shaking hands. Okay. So with that, I've put some suggested language here on the screen. I'll let you read it over. It's just again, taking that staff recommendation. And I will turn it back to you to your doctor. Thank you. I'll go ahead and make the motion. I moved to approve a Medicare benchmark of the staff recommended maximum allowable trend rates of 4.3% for non ESR D. And 6.7% for ESR D to include the advance of the 9,956,390 dollars for blueprint for health and sash programs. I'll second it. Any board comment or discussion. And any comment or points from the healthcare advocate. I think from us chair faster. Thank you. And any public comment. All those in favor of motion, please say aye. Aye. Aye. Aye. And the motion carries unanimously. Thank you very much. Mr. Gray. Thank you. Happy holidays, everybody. All right, you too. We'll take a quick five minute break. And then we'll come back at 250. We have one last substantive agenda item, which is the one care of Vermont fiscal year 24 budget. With a potential vote noticed and I'll turn it to Michelle Sawyer, our health policy project director and Marissa Melamed. Our associate director of health systems policy and they are also being assisted by Matt Sutter our health systems finance principal analyst. And staff attorney Russ McCracken. Thank you, chair Foster. I'm going to kick off the presentation. Thank you. Michelle had to be out so I was feeling in but she's jumping back in as of today. So we're going to work through this as a team and pick up our conversation from last week. So if you'll allow me, I'm going to share my screen. I'm not showing up for everybody. Okay, I'll, I'll begin. So again, thanks and good afternoon, everybody. Welcome to the board and the public. Today's discussion is the ACO oversight FY 2024 ACO budget for one care Vermont. And we are going to walk through budget modification and approval recommendations. Any board discussion questions, public comment, and a potential vote, if you're ready to do so. I am going to turn over the next couple of slides to staff attorney Russ McCracken to walk you through the budget review standards and criteria. Yeah, thanks, Marissa. So I, we thought it would be useful just to walk through the board's rule on how the budget review boards rule on budget review process. This is for ACOs with more than 10,000 attributed lives. So a couple of excerpts are on the slides here. First is the board rule 5405 this sets out the review process. We have an overall principle. The ACO has the burden of justifying its proposed budget to the board. The rule goes on then to say in deciding whether to approve or modify the proposed budget of an ACO. The board will take into consideration four things. And it's 123 and four. The first are any benchmarks established under section 5402 of this rule. We'll look at that next. The criteria listed in 18 VSA 93, 82 B1. That's the ACO oversight statute. The elements of the all payer model agreement. And lastly, any other issues at the discretion of the board. So we can look at the next slide. Section 5402 of the rules says the board may establish benchmarks for indicators to be used by the ACO in developing and preparing the proposed budgets. The established and as a reminder, the board did do this. They're in guidance. They're called targets in the guidance. For clarity, though, the target and the bench lowercase benchmark here are the same thing. So as, as you're familiar with them, there are those targets established in the guidance. The rule goes on to say that the established benchmarks will be included in any annual reporting or budget review manual. So they're in the guidance and will assist the board in determining whether to approve or modify an ACO's proposed budget. So first the board will look at those proposed budget targets. And then next under the rule, the board would look at the statutory criteria. So we can go to the next slide. Which I've so for reference excerpted and put into the slide here. I don't think it's needed to read through all of these. But they are the 16 different criteria that are set out in the statute. There are some more so we can, I think, just flip through these slides. Sorry, we can go back one. So the board should under the rule, the board looks at the targets. The board looks at these 16 different criteria. Elements of all pair model agreement and any other issues at the discretion of the board. That's how the rule work, how the budget process works under the board's rule. And I think if there are specific or detailed questions about this, the board might consider whether that's appropriate for an executive session for advice of council. And with that, I can turn it back to you, I think. Okay, thank you so much. Next slide is a summary of the public comments that we've received on the one care budget submission so far this has been updated as we've moved through the presentations in total 14 public comments were received as of today. Here are the themes that we heard in the public comments. I'll go through them for you. And that discussed the value of one cares improved health outcomes higher quality care lower cost and that's coordination of care, the value of care coordination and strengthen partnerships with local care organizations. Comments also expressed concerns about access to care and long wait times to see providers concerns about cost of healthcare in Vermont. And the fact of one care administrative costs relative to demonstrated value. The loss of the blue cross shield program and increasing executive salaries. We received just one new comment from the last presentation and that was from health first independent practice association. And the public comments where commenters wanted their remarks posted are on our website for review and the board has received each of these as they come in. The next slide again to repeat this was reviewed on December 6. These are the targets that Russ was talking about that were set in advance in guidance. So that one care could use them and the board of managers could use them as a as a guide for setting their budget over the summer. Through the staff analysis. It was determined that of the nine seven were met. I'm not going to go through each of them individually because we did that on December 6. Two of them were not met numbers three and four and that is that the ACO must hold 100% of the Medicare advanced shared savings dollars at risk at the entity level and not pass the risk along to the provider networks. And that the ACO should increase the risk corridors for all payer programs above the FY 23 levels. The one care declined to meet those parts of the guidance. It was discussed during their hearing. It was discussed at our previous presentations and we're going to discuss recommendations there today. And the other one I just want to draw attention to is number eight, which I'm going to look on my other screen because it's very small, but the ratio of population health management funding to number of attributed lives must be at a minimum of the FY 23 revised budget amounts. I'm not going to read the whole thing. This generated a bit of discussion around the way that those ratios were calculated. The HDA did an analysis. The Green Mountain care board analyst did an analysis of what that ratio look like and number is the number that we had in there is 166 per life, which is greater than the FY 23 revised budget amount. So we looked at the various, the alternative ways of calculating it and found that under the alternatives, it's still met except for one alternative where you remove the blueprint dollars. But staff believes in the case of this target that the blueprint dollars should remain as part of it. So we did relook at this and and determine that this particular target was still met. So we can discuss, you know, population health investment and the ratios for attributed lives is going to come back in the discussion under some other criteria that we looked at. So that brings us to the staff recommendation. So the options that were presented last week and December 6 have been further refined into a Green Mountain care board staff recommendation based on board member discussion and feedback. So I'll go through each of these and there's some accompanying slides that give you some numbers and in such to help you to help aid in discussion and deliberation. So the first is to modify the ACO risk model. And that is that one care should increase the Medicare risk corridor from 3% to 4%. The additional risk so that additional 1% risk should be delegated to one care as as an organization so it would not be spread out to the risk fairy entities or the hospitals. I'm going to go through this a little bit more but we calculated that amount at approximately $5.7 million in additional risk and reward for the ACO. So that number is based on budgeted figures from the one care budget and would have to be recalculated based on the the final benchmark, but that was our best estimate with the numbers we we have. Also on this I want to mention that the settlement policy the one care settlement policy would need to be updated to reflect distribution of the additional risk and reward this is significantly more risk than they are currently holding. And so we recommended the board would want to take a look at that settlement policy and how any reward that's earned is distributed. We also talk about the risk mitigation on the flip side on the risk side, the risk mitigation plan that that one care would need to have to cover any potential losses on this additional risk. The second recommendation is that one care modifies the operating budget and investment in population health and primary care. The recommendation that we're putting forward is to reduce the operating budget by $957,000. This is based on a five year average ratio of operating expenses to attributed lives. And this is based on this ratio that we reviewed which Matt from our finance team is going to go through with you again and this was a methodology that we selected to to try to look at the operating budget over over time. And we're going to discuss some, you know, other factors in making that decision when we get to those slides or making that recommendation. And that you reallocate the operating budget cut to population health primary care programs. So the first recommendation the modification of the risk model creates significant additional potential reward or earnings that one care network can earn. So we believe or the staff believes that one care may want to look at its budget to figure out how to reallocate operating expenses to population health programs to support success under this increased risk model. And it would also adjust sort of the ratios of operating expenses to to population health. So it's the second recommendation and then the third is to include the reporting monitoring and other conditions which were reviewed on December 6 and we brought them back with it with a couple of additions. These are the reporting monitoring requirements and other things that one care is required to do which we will document in our reporting manual that gets published after the order. And I just want to highlight that the revised budget. That is in compliance with the board's vote on the FY 24 order, which would be inclusive of any budget modifications and reporting monitoring requirements that you vote on today. That would need to be submitted to the board by April 1. And then we would schedule a revised budget hearing later that month most likely or early May as soon as we could to review the revised budget. And as a reminder, this is standard process that we have a revised budget submission because. Excuse me, attribution numbers are not finalized after the first of the year. So that's going to adjust their, their total budget, no matter what. And so we'll, you'll want to take a look at that in the spring. Excuse me. So that's an overview of the recommendations and we have several supporting slides. Which I'm going to go through with some help from other staff. So on the recommendation to modify the Medicare. Risk model. So again, this is an increase from 3% to 4% risk corridor. We calculated the value of that additional risk at 5.7 million. The rationale or discussion around this recommendation is that it increases both the upside and the downside risk potential. So it increases the value that can be earned from the cost of operating the ACO. It also increases the risk. So the incentive to. To perform. And again, this was a budget target that was not met. So it was presented to the ACO. Long before the budget was submitted for their, for their consideration. So it's not a surprise that we may order this. The second part of that recommendation is that the ACO holds that additional Medicare risk at the one care entity level as submitted. The one care budget has 1.84 million for provider specific risk mitigation at downside risk. With this recommendation, one care would hold a total of again, we estimate about 7.6 million. The value of the additional 1% of Medicare plus the existing provider specific risk mitigation. And again, we believe this recommendation supports hospital participation in the model. It increases accountability at the ACO level. And, you know, another way of saying that is that the ACO, you know, has accountability for their value as an organization by backing some of that risk. You know, with the settlement or distribution of that risk. There's also kind of a decision about how those dollars could be reallocated in their network or programs if they are earned. I think we've probably gone through this pretty thoroughly, but I'm bringing there's a slide that brings the math back about this. As a reminder, the bottom calculation there. The original target was that one care should hold all of the Medicare advanced shared savings risk, which would be 9.95 million. They didn't do that. And after consideration, we're not recommending that we think increasing the risk corridor actually brings more value. And the total risk that one care would hold at the organization level is less than that original target, which was the 9.95 million. The total now is, you know, that seven point checks that we've been discussing about if we have more questions about the math, we can we can go through that as well. And again, this would have to be recalculated for final number. A couple of other ways of looking at this as a whole. The adjusted risk corridor bumps bumps up both the upside and the downside potential for the organization as a whole. And it changes the kind of percentage of provider held risk and one hair care held risk, which is which was part of the goal of the of the budget target that one care would hold more than as an entity. The other line to look at here is the bottom line there the net and that assets and equity, which have accumulated over time to over $8 million. So, the, the ACO any ACO is required to have a risk cap and a risk mitigation plan per the rule. I think that was anticipated in that the, you know, the ACO may propose a higher risk level than than maybe desired, but that hasn't that hasn't happened over the history. It's been more that the risk level that's been proposed and perhaps been lower than the board wishes it to be, but there they do have to have a they do have to have a risk cap and a risk mitigation plan. And the we show the net assets line to show that there is currently an accumulation of net assets and equity in excess of what the the cap would be with this additional risk. So, one other just just a visualization of the risk being held over time. The provider held risk to most of the risk and one cares model is delegated to the risk guarantee is the hospitals that's the blue there, you know, see the highest year that was proposed was 2020 that significantly cut over the last couple of years it has been building up the risk amounts have been building up over time. What we're trying to show here is that what the recommendation does you can see the 2024 and then the 2024 adjusted. It increases that total risk amount increases the amount held at the one care level, perhaps just a little faster than one care has proposed in their in their budget. The prices outside are slightly different because of the Medicare advanced shared savings which is paid on an advance so can't be earned at your end. But the downside all comes at the end. So, that reminds me of one more sort of important piece here in that a reminder that any savings or savings paid don't happen till about a year after the end of the performance year so these additional dollars that could be earned or paid out. They go through the entire 2024 performance year. And then those are calculated after and paid out after at settlement we usually have those settlement presentations around November of the following year. This could be monitored over the year through projections. And, you know, we would have information about how they're doing against, you know, against those against the risk quarters as we go and that's not money that would be seen or available until a future a future budget consideration immediately available. Okay, this slide is just a reminder on board ordered restrictions on reserves. So again this is back to the point I made earlier around the risk cap and this mitigation requirements in the rule. So, our board the remount and care board would want to take a look at the settlement settlement policy and distribution of any savings earned that would likely go to reserves and the board would look at it, approve any savings and then those those dollars could be distributed to programs or providers based on that policy. This is consistent with passport orders in FY 23 the order restricts reserve the use of reserves to additional funding for population health and additional backing for risk incurred by participating providers, maintaining ACO risk on behalf of participating providers. Temporary cash flow issues associated with payer revenue delays and other uses pre approved by the Green Mountain care board. And there's also language in the order that states that if one care uses reserve adjust its participation fees, or uses its final credit it must notify the GMCB within 15 days of such use. Notification must include the reason for the change, or any use authorized under this condition, and a corresponding cash flow analysis. I'm going to turn the next couple slides about the operating budget recommendation over to Matt Sutter from our finance team. Hey, can you all hear me fine. Great. Just to reorient to this table from last week I'll just explain it again quickly so someone last week we compared the operating expenses is budgeted to some historical ratios of operating costs to attributed lives. In order to do this consistently we converted to $2023 for determining the ratios. So the budget impact columns can be understood as the cut necessary to reach that inflation adjusted ratio in that row. Like if I was going to read one out loud the staff recommendation which is number two would be so in order to get to an $83.50 operating budget to attributed life ratio. The average of the last five years one cares operating budget would need to be cut by $957,000 from submission. And real quick just sorry if we could go back real quick if you'll you'll notice that the dollar amounts have changed they're slightly larger than they were last week. This is owing to an adjustment to the assumed 2024 inflation rate in the prior model we'd assumed 3.2% or 3.7% excuse me and revised it down to 3.2. Which is the most recent CPU figures. Some other aspects of the operating budget we looked at included executive compensation unclear how bonuses are tied to organizational performance unclear if executive compensation set relative to an appropriate benchmark. We're unclear if or how performance measure or return on investment is measured. We noticed a historic overestimation of OPEX operating expenses in their budget compared to actuals. Looking from FY 19 to 23 as an average about 1.25 million a year. That was over budget and operating expenses. And then other areas for fiscal responsibility we look at and considered not well supported include marketing expenses we. So under submitted budget that they reported $661,000. For public affairs salary and benefit costs. $4.3 million for purchase services, which we know includes the additional analytics. And $123,000 for supplies occupancy and other. Spenses and finally we have a table here kind of just illustrating over time how net assets have accumulated. Looking from 2018 on and then some key drivers of this. Obviously their net assets will accumulate based on there's a revenue and a spending component of this. But we wanted to focus largely on their operating expense over budgeting. The last few years and how that can affect or has affected their net assets over time. And as part of so we go to the next slide apologies. And so our recommendation would be for any of these opera cuts to operating expenses to reallocate to population health or primary care programs and have 1 care present on this. How they reallocated these funds in their FY 24 revised budget. And I think I can pass it back to Marissa now. Yeah, Michelle's actually going to walk through the conditions consistent with previous years that we've gone over with some additions that have been made in the last week or so. Perfect. Thank you. So, as Marissa said, these on this slide in the next couple of slides should be pretty familiar to the board. So, I'm going to go through the bullet's their summaries. The order will include the full conditions, which are generally consistent with previous years. So, first one one care must submit reports and information in accordance with the GMCB reporting manual, which will be developed by staff early next year. One care must notify the Green Mountain care board of any material changes to their budget and explain the variance. The expenses must not exceed the amount ordered by the Green Mountain care board. One cares administrative expenses must be less than the healthcare savings. One care must submit a revised budget by April 1, 2024 and present on the revised budget in April 2024, including final payer contracts attribution by payer, a revised budget hospital dues and risk. To the risk model and sources of funds for population health programs. One care must also notify the Green Mountain care board of any use of reserves or line of credit or any adjustment to participation fees. One care must notify the Green Mountain care board of any use of reserves or line of credit or any adjustments to participation fees. The use of reserves additional participation fees or funds drawn from the one cares line of credit shall be limited to the following additional funding for population health investments. Financial backing for risk incurred by participating providers. Maintaining ACO wide risk on behalf of participating providers. Temporary cash flow issues associated with payer revenue delays and any other pre approved uses by the Green Mountain care board. The next one is that one care must implement the risk model as modified by the board with the requirement to for one care to submit copies of contracts and a requirement to notify and seek approval from the Green Mountain care board as early as possible of any proposed changes to the risk model. The last couple ones. The one care must implement benchmark trend rates for payer contracts in alignment with the Green Mountain care boards decision on Medicare only ACO benchmark, which you all just voted on. The Green Mountain care boards Medicaid advisory rate case and for commercial payer contracts in alignment with ACO attributed population and the Green Mountain care boards approved rate filings. Also one care must engage in payer programs that qualify for APM scale to the greatest extent possible and align payer programs in key areas to the extent reasonable. And they also must explain any non scale qualifying programs and areas of misalignment. And we will require continued reporting on payer programs. Few more that are consistent with previous years. We expect that one care will fund population health management and payer reform programs as detailed in the FY 24 submission or as ordered by the board. And to notify the Green Mountain care board of any changes, including funding shortfalls, changes in program scope, and an analysis for each program line item as to whether and why the funding is appropriately scaled for attribution or some other factor. They must report evaluation results and evaluation focus areas for 2024 to the Green Mountain care board. They must fund the support and services or sash program and blueprint for health payments to primary care practices and community health teams consistent with the amount approved by the Green Mountain care board in the Medicare ACO benchmark process, which you just voted on. And here are some updated or or new potential conditions. The ones that are in black may have some updated deliverables, but the intent behind the conditions does remain consistent with previous years. One care should work with Medicare Advantage plans operating in Vermont with a particular focus on Vermont based plans offered by Blue Cross Blue Shield of Vermont and UVMMC their MVP program to develop scale qualifying programs. We just removed the time constraint around that. Second, report FPP data and progress towards the goals as specified in the ACO reporting manual and FY24 guidance. Report on the CPR program and make some improvements to the benchmarking report, meaning the Medicare ACO benchmarking report that they have been submitting to us by annually. The two updates would be that they include a statistical significance analysis and their next submission, which would be expected at about the same time we receive their FY24 revised budget. And we would like to see them include the risk levels of all cohorts for each year in that report as well. The next few are new potential conditions for the board to consider one care to submit accumulated net asset statements from 2018 to 2023 actuals. Annually, or alternatively we could adapt the sources and uses table to fulfill this purpose as well. The second would be for one care to reconcile PHM payments after year end. And they can, we can get that information through a year end sources and uses Q4 reporting, or we could put that in in guidance. And finally, we would want one care to verify to the Green Mountain care board that payments for primary care are being used to support primary care consistent with 18 VSA 93 82 B1 G. And how we go about that is up for discussion. I will hand it back over to Russ to lock us through some potential motion language. Thanks, Michelle. So it seemed like there were a couple of decision points here for the board and the best way. So they're going to be a couple of motions to if the board wants to address all those decision points. So it seemed like the best way to do that was we have some potential motion language for modification of the Medicare risk corridor. Some potential motion language for modification of the operating budget. And then on the next slide some potential modification motion language for approval of the modified budget with the other conditions that Michelle just walked through. It seemed like it would make the most sense for the board to kind of take these in order if that makes sense to the board members also. Russ, sorry, was there one more page of potential motion language? Could you go back to the 24 please? Is there anything else from the staff at this time? No, we turn it over to you. Great. Thank you. All right. I'll open it up to the board for any questions or comments anyone may have. Can I just start with a huge real question? Russ, was your intention that we work through these one at a time or Owen or do you think you can discuss and then go from there? It might make So the way I'll do it is if you just have any board members have questions or comments, I'll sort of keep track of where people are on these issues. And obviously you may have other comments relating to other things. But if you can in any comments, you may have suggest any thoughts you might have on what was put up or where you might want to do something differently. And then it'll give me information as to whether or not we need a roll call or whether or not we can have a motion on these suggestions or different motions. And I think just for timing purposes, ideally, we'd be able to get through a vote today. We could come back and do it later. Although I think if there's significant changes, it's more difficult on one care with their contracting with hospitals and getting to an agreement with Medicare and signing an agreement. And so hopefully you can get through it all today. Don't all jump up, but I guess I'll go, I'll go first with a couple of thoughts that I have since I have the mic unmuted. There's a lot of positives in one cares budget this year. There are some improvements that I think were really important that we had hoped for and we wanted to see the couple that stuck out to me that I'll share was that they increased the bonus pool. I thought that was a positive. We want to see more risk. We want to see higher bonus levels. We want to see financial inducements that cause providers to make the changes that we want to support our health care reform efforts. They also hit some of the key guidance terms. The one that stuck out to me was, I think it was number nine, where they're targeting specific areas for improvement. I like the ones they selected. Those are really great ones. I think it's ED utilization, wellness visits and primary care visits. So I thought that was an appropriate place to target for improvement. And that was a positive. A couple things I was concerned about with the budget was that we haven't seen programmatic impact on a lot of the programs. Certainly there's significantly significant support for the CPR program and a lot of value there as a program that I really support and I'm glad it's continuing in a healthy fashion. There wasn't showing of significant increase in quality caused by programmatic efforts. And there was a lack of support for the administrative costs, particularly relating to compensation, which we had hoped to get, but that wasn't able to happen. And there, in my view, is insufficient support for primary care overall. We have seen the primary care benchmarking data and it hasn't been on the right trend line. And that's a huge crux of the program. I know it's an effort that an area where one care wants to really improve. And I think this gives them an opportunity to do so, the staff recommendation. I think moving more money towards primary care is part of what we were trying to do with this reform. It's a statutory requirement. I know it's something that one care cares about. So I supported that concept. I think it's really all I had. I support the staff's recommendation, all three of them. I support moving to a higher level of risk from 3% to 4% programs based on risk. Risk is how we're trying to incentivize and change behavior for the benefit of her monitors, providers and patients. This will allow us to have more money potentially brought in from Medicare for the state. And I think Miss Sawyer showed us a presentation with the amount of money that was left on the table from lower risk levels in the past. The target that we set today is the highest level of target we could set for Medicare. So it's actually the most favorable to achieve those savings with this level of risk. So I think that's beneficial. And I thought it was relevant the point about how much money had been over budgeted historically that there was, I forget the exact numbers, but it was around a million or so each year operating budget that was projected that was not necessary in the end. And so this recommendation sort of aligns with that amount. And I don't think it causes too much disruption and it allows for one care to take on that additional risk. So I support the staff recommendation. I guess I can go. I agree a lot with most of. Oh, and discussion points regarding the things that he's impressed with one care this year and some improvements. I think I just want to just definitely echo the CPR program and also the work with Diva on having a fixed perspective payment Medicaid program for the state. It's it's the most extensive payment reform. The initiative that's occurred through the all pair model. And so I think that's an important thing to call out. I also in agreement with a 4% risk corridor. I think this again. The risk incentivizes higher performance. That's the point of having the risk on the downside and it also allows for greater rewards on the upside. And generally speaking, many years there would have been far greater rewards had a higher risk corridor been chosen. With regarding supporting primary care, population health programs with money from the operating expenses. I actually could go further than the staff recommendation. I think I was just about at the staff recommendation before realizing the over budgeting of 1.25 million on average. So, roughly speaking, I would be comfortable with 2.25 million. I think that could be justified in multiple ways, but I think that one care reached its optimal staffing, I think, or complete staffing in 2018 was reported last year, I believe. And that was a very different one care. You know, developing a statewide payment reform model. Now we're a coalition of the willing. So I would expect one cares. Operating expenses to continue to reduce over the next several years, unless there is some new development in payment reform that it is involved with. So, I would be comfortable with moving more along the line of 2.25 million dollars to improve primary care programs in Vermont and take that from one cares operating expenses. This is Tom, I don't mind going next. So I was thinking about this meeting. I. Tried to reflect on what is meant by regulation. Right. We talk about systems and processes and budgets. And kind of it's easy to lose sight of the idea that regulation is a process. That's meant to give the public and policymakers peace of mind. That we are working to make sure the policies that have been enacted improve and safeguard public well being. And that they're working as intended. Living up to their promises. Avoiding harm. And that we're monitoring for unintended consequences. Over the past couple years of presentations. It's become more and more clear to me that one cares not been able to live up to its promises. And while we just had 14 public comments this go around about one cares budget. We had dozens more. In the comments about ACOs in general just a few months ago. And we've got to be over hundreds in the past couple years. About one cares performance. In the lack it's lack of improving the well being of Vermonters. And so I understand people are frustrated that Vermont is these are our friends and families. Who we've been health care has been reforming in Vermont. But their premiums have been going up. So high that their premiums and deductibles are so high. You fear getting sick or being injured. This isn't one cares fault, but one care was enacted to try to change that trajectory. And it hasn't worked. But we're now in a system. We're now in a situation where. We keep talking about propping up this inefficient, ineffective organization. Because we need it in order for federal money to come into our health care system. We're perpetuating a failing organization to support organizations that can do good, like blueprint. That's a bad system. And continuing to fuck to fund it as if it is working or as if it might work in just a little bit more time if we keep giving it money. That's wasteful. And I'm uncomfortable as a regulator continuing to do that. So I think it's at a minimum increasing the risk corridor to 4% I support. And I think the operating budget can be cut by at least $4 million. And that money moved to more effective programs. And I say that based, not just on the, the totality of the budget information that we've reviewed over the weeks, but specifically today. And we've additionally learned that one care has regularly not necessarily on purpose, but over budgeted their operating expenses by 1.25 million on average. So if we went with the most extreme position in the chart that was shown 4.3 million, but remove the 1.25 we're talking about a $3 million difference roughly. And then look at slide 16. There's way more than $3 million on that slide. There's also because of the over budgeting over years. There's 8 million in the coffers. So I understand that we're uncomfortable. Making a big change. But I'm uncomfortable continuing to do small things. When this organization has not lived up. To its promises or plans. I realized that disrupting it completely. Would destabilize other aspects of the system. And that's what I meant earlier when I said. We're propping up a failing organization because it brings money in. For organizations that do good. That money that was coming in that has been coming in was meant to help organizations in our state transform to risk bearing entities. That's a fundamental feature of alternative payment models. But that money that's come in hasn't been used to transform. It's turned into funding. To sustaining those organizations. The system is not working. But if we remove one care. We harm things that are working. I said last week the best analogy that I can come up with. Is that as a state. We've launched a plane with all Vermonters on it. In hopes of improving healthcare. And it had trouble lifting off. And there have been repeated. And frequent malfunctions. It's not going to make it where we wanted it to go. But it'd be irresponsible to shoot it down. Or to somehow crash it. So we have to find a way to get it back safely. And we need to learn from what's happened. Over the years of this and make sure we don't do it again. To the best of our ability. Because it's failed that's. A lot of things in healthcare reform fail. Right. It's because our efforts are designed by humans. And implemented by humans in the complex systems. So the fact that it's failed and publicly saying that it's failed. Is not. Not necessarily a problem. The problem is if we don't recognize it as such. And keep doing what we've been doing. So. I'm. I think it's important to increase the risk corridor to at least four. And I think it would be wise of us. To recognize. The struggles. That have come upon Vermonters. And the inefficient way and ineffective way that one care is. Shown its ability to, to address those and reduce its operating expenses. As to the four by 4.3 and move that to primary care. And public health programs. I don't think it'd be smart to do more because it could risk. It could destabilize the system too much. But the figures that have been shown to us throughout this budget process. I think support my argument. And I can understand that it's uncomfortable for people to think about. 4.3 million dollars, but I, I, I asked that you. Look at those numbers and consider that as a possibility. When we vote. Thank you, chair. The chair, I think you've got your work cut out for you today. Thank you. In the sense of, I think we're, we're all in different places. First of all, to the staff. I mean, I know that this has been the last few weeks have been challenging in trying to come up with some recommendations and some options for the board. And I know how much work has gone into this and the evolution. And I really, really appreciate it. I also want to echo some of Owens comments and Dave, that I've seen the ACO make in the budget and the evolution of the budgets over time. I really appreciate the increased provider accountability that I see and shifting some of the population health payments and the incentives out of the base into the bonus. Very much appreciated that. I think that's the right direction. The CPR program has been proven, you know, to be one of the gems of this organization. I think it's very much appreciated by the independent provider network. And I'm glad that there's a continued investment in that program. And I do also want to acknowledge. I think we should acknowledge the efforts the ACO made to meet the board's benchmarks that we set forth in the guidance. I recognize that. I appreciate that. And I want to note that. In terms of where I'm landing on these recommendations. I do support the staff's recommendation to increase the Medicare risk corridor for the reasons that have been outlined. I don't want to reiterate them, but I think drawing down more federal dollars, increasing risk over time, we set that in guidance. It was one of our, you know, guidance requirements. They would take more risk. I think having the ACO take some accountability makes sense and seeing their reserves. I'm not too worried about where those dollars would come from. And I'm hopeful that if the ACO takes some risk that they will, you know, be thinking they're having them having some accountability will increase some of the ways in which they think about reallocating potentially their budget to ensure that they actually make those savings. So with regard to the second, so I support increasing the risk corridor from three to 4%. With respect to the modification of the operating budget, you know, I do think that one of the criteria that we have to consider is administrative costs. And I think while the ACO met the benchmark set in guidance, you know, the consistent over budgeting that we see is gives me pause. And it's been an average of about, you know, $1.3 million since 2019. If you include 2018, it's about $834,000 per year of over budgeting. So there is some buffer in the budget that's been submitted here. And given that we're facing some significant primary care shortages and the ACO has to some degree and the network, I should say has, you know, to some degree fallen short of expectations in some areas that I do believe could be improved with some population health investments and investments in primary care. I can support the staff's recommendation to reallocate some of the operating budget towards population health programs and primary care. But I'm at the staff's recommendation of the $957,000. That's in the range of what the ACO has typically over budgeted for operating expenses. So that's where my comfort is in terms of that. I think increasing it higher than that. I appreciate everybody's points and the concerns, but I want to recognize that we're asking the ACO to take additional risk, right? So we're putting more risk on the ACO. And so they're going to be accountable for that. They're going to need to, you know, ensure that their data analytics are strong. They're going to need to ensure that their care management programs are strong. They're going to need to ensure they're going to need to up their game, right, to take on this additional risk. So shifting more out of the operating budget to me seems like a bridge too far at this point. So I would support the staff's recommendation. I can see where those dollars can come from, whether it be in the conservative budgeting that we've seen in the past or whether it's taken out of some reserves or whether, you know, you look towards bonuses or marketing public, you know, public affairs budget that may not, you know, the public affairs budget may not have a direct relationship to population health outcomes and ways that other programs might. So that's where I'm at in the recommendations and I support the conditions that Russ went through as well. I was considering not saying anything for a change, but given where folks are, I feel like I should probably say something. So the chair has a sense of where I'm at. My decisions on the motions today are based on the guidance and the guidance targets that we set forth in the guidance. We indicated that quote for all budget targets that are met, the ACO should expect less analysis of this area of the budget from the GMCB and staff. So I am following the guidance that we set forth earlier. So I'll just cut to the chase. So I'm going to move on to the next slide. I'm going to move on to the board of the first staff recommendation to increase the risk quarter. And I will vote no on the second. It seems like. I didn't hear any other concerns about the standard conditions. So unless. There's a. Doesn't look like there's any concerns on that. So. I might know it. I think that, I think that we have a little bit of a division of the recommendation and on the standard conditions. And then on the, whether or not to. Accept a budget. That includes a smaller amount for admin and an increased amount for phm or primary care. There's a bit of a split. Sounds like Jess and I are sort of in the same position. Tom and Dave may be a little bit higher. And Robin may be a little bit lower. I think everyone frankly in my view made really good points. And I think it's important to understand all of them frankly, and all of them have some appeal to me. And this is not easy. I think to Robin's point about the. Guidance. My personal view is that the guidance is something we are to look at. It's one of the factors that we look at. There's of course any number of things that happened during the course of the year. That we couldn't anticipate in guidance. And I take the guidance as. In totality. Rather than piecemeal. So on the guidance, I think it would be more comfortable for myself. And probably for others as well. If there's an interest in a larger reduction, that perhaps we should do a more thorough job. In the guidance to indicate that. In the future. Whereas this year's guidance wasn't as prescriptive. So there's a couple of benchmarks that were left open because we didn't have the data. The other financial points that I wrote down were. The unsupported executive compensation. And I think rather unsupported. Marketing PR branding buckets, whatever. I forget the exact terminology, but I had 410 on one and 661 on the other. And then the over budgeting of a million. So I think that's a little bit of a difference. I think that's a little bit of a difference between the two or whatever it was. So I can certainly understand where Dave is. And I think. If you take a really hard look at sort of the broader returns. An impact. I can certainly understand where Tom is as well. So I can see why that we're a little bit split. I think one question I have is. So on the 2.25 million. Adjustment. The Dave mentioned. You see that as the appropriate number. Yeah, I came to that number. With the idea that. The executive bonuses. And the marketing money. Probably would do better reallocated for primary care. Given that we don't really have. Any information. I think that's a good point. I think that's a good point. I think that's a good point. Supporting the executive salaries, executive bonuses. And the metrics used for bonuses last year seemed. Not really specific and measurable for. Improving quality or decreasing cost of care in Vermont. And then I was additive with that. And the 1.25. Over budget. Historically. If I were looking at sort of what I view as the kind of broader results, I can understand it. I guess just to respond to that. My hesitation is a little bit about. Disruption, the unknown, all those types of things, right? Like, and I. I recognize when we say yes to things. There's all these other unintended things that happen or don't happen that we don't know. And when we say no to things, it's the same dynamic. I don't know what this will change. Will it make it. Impossible. For them to achieve like we want them to achieve or is it just making it more cost effective and they are still able to achieve. And I don't really have a great sense of that. So I guess maybe part of it's being a little conservative myself. I guess the response that I. Part of my view is that I want them to achieve. I don't want them to achieve. I don't want them to achieve. I don't want them to achieve. I don't want them to achieve. I mean, there's not a whole lot of money in the CPR program compared to their overall operating expenses. The amount of. The amount of impact this could make in those what 19 practices. I don't know how many providers. I don't know how many thousands, tens of thousands of patients that covers is. Is pretty impressive. I'm trying to be mindful of not disrupting the organization of one care because of. So many of the things that we have talked about that we. Really want a thriving ACO in Vermont. I mean, that's that's still. The goal. And one cares importance in so many of the. Programs in Vermont. So I could see. I mean, I could see being at a lower number. And just being very thorough in the guidance coming up this following year with the expectation of probably even. A larger number. And less completely justified within the budget. Of course, if the guidance had. If the budget submitted next year had. Some transformative program that was really going to show a significant return to Vermonters on their investment, then I would be supportive of not reducing the budget then, but I could. You know, I think we're at a transition of. The role of one care in Vermont's help landscape. So. So I could, I could see being in that position. I'd be comfortable with that. I think. It's palpable, right? The discomfort. And intention that that we're experiencing. And to go back to the analogy with the plane, we've got to figure out a way. To. To keep it in the air. I said last year and Dave's comments reminded me of it. When an organization is struggling. The general consensus on advice to it from a consulting standpoint. Is to identify the essential functions. And strip everything else. And keep just the essential functions and do it really, really well. Then try to rebuild. And as far as I can tell the essential that one care serves is. As the receiver of the federal dollars and distribute, it's a pass through organization. Because of the way they do their budget, I have not over the past few years been able to identify how much it cost. To be a pass through organization. So the 4.3 may be high. I think the lower figures that we've been talking about. Don't recognize that we're not taking money out of health care. With this decision, we're redistributing. We're moving money. Out of administrative expenses. And. Potentially moving it into. Programs that have demonstrated. Effectiveness. And I'm struggling with our reluctance to do that. So I'm not stuck at 4.3. By any means. Because I don't know. That we can arrive at a perfectly identified number. So I'm open to compromise. And I appreciate you listening to my arguments. Let's do that. I think there's some. Staff and folks that have hard stops today. And I want to be mindful of that. I think, I think it's around 4.30. That we have a hard stop, I think. Why don't we take up what seems as though we can agree upon it this time, which is the first motion in the last motion. And I think after that, since we've published the motions, the motions that we've been talking about. And I think after that, since we've published the motions, the motion language. And I guess we're not sure which, if we're going to make the second motion or not. But perhaps we can take some public comment. And that might assist us in thinking about these issues. Russ, if I take public comment now on the motion that's, that's published the second motion. Do I need to take another round of public comment? If that's the same motion that ultimately gets made, or if I do, if it ends up being a different motion. You know, let me do this, Russ. That's probably, that's probably legal advice. Let me, let me just do this. I'll, I'll ask for public comment as to what we were working on. And I can ask you that question in the break. So I moved to modify one care Vermont's fiscal year 24 budget by requiring one care to increase its Medicare risk corridor from 3 to 4% with one care Vermont holding the additional losses using its net assets as risk mitigation. And for one care to update its settlement policy to reflect additional potential upside consistent with the board's discussion today. I'll second. All those in favor say aye. Aye. Sorry, sorry, I forgot. Yeah, you got me Russ. Thank you for the second Robin. And I will turn into the healthcare advocate for any comment on that motion. Nothing from us, chair Foster. All right. And Mr. Berman, the CEO of one care. Do you have any comment on that motion? I do. Thank you chair Foster. And thank you for the opportunity to speak. The Vermont all pair model specified that the Green Mountain care board work in collaboration with Vermont is yours to achieve the goals that forth in the agreement feel sometimes from the discussion that's going on here. We've lost some sight of what those goals are, but I'll get back to that. It makes sense that our shared desires for the ACO to partner with local healthcare providers to transform Vermont's healthcare system from a traditional uncoordinated Confederacy to a collaborative ecosystem that focuses on health goals by providing actionable data and innovative payments that foster better outcomes for all. I think our common vision is to create a trusted equitable healthcare system where patients and providers work together to achieve optimal health and exceptional healthcare experience for everyone in the state. I'd say in the spirit of partnership and vision, we created a 2024 budget that meets the operating budget requirements and guidance that were outlined by all of you earlier in the summer. I'm really concerned with what's going on now because the changes you're proposing are moving those goalposts out further. The guidance issued over the summer stated that the ratio of operating expenses to PHM payment reform payments, including the FPP and budgeted bonus payments, must not exceed the five-year average of 3.25% and that the ratio of population health management funding to the number of attributed lives must be at a minimum, the FY23 revised budget amount. I think you'll all agree that in our submitted budget, we reduced the operating expenses in 2024 to comply with that guidance. The GMBC staff verified that we met that criteria with a 3.14% ratio. So set another way, we met your requirements and now you're asking that we adjust our budget based on different previously unknown criteria and to make changes that are not based on any other established criteria. I just want to be clear that for one care, cutting the operating budget means losing essential resources needed to fulfill the strategic objectives set forth by our board of managers. Further, while drastically reducing our funding, or at least proposing that, you're at the same time asking us to hold more risk centrally. We weren't designed to do that. We were designed to bring healthcare providers and hospitals of all stripes together to participate in value-based healthcare contracts that seek to facilitate improved provider network performance and higher value for Vermonters. Going back to our founding 10 years ago or more, one care was simply just not designed to hold significant risk and doing so is not consistent with the model that's been in place from before the APM even existed. We are, in its sense, a network of the providers and specifically the hospitals that take risk on behalf of their communities. Placing too much risk centrally on the statewide ACO as opposed to allowing the function is designed and place risk within each healthcare service area is contrary to the entire concept behind creating accountable communities. Further, it's moving accountability in the opposite direction of the path that the state of Vermont would like to transition towards in 26 with the ahead model. In that model, risk is going to be held at the provider level due to the required hospital global budgets. So we're going backwards from that. Lastly, you're simultaneously ordering us to increase the risk corridor with Medicare even though you've stated that this decision-making authority rests with the ACO. I just say while you appear to be really focused on the amount of money that one care might be leaving on the table, if we don't increase that risk corridor, I encourage you to consider the very real possibility of downside risk. We anticipate that the utilization may actually increase in 24 when compared to the prior year as hospitals seek to address the pent up demand for services in the post pandemic era, which I think you pointed out in the hospital budget process. Just saying closing, we're really proud of the collaborative entity that we've built. We remain committed to supporting our participant network in particularly primary care. We agree with you. That is very important. That's why we built the programs we have and want to scale them up and really harness the performance in 24. On the subject of risk, we'll consider how we can comply with those orders. I think we might be able to do it. But with regard to us operating below budget in past years, I think it's really important for you to know that a lot of those years were during the pandemic era and those budget changes were due to shortfalls or surpluses or due to staffing vacancies. That was common across the United States just as people were rampantly over budget as they tried to supply things that weren't previously needed before the pandemic. And I want to be clear that we've already addressed that by reducing the budget in 2024 substantially. So if you move those goal posts out further with regard to our operating budget, it's really going to cause problems. And we ask you to reconsider the same thing for the health care system of remonters and approve the operating budget to submit. We can work with you on the risk front. But I want you to be really thoughtful about what it's like when you're asking us to take increased risk and try to get these programs scaled up to the level you're asking and drastically cutting our funding at the same time. And whether that's really the right thing to do. So again, I appreciate the opportunity to comment and I appreciate this is a thoughtful approach to it. Thank you for comment. Is there any other public comment? Okay. All those in favor of the motion please say aye. Aye. Aye. And the motion carries unanimously. Could you put up the third proposed motion language? I move. Sorry, go ahead Russ. Sorry, before you do that the motions that were set out were kind of contemplated sequentially. So if you think that the board is coming back to the second motion you may want to adjust this motion to just approve the conditions the other conditions. I see. And I have a this was kind of meant to be kind of a summation of the whole of the whole and so you may want to save that for the end. I see. Can I ask a quick question? I'm sorry, Owen. Are there any conditions that are tied to the cut in the operating expenses that should not be voted on prior to the motion being approved or disapproved? So I think there are a couple of conditions that say as that refer to operating expenses as adjusted by the board. You know I think I would have to go back and flip through those slides to be able to answer that question completely. Let's do this Russ. Go back to the go back just I want to keep an eye on the time and I'd really love to be able to hopefully get this done so that one care can take the next steps if there are any. So what I'm going to do is I'm going to make this motion. I'll see if there's a second and then we can take any additional public comment and maybe that helps us think about it. So I'll move to modify one care that will be reducing operating expenses by the exact amount the amount recommended in the staff recommendation in the $900,000 range and requiring one care to instead reallocate that amount to population health and primary care programs that will achieve the best return on investment consistent with the board's discussion today. I will second it. And is there any public comments? Mr. Boris, the CFO of one care, please go ahead. Thank you chair Foster. Good afternoon everybody. I just want to comment quickly on the kind of over budgeting theme from today and a little bit of context and color. So one care was formed in 2012 by providers to help create an efficient platform to enter into value based care services. So one care was formed in 2012 by providers in Vermont and New Hampshire as well makes a lot of sense. It still does today over 10 years later. We work very collaboratively with our provider organizations and particularly the hospitals that fund us to develop a budget every year. And really I think what's been characterized as over budgeting this year to me is actually sound like it's my job to make sure that we are using the funds they offer to us efficiently. And if we have an expense that we don't think we critically need for a year, we will shelve it. Additionally, I also think it's important to note that through the pandemic business was disrupted for many people and organizations and one care is no exception. We transition from a highly active workplace with a lot of travel to a lot of organizations across the state, which in many ways is the most important part of the remote structure. And through many of those years we did not know whether or not we would revert to a full in person model again and as the pandemic lingered on and on, we decided at one point to make a decision to shrink our office base and really just adopt the remote structure over the long haul and that's the way we continue to operate today. So some of the characterizations of over budgeting are really important to note. I will also note that the conclusion of every year, we present to the one care finance committee and the board the results from the budget year. And we analyze and show them a presentation of here's what we budgeted and expected to spend relative to what we actually spent during the year and we ask of them, what's your preference? Is it to retain those earnings at one care to Vermont to build reserves so that we can return the funds back to our funding hospitals. So I just think it's important to note this is a very collaborative arrangement that we have with our hospitals to make sure that one care is a good and sound steward of the funds made available to us by them to support value based care programming across Vermont. And to echo Abe's comments, I think there's a real paradox between asking the organization to take on more risk, which as he said, I think it's important to take on more risk while also reducing the resources. We're a small business in Vermont. We don't have a huge staffing workforce to be able to integrate into every practice and organization across the state. So it's a really careful balance to take on more organizational risk with fewer and fewer resources. Again, we just like to make the point we complied with the budget guidance intentionally. I was very intentional about that, but I really think carefully about the decision on this matter. Thank you. Thank you. Miss Rader Wallach and been asked to introduce people if they're associated with a regular identity. So I believe you're still the chair of one care, but I don't know for certain. And I hope you're doing well. Great. Thank you. I appreciate that. Yes, I'm here as the chair of the one care board. I'm here. Basically, since it's inception and one care was created as a result of the Affordable Care Act federal law. It was organized under federal law to have a broadly representative board as is required, including having a diverse array of consumer representatives on our board. That board takes we take our job very seriously and we review annually both the budget and the operations of the organization and the goals that we set as an organization. And in fact, just voted at our last meeting last week on strategic goals for the coming year. And I think you'll see reflected in those strategic goals for the coming year. Precisely the kind of enhanced focus on core capabilities and efficiencies that some of the board members have been talking about here today. But I want to first emphasize that we're a private organization organized under federal law. No other ACO in the country is regulated the way that we are. And I want to suggest that this is one tool in the state's toolbox. And one way that we can achieve the lofty goals that we set out to achieve 10, 12 years ago. But it's not the entirety of the Green Mountain Care Board's job. And it's not the entirety of One Care's job to achieve health care reform on behalf of Vermont. And so focusing on the success or failure of One Care I think is kind of taking your eyes off the ball in some ways in terms of what the overall goal of health care reform is. And I challenge you to find a place that's done better. One Care has not been successful in all of its endeavors. But it's been a great thing in Vermont. It's achieved a lot. And so I think it's sort of unfair to equate One Care's achievements with has Vermont achieved health care reform or not. But it's been a great thing in terms of what Vermont achieved, something that nobody else in the country or frankly in the world has achieved. So that's just one point I wanted to make in terms of risk. One Care has both Abe and Tom have stated was never meant to be a risk bearing entity. It was meant to be financially fragile. Could assume some risk but not too much. Not so much that it would imperil their financial health and risk them going under in communities that depended on their services. But the idea was always to pass through risk to providers because that is the fundamental concept underlying the organization that providers should assume risk should have some financial risk for the cost and quality of the care they provide so that they'll try to improve on both of those fronts. So the idea that you hold that at a corporate level and don't pass that through to providers just is kind of antithetical to the whole underlying concept and as Abe mentioned it seems inconsistent with where the federal government is going in terms of their next model. I think that's about all I'd like to say except that I think as we enter into the next phase of the all pair model where we have to analyze what is what are the federal what is the federal government proposing and what's the potential impact on Vermont and Vermont's healthcare providers. I think one of the only sources of really good knowledge about this and one of the only places where providers will be able to get together and discuss this and shed light on is this a good deal or not is it one care so I hope that you don't discount that value the fact that one care pulls providers together to discuss these things and to aggregate the knowledge of the folks who actually are on the ground receiving money taking risk providing services about the impact of these models and then last thing is I think in terms of getting into the operational budget I just think you're out of bounds that's the only way I can put it I think we complied the board of one care reviewed the budget we complied with your budget guidance and for you to go beyond that and say as as Abe said that you're going to now move the goalpost is not fair play and also makes me question why is there a board of directors of one care if you're going to get into line item editing of our budget thank you and I appreciate your comment any other public comment on the motion why don't we take just a we'll take a three minute break oh sorry Sam I'll turn to you I'm sorry to have not called on you please go ahead no worries and I apologize that I've not turned on lights in my house I'm not broadcasting from a dungeon I just wanted to say that we support the motion that the staff recommendation that was proposed and I think the board knows where we stand I mean obviously we submitted an extensive public comment so I won't resummarize that I just wanted to make that clear thank you thank you and thank you for submitting a comment any other public comment okay um we have a little bit of scheduling things to deal with and I'll take a five minute break till 427 we'll come back at 27 thank you okay I think we can resume and we made a couple adjustments I think a couple folks can stay a little bit longer so we can see if we can resolve this today or not and we've checked some calendars we should have a little more time um so I don't know if any other board members have any other thoughts they want to share but I'll open it up in the event that there is I just want to ask the staff a question um Mr. Berman mentioned a substantial reduction in operating budget in 2024 can you comment if there was a substantial reduction in the operating budget in 2024 my memory is is actually increased compared to 2023 so you're muted can you hear me now I was double muted um I did look at this I don't have the slide in front of me um maybe Matt can pull it up or we can get it but my understanding from the one-care hearing on November 8th is that they presented a budgeted to budgeted look and that is a decrease um in their operating budget we looked at an actual to a budgeted so their actuals for 23 projected to their budgeted 24 is an increase okay that exact numbers I don't have in front of me okay that that's helpful that's helpful um my only other comment is I think that sometimes we you know there's questions about what the board's role is in evaluating one care specifically it seems to come up and my impression of the funding from of one care is that there's basically a pass through from Vermonters or people who paying for healthcare on behalf of Vermonters commercial rate payers federal payers state payers and I guess if you one care does mention the cost shift so it would be commercial rate payers have a pass through hospitals to one care for their operating budget so while hospitals allocate that money to one care it is really Vermonters money that's going to one care and I think that that when I think about evaluating one care's budget I think about our responsibility as a board to ensure that Vermonters money is being spent in the most optimal way to meet the goals of improved access, improved quality reduced cost, improved equity those things that's just my one comment on that but thank you Marissa for that clarification. Any other board members have any questions or thoughts? Right so I think the folks with the public comments are really helpful in sharing their views and I think one of them was similar with what member Lungen said and I think it is more comfortable to think of it that way as an opportunity to put some of this more in guidance next year to be more prescriptive. I know the board had asked or I think Dr. Merman had asked or staff had asked for programmatic costs and what I'm hearing from Dave and Tom is that you have concerns that this cost more than what we needs to. Some of these programs are working and we're paying for them and you have an obligation to take care and be responsible stewards of that money in this role and I understand that completely. I think maybe what we could do is put in guidance next year that we need to understand those programmatic costs better and to have a better ROI on the programs what is working and what is not working. I don't know if it's so binary as you know pass through versus not pass through because it has all these programs that help really care for monitors in significant ways but I think we need to kind of drill down on that a little bit before I think we should make a very large reduction. I think we need to understand that before we do and I think the right place to do that at this time would really be in guidance. I think there is over budgeting I mean it's over budgeted every year whether it's a pandemic or not it's more the guidance isn't binding it's more important for us to consider beyond the guidance including the statutory factors I had concerns about frankly some of the administrative costs but also the resources for primary care and some of the public comment that was shared and also B1D and some of what we saw and some of the claims regarding savings I had concerns about some of that so I would ask members to consider this more measured and moderate reduction at this time and that we can take a really hard look at what's more appropriate next year so I think what I'll do in the interest of time and I do want one care to have a decision today if we can is I'm going to ask Russ to take a roll call vote and I ask you guys to think about this and if we can't get it we can't get it go ahead Tom before we vote would you please remind me the wording of what we're voting on specifically Jack I don't know if Marisa you have that Marisa do you have the um I wrote it down somewhere but the the actual dollar amount that was put up in the recommendation I believe it's $957,000 I can go back to a previous slide okay well while you do that Chair I just wanted to say that I understand your position and what you've just said and I am willing to compromise there were in the public comments some comments made about asking to increase risk while decreasing budget and that that created some discomfort I like what you've talked about trying to help programmatically figure out how much it costs to do different things because on slide 16 there was nothing mentioned about risk bearing tolerance being part of those budgeted items talking about executive salaries marketing etc purchased services so it's difficult for me to just accept that argument the increasing risk while decreasing the budget is an impossible ask without knowing what is needed to take more risk so I like the approach that you've outlined a moment ago where we could understand with a little bit more detail what's needed to take more risk to deliver these programs what's needed to fulfill the pass through what I think of as the essential component of the ACO and I'd also like to say that I some board members noted that they want this to succeed I'm one of those I'd like this reform effort to work so with that I'll pass back to you yeah I guess I would just say in response that any vote I make on any of these things is so that it works and then it succeeds and that's I think the goal okay so Russ I think he can take a roll call vote with I didn't have the exact numbers when I made the motion but it was $957,245 dollars okay I'll do a roll call vote on that motion in alphabetical order so board member Holmes yes board member Lunge no board member Merman yes board member Walsh yes and chair Foster can you go to the other motion I move to approve fiscal year 24 budget is modified today by the Green Mountain care board and subject to the conditions presented today by GMCB staff I'll second then sorry did we have any additions or modifications that need to flag Russ I don't believe so Marissa jump in if I'm wrong but I don't think there were I think this the way this is written it's inclusive of the ones that were new since last week I didn't hear any motions in addition to that of things that needed to be added okay yeah that's correct so it's all the it's all of what was on the slide that Misha the slides that were walked through okay right so I move to approve the one camera mod fiscal year 24 budget as modified today by the GMCB subject to the conditions presented today by GMCB staff Robin already second second second all right all those in favor please say aye aye aye and the motion carries is there any old business to come before the board any new business and is there a motion to adjourn so moved then second all right all right all those in favor say aye aye Marissa Michelle and Russ and Matt and the teams thank you this is never easy and thank you for a lot of really really really helpful analysis last second questions all kinds of information you guys did a really great job as always so thank you very much for helping us work through this naughty and difficult issue and have a really nice holiday everybody thank you