 Good morning, everyone. Welcome to the Green Mountain Care Board meeting. This is a follow up and an adjournment from last week's meeting for the purpose of hearing from Northwest Medical Center on a request for a mid-year rate adjustment. Before we get started, couple announcements, first of all, there will not be a board meeting on Wednesday. We will have the discussion on hospital budget guidance the following Wednesday, May 13. Since a journey last week's meeting, we did receive follow up information that was received from Northwest and we received two public comments, one from Ham Davis and one from Julia Shaw at the office of the health care advocate. Patrick, does the staff have something to add to keep this off? Yes, I will make a brief announcement that following last week's presentation by us, it was brought to our attention that we didn't factor in the compounding nature of this rate request. So we originally had the combined increase as I think 20.8% and you can see here on slide number two, the appropriate map which brings the increase to 21.7% and we verified this with the folks at Northwestern Medical Center. So that's the change to this presentation and for the court report of this is Patrick Rooney of the Green Mountain Care Board. Thank you. So at this time, I'm going to take an attendance so that we have an accurate record of who was at this meeting and the numbers that I do not see names for, I'm just going to call off the last four and if you could tell us who you are. So the first number is 5001. Julia Shaw with the HPA. Thank you, Julia. 6959. Is that you're going to be from the Moscone Hospital? Thank you. 0476. Lisa, if you're on from Blue Cross to Vermont. Thank you, Lisa. 2505. Good morning, Jennifer Callis, Museum Medical Center. Thank you. 7438. Ann Davis. I am. 5835. Lisa, Abigail Connelly. Okay. 8975. Marbeni Green, Northwestern Medical Center. Thank you. 9314. This is the court reporter. Thank you. And 9806. Mike Fisher, healthcare advocate. Good morning, Mike. Abigail, do you have everyone else's name listed? Yes, but if you could call anyone who didn't, you know, you didn't say their name out loud. Besides Becky Lewandowski, I think we got everyone. Okay. Is there anyone? This is Robin Alves. I'd also like to say that I have Devin Bachelder and Stephanie Grove with me. Thank you, Robin. Is there anyone else? Hearing none, Robin will give you the opportunity to add anything that you would like to add. Thank you, Kevin. Robin Alves, CFO of Northwestern Medical Center. A couple of points that I would like to make and just to remind for the board. One, as you can see from the slide that Patrick has, obviously the percentage rate is very high. But if you look at the dollar impact to the system, what we're asking for is still $4 million, more than $4 million less than what our approved revenue would have been. I think that's important to note also while we feel that we have done our appropriate due diligence with our payers, this rate increase even at the full amount would not increase the net dollars that they would have paid out for claims. If we were on track with our revenue budget that was approved back in August. Thank you, Robin. Patrick, you have any questions for Robin and her team? I do not know. Okay. With that, we'll open it up to the board to begin discussing this case. Would anybody have any questions or comments? For this morning, I can start. So the request, you know, for a 14.9% commercial rate increase as presented was driven by two pastors, a $7 million loss due to slow revenue to the end to the EMR implementation, which is worth about 11.5%. And a $2 million increase due to the cost of travelers, which is 3.3 million. The full year increase recoups 9 million or 100% of the lost income. Primarily result as a result of the above factors. NMC will lose approximately $10 million in that income this year after suffering losses in the past several years. Looking at the drivers of the request, a rate increase to me is not the solution. If the $7 million loss is due to the EMR implementation, it should come back. If it is primarily gone, then changes need to be made to restructure to offset a revenue decline. Clearly the best solution is to bring the productivity back to the pre-EMR state. The balance of the request was to offset the increase in travelers from a historical run rate of $400,000 in 2018, $690,000 in 2019, and then $2.3 million in 2020. This expense should have an offset in salaries at approximately 50%, so approximately $1 million. Typically we said travelers run at about $20 of what would be staff's cost. There will always be variances in the budget, and it just seems a mid-year rate increase at this point to recover $1 million, which is half of the nursing staff travelers increase, does not seem warranted and should wait until the 2021 budget cycle. The hospital has stated they have been doing cost cutting and cost optimization to offset shortfalls, and they don't feel they have more to offset. But in order to be financially stable and sustainable, the hospital needs to put together a plan that supports lower revenues if they're not going to get the revenues back from the EMR, and not have such a reliance on making up the shortfall with commercial rain increases. So with that, I will kick that off to everybody. I'm happy to jump in here. Somebody else wants to speak? Go ahead. Okay. So I actually, you know, have a lot of agreement with what Maureen just said. I'm sympathetic. All of our hospitals are financially vulnerable right now, and when we immersion this, we're going to have a ton of work to do to ensure that our system is strong. We're going to probably set a span of delay plans from everybody, is what I think. But Northwest is coming to us now with a one off mid-year emergency adjustment. And if you actually dig into it, it's really a 19.5% increase applied to hospital services with 0% applied to the ambulatory care. So when you annualize that, when you consider we had a 5.9 already last October, and you add that to the 19.5, we're talking about an annualized increase of over 25% for hospital services at Northwest. And in my time at the board, I cannot remember ever allowing such a substantial rate increase, especially not mid-year, and frankly, with so little documentation. We're in unprecedented times, but we have to remember this is a pre-COVID request, and I'm still unclear as to what's happening at Northwest. If it's lost volume due to EHR transition, that should come back. If this is the new normal for Northwest, then where did all that volume go and why? In their written submission, they talked about losing physician FPEs, but then at the hearing, they said that didn't sound right, but we never got a correction in subsequent correspondence. So I don't really know what's happening with staffing, what's driving this lower volume, whether it's the new normal or not. If it's temporary, it should return without a need for a permanent rate increase. If this is the new normal, then I feel like we need far more information about how they're going to adjust to this new lower capacity, how they're going to meet community needs before we could possibly, in my mind, approve a rate increase of this magnitude. So I can't support it at this time. I would really need to see that they've left no stone unturned before approving that. And particularly the time when businesses are facing closures, job losses, furloughs, uncertain financial futures, this rate request seems a little out of touch with the reality that they're facing for monitors right now. So my suggestion is instead of a 25% roughly annualized rate increase on acute hospital side charges, I'd love to see them look a little bit closer at expenses. If these are really new lower volumes, then there should be a substantial adjustment downward in expenses. Service lines need to be reviewed even more vigorously. I want to understand the ICU. A large proportion of the $2 million traveler's cost came from the ICU. It seems like, I don't know, I don't have an actual real sense of what percentage, but it seemed as though that was one of the drivers of that traveler's cost. Is a six-bed ICU necessary with an academic medical center 30 miles down the road? What is the average daily census there? How much would Northwest save if its critical care unit closed? Could Northwest patients be absorbed? I don't have the answers for this, but I feel as though since that was one of the major cost drivers, we would need to know those answers before we could support a rate increase of this magnitude. I really want to see a sustainability plan that reflects local community needs, a full analysis of their contribution margins by service line and the recognition of what's available down the road. I'd like to know where other revenue sources are. They hadn't reached out to Diva, had local donors we solicited. What's happening with federal money? There's a big new ask of the government now for hospitals to have another round of funding. So before we do a permanent and massive commercial rate increase, I'd want to know what was happening with with other potential revenue offsets. I'd go back to the point I made last week. I think that, you know, I'd rather see Northwest use the 15 days cash on hand necessary to cover the current shortfall. They would still be above the Vermont median in terms of days cash on hand and it seems to be a better solution than an unprecedented rate request that's forever baked into commercial charges and ultimately into consumer insurance premiums, co-pays and deductibles. Now I want to say this is this is a hard position to take because I sympathize. I really do with where Northwest is. I know the pain is real and the timing of these shops could not have been worse given COVID. And I what I would like to see is that we revisit all of this again in July when the budgets are submitted, July, August, whenever those might be, when we're better able to assess how all hospitals are fairing, not behind fairing, how much financial support has been provided from the federal government? How much, what happens to utilization now at Northwest post EHR implementation and post COVID? So I'd rather look at the system holistically and so I can't support this right now with the data that I've been given. Thank you, Jess. Robin or Tom? This is Tom. This is a little bit difficult because there are some areas that quite frankly don't have much to do with this request that I am sympathetic, that make me somewhat sympathetic and that is the five-year charge trend of seven-tenths of one percent which is very low, well below any system-wide average. And you know I wasn't around for a lot of that but I would think it will have been a wind in the face of the hospital for these past five years. Also the payer mix, again something not directly related to this request but you know Northwestern does not have a you know a great payer mix at 49.2 percent commercial versus 17 17.6 percent Medicaid well as compared to the system at 54.1 percent commercial and 11.4 percent Medicaid but that said you know I'm looking at the annualized amount of this increase if it were granted and it's you know on a 2020 annualized basis and it comes exactly to the sum of these two moving parts with one being the EMR and the other temporary staff at nine million dollars a little over nine million dollars and so if these are granted and rolled into the face as we head into the 2021 period you know that's a that's a pretty substantial rollout. So my you know while I'm sympathetic there are so many moving parts here that aren't being addressed in terms of the FPP snafu which is a five point eight million dollars the investment and gains and losses the integration with the emergency department request. I'm looking at Medicaid in this proposal where Medicaid would be dropping from their budgeted amount of 20 million five hundred thousand down to 17,600 so all of this burden is being shifted onto the commercial payers which just does not seem you know it's kind of a fair allocation so like the other two board members I you know I I'm looking for a healthy discussion of all of these including how this all integrates with the northwestern participation in the ACO which you know by every everyone's view is has been quite spectacular in terms of leading the charge as a hospital so but it's just hard to get my arms around this and the rollout of it into 2021 without going to a more thorough and comprehensive budget process that puts all of these issues on the table and that we all together can find a path forward that works as best as possible. Thank you Tom Robin. This is a tough request because while it is pre-covid there's so much financial change swirling around related to COVID that I think it is difficult this particular year to grant a pre a rate increase without understanding the full picture and understanding the picture on a statewide basis I do think of the commercial ask as a kind of a statewide analysis that we need to be thinking about because we do know they have a direct impact on commercial premiums and I think we're going to see as we move into the regular budget process quite a bit of pressure on the rate side now with that said if we were thinking about this as a global budget we would be looking for traded trade-offs between price and volume and so I hear what North West is saying that overall an increase in price to the decrease in volume would even out but I think again it's too hard to do it as a one-off given our current situation so I think I'm on board and consistently what everybody else has said. I would just say that I think we're going to have to I'm kind of glad we pushed the hospital budget discussion by a week because I do think we have to for that discussion think about how we're going to approach rate increases and volume declines in a create more creative way than we have been able to in the past. Thank you Robin. Councilbarber question for you since we took public comment on last Wednesday and we also had the open public comment period do we need to throw it back out there again right now yes okay thank you so with that I'm going to open it up for public comment would anyone wish to make a comment hearing none is there a board member who would like to make a motion I can do it if nobody else wants to but I'm happy to have somebody else do this one. Go for it Robin. I move that we deny Northwestern rate increase request. Is there a second? Second. Is there further discussion? Hearing none Councilbarber if you could call the roll. Member Holmes? Member Pelham? Yes. Member Eustaford? Yes. Member Lunge? Yes. Mr. Chair? Yes. With that is there any full business to come before the board? Is there any new business to come before the board? Hearing none is there a motion to adjourn? Second. Second. It's been moved and seconded to adjourn all those in favor signify by saying aye. Aye. Aye. Any opposed? Thank you everyone have a good rest of the morning.