 and solve complex problems smartly and creatively and should have a room to do that. I'm not gonna touch on all these. You heard plenty over the last two weeks about this list. I just want to highlight a couple for purposes of kind of an overview. Workforce would be the first thing I think we need to highlight because there was not a single presentation out of the 14 that didn't mention that. And it's not just physicians and nurses, as I think you heard. It's people all along the continuum of care and throughout the hospital. So it's IT people, and you're not only competing with UVM Medical Center and other hospitals for IT people, you're competing with other kinds of companies that need that expertise. So it's not just caregivers in that category. And of course, as I mentioned in my public comment a week ago at the UVM Medical Center here, it also creates wage pressures and cost issues across the state as we try to manage those challenges. Next I would just talk about bad debt very briefly. I think you heard many, if not all the hospitals talk about how they do see a growing number of bad debt. We are compiling that on a system-wide basis and it does appear that bad debt looks to be in close to the range of pre-affordable care act levels. As Tim Ford mentioned in his presentation, the Affordable Care Act is under constant assault whether it's suspending the CSR payments or creating uncertainty in the insurance market, which is a continual problem that contributes to the bad debt issue. And then I would say as far as the final challenge I would highlight on here, it's really the challenge that I mentioned earlier in trying to do all the things hospitals are expected to do routinely and every day in community-benefited caregiving, but then also moving into this risk-based payment arrangement and doing it while you're, as you've heard, a small hospital, a small hospital in the struggling community, a small hospital maybe with a very thin margin or a negative margin, and still saying I understand the importance of this and I'm working on it. So I just think that's something else to keep in mind. To extend the federal pressures conversation a little, I think hospitals left this out. You did hear from a couple. Tim, I thought was articulate about talking about what you've used federal pressures, but most hospitals didn't talk about it. What you did hear from almost every hospital that came before you was that 340B is critical. It is literally the bottom line maker for many of these hospitals. And I just want to emphasize one point on 340B, in addition to what the hospital said about its importance, is that I think it's worth reminding everyone who pays attention to these issues and has the stake in it that 340B, the program does not involve taxpayer dollars. Really important to remember. These dollars that create the savings come from pharmaceutical companies. And then the last thing I want to say on this slide is that whether we're talking about payment rules that occur at the federal level, so that could impact things like your dish payment, your Medicare kind of hospital status, all of those sort of Medicare categories that can change and swing budgets a million or two or three million dollars at a time or even more. But there's one thing that's not on the slide here that I think may represent the greatest federal pressure going forward and that is the tax cuts and jobs tax of 2017. As you probably know from just following the news, the tax cut law that was passed late last year adds two trillion dollars to the deficit over the next 10 years and that's a conservative estimate. Healthcare economists widely agree that some of the impacts of this will be a higher budget deficit. That's not even up for dispute. Greater income inequality across the country and then the two most important things for our purposes, significantly lower healthcare coverage and significantly higher healthcare costs. And as I sort of prepared for this and looked at some of the research that's out there on this topic, I found a fascinating article that I would encourage you to look at from the June 18 article of the American Journal of Public Health that looks at the implications for healthcare of the tax cut bill, the law. Number one, that it would erase some of the ACA coverage gains that we've made over the past many years, that it would diminish significantly funding for public health and simultaneously put pressure on Medicare and Medicaid at the federal level which of course denures to the states. And then three will significantly increase the rates of uninsurance which is likely to lead to higher levels of uncompensated care. And on that front I'll just read one brief passage from the article that I think is really important. Increases in uncompensated care in turn will shift the cost of caring for the uninsured from insurance programs to hospitals and health departments. Such a shift will almost certainly deflect both finances and attention away from the growing efforts to have community health providers, hospitals and health departments invest in public health, the social determinants and prevention. So growing debt means spending reductions elsewhere in the system and Medicare and Medicaid are prime targets because they are big pieces of the budget. And so I just think as we look forward, one final passage here says efforts to maintain these entitlement programs in an era of debt-fearers could have serious effects on public health by cutting discretionary programs such as those administered by the CDC and others that fund the nation's public health infrastructure. So I just mentioned that by way of demonstrating how significant the federal pressures can be and as we look out that both the decimation of the Affordable Care Act and the implications of that tax law could be quite significant. So I think that the Green Mountain Care Board and hospitals alike deserve great credit. We are quick to cite the statistic about $600 million in cost savings since the advent of the Green Mountain Care Board. And I think that's something that both the Board and hospitals should share sort of credit for helping to achieve. I would just hope that you evaluate this year's budgets. Two things, one, to take a systemic view. Clearly, it's your job to regulate every single hospital in the system, but I encourage you to keep a statewide perspective in mind. As I mentioned earlier to this board, I view our system as very small and interwoven and interdependent. And for that reason, what happens in one place is potentially past the entire system and worth making sure we always keep the broader perspective. And then secondly, as we work in this regulatory framework, squeezing hospitals too much or putting too much pressure on them, I really do think they threaten their ability to make the needed investments in health reform and the activity that's so promising in the space of the all-care model and accountable health communities. So just to close, I think probably the most important thing that I would close with is that we all share the same goal, which is really to achieve the triple A, right? Better care at lower costs with greater patient satisfaction. That's why we're all here. That's the work that I know hospitals are engaged in every day. It's the work they're passionate about. And I think you saw from the quality of the presentations over the past two weeks, I mean, I'm always just amazed at the quality of the people who work in these organizations and their attention to that issue. And I would just also say that part of the equation here is making sure that not only do we have an affordable system, which is so important, but also that we have a sustainable one and longing to the future. And so the actions we take today impact our ability to have that system for the long term. So I'm just gonna close by saying thank you again both for the opportunity to be here today and for listening so carefully to the hospital stories. This is a complex constellation of issues that you have to think about. Lots of moving parts. So I just ask that you do so by looking at every issue that's been presented and thinking about how those all work together. And do you remember hospitals motive and all this, which is really to do the right thing for the patients and the communities they serve. And with that, I will stop. Thanks so much. Thank you, Jeff. That has been very clear throughout the budget processes. The dedicated people that we have working in the hospital system in Vermont and properly speaks volumes for why we're always ranked at the top when it comes to outcomes as well in comparison to other states. So Mike, I was trying to give you time to get up there. I didn't want to interrupt you. You're waxing away. Whenever you're ready, go ahead. I'll start by echoing a lot of what Jeff said. I think this is a really important process. And I'm sure that despite one press person having been here for much of it, most reminders don't know about it. And so I really want to thank everyone who just faced this as well. It's more important than Vermont originally. I also want to say that I appreciate the board's efforts at finding a way to connect the different regulatory processes. It's a bit awkward for us and I think for the board to have one regulated entity in front of them and have both, as Jeff said, a focus on that hospital's performance and what that hospital's doing and a system-wide approach at the same time. When we ask the question, is your proposed rate affordable? I understand why, whether it's a large hospital or a small hospital for another regulated entity, why they squirm and why they have, to some degree, why are you looking at us? We're just one little piece in this big system. So it is somewhat frustrating from my perspective that many of these entities say, look at the other guy. And we both have to ask that question. It's appropriate to ask it of every hospital and it's unfair to ask it of every hospital and insurance company because the systems are indeed so regulated. I also think about affordability. Everybody knows that many Vermontis can't afford it. The care that they're, that the providers can't afford it. Many providers, everybody knows that affordability is a basic access, a challenge to access. And I think everybody knows it's sort of basic. When the cost goes up, more people can't afford it. Sort of, I just want to say it on the easiest way. If we're talking about milk, if the cost goes up, then you don't have enough money. So it's nothing sort of mystical about it. It's a basic thing that I think all of us know. It doesn't get us very much further than this very complex system, but I think it's important to make it simple. I also just want to speak for just a moment about what it means when the board approves a raid for the hospitals. In answer to our questions this season, by and large, most hospitals said that they considered a raid from the board to be a fix, right, to be something that they didn't negotiate with the carriers over. I don't know exactly whether the board means it that way or whether the insurance companies understand, how the insurance companies should understand it, but I do know that there's something of a disconnect. And so my one request, as you consider your hospital budgets before you, is that, in any clarity, you can provide so that when we see a decision by the board about what the race for the hospitals will be, we'll have a common understanding of just what that's supposed to be. Holds it to that hospital and to the insurance companies. And so with that, I really want to thank you again and I appreciate both the board and all the stakeholders who put so much energy into this. Thank you. So at this point, I'm going to turn it over to that to begin to lead us to where we need to go and we have limited timeline. Our decisions will be made by September 14th and we've written decisions by September 28th, I think it is. And so basically my goal and I've expressed this path is that when we begin the process today, we begin to see what our decision points are and for the board members, if we could start to really figure out a path, and I would say, similar to last year, it seems like we should be able to make some decisions on certain hospitals as soon as next week. Not saying that it's just that we would accept what's been presented, but some may have logical decision points that we could decide fairly quickly. And then of course, the problems will be following week and we may have to have an extra board, meaning the week of the 12th, but we'll play that by year and see how we go. So with that, I'll turn it over to you, Pat. Great, thank you. Thank you so much, Chairman. For the record, Pat Jones, Director of Health System Finances and Green Mountain Care Board. I'm joined here by Lori, Gary, and Kelly Thoreau. I want to repeat again what her heroic work these two folks have done over the past couple of months at this point to pull together staff analysis to really help shape the process and just be overall fantastic team members. Thank you both for being and many others. So what we want to do today is just trying to lay out what the decision points are for the board and try to give you some summary information for each hospital. We'll do it as efficiently as we can. But really, while the focus is on net patient revenue and on the rate increases or rate changes, there's a lot of other areas that you all need to make decisions along the way to get to those two decision points. So obviously, the key metric is NPR growth. And within that, you'll see that some of the hospitals have recommended adjustments for provider transfers and acquisitions and ACO accounting changes and other such things. And so those are some decisions that we'll just need or confirm if they've already happened or verify or not confirm. So just, can we interrupt as you're going to? Yeah. So I would just say on that, I think that a lot of what we'll do is defer to the staff analysis when it comes to the acquisitions and the provider transfers. But what we clearly would want to make sure is that it's within the timeframe that's allowed. So for example, Central Vermont Medical Center had a practice, I believe that doesn't start until October 1, correct? That's correct. So that would really be knocked on this year's considerations at my viewpoint. Right, what we'll do is make recommendations on each of those adjustments or layout if they've already been approved. That's a good example of something because those adjustments are really to the fiscal year 18 base, which is the base from which NPR growth is calculated. Something that is not effective in fiscal year, year 18 is not likely to be a candidate to have an adjustment. I'm going to just add to that the other piece to look at, appreciate the staff to look into is, the idea behind that position transfers and acquisitions was to take existing services that were already in the community and if they're just getting moved because of change of ownership, it could be an off-rant for NPR. If it's a new service, then I think it should treat it differently. I think it would be good to go look back for the actual rule, but language around that. I think there's some position that transfers and acquisitions that may fall into the category of new service. And I think we talked about this briefly, but there was the legislation and then there was a policy enacted. The legislation was a little fuzzy on whether it was just position transfers, but it does recognize that was for the benefit of consumers so they would notify patients, our policy did recognize that both in and out, but it does talk about existing services so it's not supposed to be a new service for the community and the reason it was recognized as I recall, back in the original policy that the board did was not only that the legislature had a stew policy, but because we were recognizing it was part of the overall health care community and that if we not have the same impact, had they put it into practice out of nowhere that was not there before. Correct, thank you. We also have health care reform investments that obviously impact whether or not a hospital is considered for the 0.4% health care reform allowance. So that's another area that we'll need to look at in terms of the honor of it. So if you're looking at that, one of the things that became clear is that mom and stuff, we should have something of a counting. It seems to me that we were pretty specific on which reform investments would be allowed this year so it wouldn't be as wishy-washy as in the past and again we would look for the staff to make recommendations on whether or not the investments truly are within the 4.0% we're laid out. Right, and I'll note that my list of miles from our staff has done a very good job of reviewing, summarizing the health care reform investments. I have a slight comment here. I feel like we're in a little schoolyard. Yeah, we're in a little schoolyard. Yeah, I just thought that would be nice. But one of the other things that occurred to me this year is it hadn't occurred to me in the past and I did take the time to look at each of the health reform investments. But if a hospital has taken a health reform investment in the past for a program or service, let's just say, and then discontinued that. I did look at that. Okay, well I was gonna say, can I finish and then you definitely jump in. It's in the base that health reform investment is in the base and then it's growing because of the impact it's growing. So I just think we should somehow factor that and we should look at it to see if there are prior health reform investments that were in the base that were now discontinued and now there's an ask for an additional health reform investment that may be related or unrelated, but I just wanna make sure that we're capturing that. It doesn't mean that we wouldn't have so improved the health reform investments that were proposed but I just think we should be looking at things that were introduced and then discontinued. And I did look for that and I didn't find any that were discontinued. Okay, perfect. This year? Great. Thank you. And Jacks? Okay, we already talked about other proposed adjustments. Those include just a couple of notable ones. Brad Burrow believes that we inadvertently reduce our NPR at 18 and so that's an adjustment that we'll need to look at and then... So while you're on that one, let's take them one at a time. Let's try to get some decision points made today. Could we do that when we're actually talking about the hospital? Okay. Because there's a paint on each hospital so all of my notes are on each of those pages. Okay. We'll follow Robin's suggestion. Thank you, Robin. I'm not sure if I will get to this slide. The match will be, can I get through a sentence? I think I can. Obviously, another key decision point for you is what to do regarding the rate. In this case, all came in with rate increases this year. Now, some other areas of inquiry that aren't on the slide that we've been discussing throughout the last two weeks are first of all, booking their ACO risk and reserves to cover that risk. And so that's an area that you may want to weigh in on how basically we heard that hospitals are changing. It's different length, it's new, they're getting their different advice from auditors and so forth, but clearly for the future of standardization as we embark on this new journey with the ACO on how to cover the risk is going to be important. And then one piece of guidance that the board gave to hospitals when we were actually issuing the guidance was to discuss how they come in against their 18 actuals. We ask that as a standard question. One of your projections for 18, we ask them to update that during their presentations. And especially for some of those hospitals that are continuing to be over, but also the ones that are coming in under as well. That might be another area of consideration as well. So I will stop there for a moment and see if you think we missed anything that we haven't already discussed any other areas where you think you're on the hook to make decisions. So if I could jump in. I would add the CON follow up. So one of the areas we needed to look at was specific to a change in the CON law. And I actually have a proposal about how we do that, which would be not that we try to do all of that follow up and analysis in the next two weeks, but that we include something in the budget order for those hospitals that addresses the need to do that follow up so that we have the opportunity to do it. But it's not a huge lift for the staff. And if you guys need help identifying which I asked the, I sort of went through all the CON information in the packets and tried to identify the hospital's work that I think we need more information and asked that during the hearings, but I can go back through my list with you if that's helpful. Great, thank you. So the one comment I would make here is on the question on how hospitals are treating the ACL risk. I think we've had several conversations, Pat, and I think that we really look for Jeff and Michael and people from VOS who work with your team to try to figure out a way that basically they're standardization. We should be able to as a board put out a request for information for the budget approval that gives us information that's standardized so it's not being treated differently by different hospitals. And the ACL risk is just one example of all of them. Sometimes it's not apples to apples. So I think that not to layer on work to you, but I think that's something that's gonna have to occur after we get through this year's process to convene a group along with VOS to try to create better standardization as far as speaking to financial statements. Yeah, I think the staff concurs with that. Kelly's so far resident expert on all things ACL, but we agree that there's been enough questions or uncertainty and everybody's definitely doing the best that they can in the accounting for the ACL. Not only the risk of revenues and so forth, but we agree that during what I affectionately call the off-season, which I'm not sure there actually is one, but we agree that that would be a good time to really, those who are directly involved with the giant standard. We're actually gonna insist that you've got something that the off-season have to know. Receiving emails after two o'clock in the morning is a little bit crazy. That's a long-standing answer. I just have a quick question about related to ACL risk treatment, standardization, I totally agree with you on standardization. Just in general, there were some hospitals that did not book fixed payments in their budgets, but declared in the narratives that they were in negotiations or planning to be in the all-fare model of one care. So I'm just wondering at what point in time would we reconcile if they've made the decision to join one care on one, two, or three payers, but their budget doesn't accurately reflect that they're in, yet if there's more information coming out in the next two weeks from some of these hospitals, they're in negotiations now, how do we deal with that? I'm gonna look to the team on this, but my first thought is that we definitely would wanna look at that in actuals for sure because if they begin participating, we'll start part-way through the fiscal year on one one, we'll start to get those monthly payments, at least for Medicare or Medicaid if they're participating in all the programs, and we think of start to see that in actuals and do some reconciliation at that point. I mean, it really means that last fee for service, revenue, more FPP. Do you, Maureen Kelly, do you have any other thoughts about that? Nothing, I think it really, it materially changes the NPR and FPP calculation that we've wanted to amend the budget, but if it's not, it's just a change or reclassification of everything that you don't have it changes, or we just still change it so that we take into consideration the FPP. I think for the 2020 process, we could probably put together a reconciliation of some sort for this year, so we could look at how the different hospitals recorded things this year and get an apples-to-apples comparison for this year versus, or for 2019 versus 2020. I just wanted to add one bit, on the ACO, the accounting, just set out there that how the hospitals have submitted it and how we roll it up can be different and probably it will be different. Specifically, as we talk about risk, I understand some of the hospitals feeling the need to put that risk into their P&L and talking to their auditors and they need to have that in there. I was strongly put out that I don't think it should be a reduction of NPR and it could go into another revenue category that we needed to because that clearly is a differentiation between the hospitals that put it as a reduction of NPR. A point-out porter did a $2 million, which is fairly significant, versus other hospitals that didn't and so we're kind of comparing apples to oranges there, so I think we are gonna need to make that determination. We may say that we allow them to put risk into their budget, but it may not affect the NPR calculation year over year, otherwise we're dismanaging some of the other people who don't put that risk in. Yeah, Maureen's been, as you remember, self to this team in general, really has served as a mentor for us, but has been particularly focused and articulate on this issue, so there's definitely some apples to oranges or at least a brandy cement, a red, so let's just take a few packs. Can I just chime in on that? I would be interested in other people's thoughts about how that either induces or doesn't induce hospitals to take risk in general. Like, in terms of whether or not it's in the NPR calculation, it seems like to some extent that kind of privileges people who stay in view for service. So I don't know, I'm sort of thinking out loud here, so I just pose that for people to think about that. Yeah, I would almost say the opposite in some cases because it depends, like if a hospital books risk, and they actually put the risk into their P&L, then they're absorbing, they're supposed to get a hundred million and their risk is three million, so they actually book three million dollars worth of risk and they take that to the bottom line on the P&L. They actually have to make that up somehow by either increasing rate or because they're losing that three million dollars. I do understand that they couldn't necessarily absorb that three million in their P&L, but on one hand, this risk is upside or downside, so it could be three million favorable and three million unfavorable. So it's a tough one as far as if it's, if we said, if we made a directive that some hospitals are putting risk in and all should, that certainly would probably be a disincentive for hospitals to do it because how can all of a sudden somebody book some of these bigger hospitals, book 10, 11 million dollars of risk onto their P&L and hit their numbers, so it's a tough one. Yeah, thank you, I appreciate your thoughts on that. And my concern is, we faced this last year, if they book the risk and then increase the rate, the coverage is not really risk, but that's true. So we have to make sure that we're managing that. Yeah, and that makes sense to me because, but, and maybe I'm being too simplistic. It seems like depending on the hospital, booking either making it up is great. To me, it's a different issue from the NPR, although they're obviously connected, depending on the hospital and what their volume is. Okay, ready to move on? Sure. So, what we did for each hospital, I'll just give you, we're not gonna go through all of this data for every hospital, we're just gonna hit the high points. But what we did, just to give you a tour using Brown, what it was, was first we identified what we thought were some key financial indicators reflecting health, financial health, the fiscal year 19 budget, operating margin, and then days kept in our hands. So two metrics that might give you a sense of how the hospital is doing. We then showed the fiscal year 18 approved budget, and then if there were any adjustments that were recommended by the hospital, we put those in as well. And so this is an example, this is the Brattleboro adjustment. Speaking of ACO risk, last year for Brattleboro, they built their risk in and then they raised their rates to cover the risk, and so we found the board indicated that would apparently be risk. So in the order, their rate was reduced, but their NPR was also reduced so the way that they accounted for that risk, it didn't impact their NPR, so it was reduced when it really wasn't in the NPR. And so they had brought this to our attention right after last year's budget hearings, actually, and after the orders came out, and we were going to deal with it in the spring, but with the transition that didn't happen, so they were requesting that their 18 budget had that $1.3 million in the store. Then we show the 19 proposed budget and then the NPR growth rate. If there's an adjustment, we show the grocery with and without the proposed adjustment, so without Brattleboro's $1.3 million adjustment to 18, it's a 6.5% NPR growth rate. With that adjustment, it would be a 4.8% NPR growth rate. Then we show the health care reform investments that they proposed ending the amount and what the percentage is of NPR, so that'll give you a sense of whether it's over or under the 0.4% allowance. I want to note about which ACO programs, if any, that they're participating in, in the case of Brattleboro, they were one of the early adopters who are participating in all three ACO programs in 18. And then the rate requests, so in their cases, 4.9% is the requested rate increase and then we show the estimated value of what a 1% rate increase is worth. In their case, it's just under $400,000. And then we add one of the decision points for you. So in this case, the decisions are, do you accept the proposed adjustment to that fiscal year 18 base NPR? Do you accept their proposed health reform investments? Do you accept their proposed NPR? Would you accept and same with the rate increase? So let me stop there and see if this, hopefully this is helpful information. I think this is very helpful and gives us a good template as you go across all 14. I would just say that for me, I actually thought they made a compelling argument to for the adjustment. And I'm not convinced so that they made a compelling argument that they should have the 4.8, which is 1.6 over the guidance. And I think that's for a much further discussion. But I'm just curious if other board members felt that they made a compelling argument as well for the adjustment to the base NPR. Before I go there, I do think they did. I think that's something we should just resolve last year, over its tough when they do it now and they're not even hitting that number and they're hitting where they came in. But I do think they should get that. Just on the format of this chart, I would ask if you could add two things, which is a total margin, not just operating margin, because many of the hospitals are showing some good solid numbers in that. And they actually, as we saw today, some target 0% on their operating margin because they have money elsewhere there. So I'd like to see that. And then on the ACO, to the extent you could put in, maybe put in two numbers, one, what's the total risk that they believe that they need to be absorbing on the downside? And if they put any of that into their P&L, and I know some of them are still trying to figure out what they do, whether they budget it or they don't budget it, or they book it in actual, so there's some disconnects there, but clearly some hospitals put some of that into the numbers and understanding if it is and where would be good to Kevin's first point on the, yeah, the 4.8, we just didn't do that correctly last year. And they did come in for an adjustment and we should have just adjusted that as my whole view on that. I won't go into the other words. And just to answer your question, I agree that it should be an adjustment. I think I was in that room with you when we had the first conversation with them last fall and I think somehow in some way it just did get accomplished, but I agree with you. So maybe we could start with that as the, where they're starting with the other three. Does anybody disagree? I was in here, but I read the material and it goes back right after the decision that made it so it's been on the table. Yes. Now I'm surprised that it seems reasonable to me. I would agree. I have one other comment about this hospital. Yes. I can jump in. So, Broadover in their healthcare reform investments included both the ACO fee, which is something that we explicitly list as an example and allowable, but they also included the deductions from the fixed perspective payment for the primary care PMPM and the care management fees. I think that is the deduction. So we need to check that. That would be different from what we've done in the past. And since those payments are basically a redirect from the hospital to primary care, if it's going back to the hospital through the primary care doesn't make sense to me that it would also be a healthcare reform investment that allows for additional NPR. Rutland is the other hospital that did this. They're in a different situation in terms of their primary care, but we should have a discussion about how we want to handle that, because that's something that could affect any hospital in the ACO. So I haven't talked to staff about sort of their thinking on this. It's probably premature to make a decision on that today, but it is an issue that we need to resolve. So one of the things on that Robin, is that I think we really need staff to do, like in this particular case, they talked about a 1% allowance for healthcare reform. We're allotting a 0.4. And so the discussion on this one may be mute. Right. If the allowable is still covered by the 0.4. So we're going to need those calculations really on. I think it did go over because I was looking at that when I was myself looking at it. It would result potentially in a below the 0.4, if I'm right, that it is introduction from FDB. Okay, we will see what we can do to quantify that. Just a quick question about process. So I didn't anticipate today that we would sort of lay out what the decision points are for each hospital, but I understand that there's what you might consider some low-ranking for decisions that you can make today. So if the board is prepared on this adjustment to make a decision, I guess my question is, does it require a motion and so forth? So I'm not so sure necessarily requires motion. Motion would be whatever we end up with the final NPR. Clearly the board has agreed to that adjustment. Okay. And I just want to add something on process too, Pat. I didn't anticipate any votes on any of the hospitals today. I thought this was laying everything out for what other information might be needed. There were some suggestions here all day, so I wasn't anticipating that. When we're talking about low-ranking fruit, that would just be more policy discussion and things that you may want to go back and look at for the board that they want to take a different view on or want some additional information. So contrary to Judy's point of view, any kind of decisions that we can make today, I think we should, because I remember the anxiety that was created last year when we got down to, I think it might have been the final four, the possible ones in that final week of decision-making. I don't want to go through that again. I'd rather start proceeding to get rid of some decision plans that can be made so that we're not stuck. And we probably will still get stuck in that same point that we were in last year, making some very difficult decisions in what I consider to be too hurry to manner. So I'm just trying to expedite this process. Yes, and I just want to also remind you that we still have an open comment period also. So as far as making any of the ultimate decisions, I would advise you to hold on to the answer. We're not going to vote on the ultimate NDRs or the ultimate rates today until after that comment period is finished. But I think that clearly we can determine which hospitals we think we could finish shortly after the public comment period ending on September 10th, which would be September 12th, and try to get the framework in place so that we can have those votes when we come in next Wednesday, and then turn the discussions on the ones that we can finish up and continue to try to make progress towards that so that all final decisions would be made by the 12th, so the 5th and 12th, I guess, I will say. Okay, so I'll actually just quickly move through the next few hospitals, and then Kelly and Lori are going to help as well so they can help to listen to them all the time. So for central, we're not at the center. Some of the key elements are that they are, requesting two proposed adjustments. One is almost 2.6 million for an ACO accounting change, and that's basically how they accounted for their ACO participation fees, and that would increase the 18 base. And then they also have some provider transfers that they had requested be added into the 18 base. One provider transfer that they requested was the one that Kevin alluded to earlier, which was, it was 251,004 of dermatologists who will not be present until 10-1 of 18, which is fiscal year 19. The staff is prepared at this point to recommend that that transfer not be included as an adjustment to the fiscal year 18 base, because obviously it's not part of fiscal year 18. Does anyone on the board disagree with that? Okay. Okay, we should not talk about the account change. Yeah, we gotta talk about the account change. So just on the accounting change on this one and for the UBI network, I mean, what I would propose is that we keep it the way that we normally, that we have looked at it historically. I do understand that this may be the way that they need to change it on their reporting, but we'll be kind of half the hospital or half the total ACO piece will be done one way, which is an NPR and half wouldn't be done that way. And I think it's harder for us to make that decision on that. So they may need to account for it where they account for it, but I would suggest that we look at it apples to apples this year. And as we talked about, we need a separate group from the course of the year to just hash out how we look at it. So just to clarify, you're recommending that we not adjust the 18 project for that accounting change? Correct. But that's... Wasn't it a deduction last year? Like, wasn't the net included last year? Isn't that... So maybe I'm confused, but I thought that the difference was the way the other hospitals are doing it this year and these guys had done it last year is that they just had the net of the FPP minus the withholds and the net was included in the NPR. Am I wrong about that? And that what they did this year if they put the whole thing in and then subtract it out later? Yeah, what they did is, the net is how everybody was doing it. What they did this year for 2019 is they took all the participation views and they put that in expenses. So it's completely out of NPR. So they have some of their ACO stuff in expenses where everybody else has a net of NPR. We would have to make adjustments on our schedule though to adjust their expenses out of expense and put a net of NPR to make it apples to apples. It shouldn't be that far off what they're saying. So what we're showing in our schedules is not correct either because the way we reported it in our schedules was 2018 as they had it and then 2019 with a higher inflated NPR, if you will, and money down in expenses. So what we're showing on our analysis is not correct either. It's gonna be closer to what they have, but what we're showing on our analysis is a lot of possibilities and we need to change them. But their 2018 budget, has it netted in NPR? And their 2019 budget has it in expenses. All I'm saying is however they reported it, we did not change it. The other thing that I understood in the public misunderstanding is the UVM network, those fees were actually to true up fiscal year 17, their 17 to true it up to match the ACOs fiscal year 18. So last year had from September through December was their fiscal year, our fiscal year 18, but it was the hospital, the ACOs seven, so that's some of that money that's in there too. So it's a complicated issue that we definitely have to discuss with all the hospitals. For us to then change their submission so that it's the net like it was last year and that way we had apples to apples for NPR and not inflated. Right, I think now it would help make the decision and then harder it is because we didn't find out about it until they put their submission in, although their auditors told them about this in January or February. So we potentially could have had some time to work through this, but we found out about it when the budget submission came through and then they made this accounting change. I think we should just look at it the way we historically looked at it. So we can try and put some looks together on this. You know, get a little more concrete on it to give you all some reaction. How was that time for next week? Sounds good. Okay. So September month with proposed adjustments, their NPR would increase by 6.5%. With all adjustments it would increase by 5%, obviously with the removal, the dermatology adjustment it's going to end up somewhere in between and we'll get that figured for you. And of course, we all know what happened with the NAACO accounting, you know. They did also request 0.4% in their foreign investments and they of course are participating in all three ACO programs in 18. Their rate request is a 2.8% increase. Estimate value of the 1% would be about 1.2 million. And so again, your decision points around the adjustments you can make one decision on any healthcare foreign investments NPR rate increase. As proposed, a budget that would represent an NPR growth rate of 5.9%. There are no proposed adjustments to their budget. They did request some in healthcare foreign investments just over 66,000. That represents 0.1% of NPR. So it doesn't rise to the 0.4% allowance. So if you were to use your guidance on earlier in the year, they would be looking at potentially if all their healthcare reform investments were approved, a target of 2.9% rather than 3.2%. They are not participating in ACO programs in 2018. All the hospitals are discussing potential participation but we haven't heard from top leaders at this point that they're definitely participating in 2019. And then their fiscal year 2019 rating request is 7.9%. The value of a 1% rating increase is just under 400,000. And the decision points here are whether to accept or propose healthcare reform investments except that it proposes NPR and the rate increase. The next question before you go in the spirit of kind of healthcare reform investment, it was related to the staff recommendation on their healthcare reform investment was to accept it. And I agree with that. So I don't know if anyone else had an issue with that or if we could just sort of say Copley is okay with their point one. The 66351? Yeah. Does anybody disagree with that? I can tell you what it's for. Yeah, what's it for? It's for social worker to continue to reduce ED utilization, Riser month program coordinator and health promotion. I think and... So the social worker's new? It's an increase. So this is just the delta between 18 and 19. So it is new and Riser's new and the health promotion is new. I believe there's community grant in there as well. Yeah, thanks. The CNN, CHNA implementation plan, that's only 10,000. I'll just say for that one. I mean, it's $10,000, so it's... It's not really a magnitude, it's not maybe it doesn't make it a problem, but here's my concern that it was just a bucket of money that is to be allocated at some point later. And that concerns me because I think that's a slippery slope to start improving a bucket of money to be allocated later. So the fact that it's $10,000 doesn't really worry me, but I am concerned about that as a precedent that would be set. And would you want to either, because we have them requiring reporting on past investments, so I think we could look at what that was actually spent on from the reporting or we could just allow it. I think we could look at, I mean, again, it's not a big issue for me, it's just I want to raise the issue of the precedent Senate. Yeah, I agree. And if we start to go down the path of having to look at past reporting and justify future reporting, then as those buckets get larger in the future, then we have to start looking at more past expenditures and assume that the future expenditures will look like the past expenditures or whatever that we can do that. So I'm just raising the question. Maybe it's for a larger conversation later on. Well, I guess this is not going to be an easy question. The answer is no. I guess not. I'm just moving on. I thought it was a small number. We'll move on. Okay, we'll give you another point at the end. And then, so the decision points here are proposed health care reform investments of proposed NPR, proposed treatment. The next is Gifford. Gifford has a proposed NPR growth of minus 6.1%. You'll probably remember from our earlier discussions on fiscal year 17 actuals, that they were running 20-day under budget. So their NPR number average is minus 6.1%. They did request a $590,000 health care reform investment that would be worth way over those year of 0.4% allowance. It comes in at 1%. They are not participating in an ACO program since 2018. And they've spent quite a bit of time talking about, you know, a blind path for them to begin to participate there, definitely. One of the hospitals in discussion. You know, I'll just note that with a minus 6.1% NPR growth, they are well under the 2.8% target that you all set in the guidance. They're also running even lower than the minus 6.1. I think there are projections for 18, but they don't have to have health care reform investments more than you're talking about. Their rate request is at 4%. And the estimated value of 1%. And the rate is 402,000. And so the decision points again, if you wanna make a decision on their health reform investments, there are a few on it, I'm not reading it. So to me, the health care reform investment isn't a decision point because they don't need it to make the target. So I would say with any hospital where I appreciate getting the information and knowing what they're investing in. So I like getting the information, but I wouldn't approve or disapprove. I would just say you don't need it. You don't need to get to that question. Looks like there's consensus on that. One less thing to do, that makes sense to me. All right, anything else on paper? Okay, great start. They oppose an NPR group of 3.5% over 18. They did not request adjustments nor did they request health reform investments. If they had the 0.4% allowance would have been close to 75,000. They are not participating in ACO programs in 2018. Their rate request was for 3.2%. The value of 1% of rate increase is 88,000. The decision points are around NPR and rate increase. Thanks, Pat. One thing actually that would be helpful is to show where their 18 trends are as well. And I guess you could put two numbers in. One is budget to budget, then so budget 18 to budget 19. I'm sorry, that's what we have. But the other is for 18, where their actuals are coming in because this one, this would be one we could probably start to move pretty quickly, but their NPR group at 3.5, they're missing their numbers this year. I strongly support that. There are a few hospitals in the world between budget to budget, and in the 2018 budget are very different and I think they're important to have the right in our faces when we're thinking about that hospital. Okay. We have a sheet. I don't know if this is helpful, but I've been looking at the sheet with this sheet and to me between the two, I don't need everything all in one page, but that's just me. Don't be right, we do have that chart. So, just to break this point up too fast, because this is not in Obama-Scotney as far as the health reform investments being a zero request. If you're looking at that 3.5 versus 2.8, and I know that we did extend the olive branch to Obama-Scotney to come back to us to try to define any healthcare investments you might want to, if we're going to be fair to everyone, if we're going to do that with Obama-Scotney, we might want to extend that same request to Grace Cottage. We're happy to do that when we chat to them. I found Grace Cottage is more definitive in their narrative that they weren't proposing health reform investments. Mount of Scotneys was a little, I think it was a little unclear then when they came today with a really pretty impressive list of health care reform investments. It seemed clear to me that those tables were a little confusing, because we had two different tables. One looking at prior health reform investments, and one looking at the proposed for 19. So, I'll make a commitment to you all that we'll try to provide more clarity around that. Should you decide to offer an allowance for health care reform investments next year? And then the last hospital I'll cover is Mount of Scotney Hospital Health Center. As you heard today, Mount of Scotney is coming in at an NPR growth rate of 5.2%. I don't believe that they are asking for $0 in health care reform investments, so we'll circle back at that as we just said. They are participating in the Medicaid ACO program in 2018, but as I think we heard today, they're planning to participate in all three in 2019, so that's no. The rate request is 2.9%. I'll just sort of note that I found it interesting that they are focused on attempting to reduce rate increases, and that they seem to be suggesting that they would prefer a more fluid process if they were coming in with revenues higher than anticipated that they might be open to making an adjustment part of the year. So just sort of put that out as food for thought that when you make your decisions, you might, yeah, you might choose to put something to that effect and to the budget order. So the decisions here are again on NPR and the rate increase. Pat, actually, you just made a really good point about that it was notable that they might be in for all three. I'm wondering if you could just add that to the template for those hospitals. I mean, I know something around the fence, but the hospitals that through the hearings have committed to all three, one or two. Yeah, yeah, I mean, the ones that I heard most commit, and correct me if I missed anybody, but definitely, that looks got me, and Robin was the one that seemed to clearly state that their plan is to participate in Medicaid online for 19. We'll go back and notes and see if there were others but those were the two that still have for me. But even just knowing what friend builder examples and for all three would be helpful and it's going to be okay if you're going west or being in for all three for being. Well, I put those on, that's on that sheet. Well, I mean, what's in there, okay, you raised a good point, because what's in there is that they participate in the 1890s were sort of making a presumption because we've heard nobody that's currently participating saying that they're dropping out. But we can clarify that. And just, are you saying add what we heard for 19 as far as we know today? Correct. Because some of them have to be. Yeah, yes, yeah. Okay. That'd be great, thank you. All right, so at this point, I'm going to turn it over to Kelly and she's going to cover the hospitals that start with north of Las Vegas. So starting with North Country Hospital, they submitted a proposed NPR growth of 3.1%. They have no proposed adjustments for healthcare reform investments. Their request amounted to 0.5%. And they are participating in the Medicaid ACO program for 2018. Their FY19 rate request is 3.6%. And the estimated value of 1% of that rate increase is just under $650,000. Your decision points here are accepting whether or not to accept the proposed healthcare reform investments, accept the proposed NPR, and to accept the proposed rate increase. So I'm going to make another stab at this. They're also, they are in for all programs in 2019 for the ACO. And they're to healthcare reform investments or for an ACO character coordinator and the increase in the ACO those dues from 18 to 19. And the staff recommendation on both of those are to approve. So unless anybody rejects, I would say go with that. Just to take one thing, just to take one. Well, I wanted to be careful what I'm agreeing to because I came up to more than the 0.4. Right, well the 0.4 by our guidance is the cap. So in no case, even. But they're less than the 3.2. So. Oh yeah, never mind. So my point is that. We don't need it. You will partially need it because right now it's 0.3. Right, so we need to be approving 0.3 to get them up to the 3.1. Correct. Is that a yes? Yes, it is. Okay. Just checking. Okay, anything else on North Country? Okay. Moving on to North Leicester. They did propose adjustment to the FY 18 base for a provider transfer, which was already approved. Cardiology transferred from CBMC to NBRH. Their NPR growth without the proposed adjustment would be 5.0% and their growth with the proposed adjustment would be 4.8%. For healthcare reform investments, they requested $300,000, which is 0.4%. And they are not participating in ACO programs in 2018. And we heard about 2019 as well. For FY 19, their rate request is 4.0%. And the estimated value of 1% is $384,400. Your decision points here are to accept the proposed adjustment to the FY 18 base. Can you remind us what those were, Kelly? For which? For the proposed adjustments. What were they? It's just a provider transfer that was already approved. And so your staff recommendation would be to approve that. So that's one that we could probably take off as a whole. Well, if it's already approved, then we wouldn't really need to re-approve it either. Yep. Yeah. So yeah, we were assuming that that was where we were going. So then the others would be to accept the proposed health reform investments, accept the proposed NBR, and to accept the proposed rate request. On their health reform investment, sorry, Jess. No, I didn't hear you. I was going to say, I go for it. So they were here, they were on maybe on the 2019 Medicaid. And their investment was at least in, I can pull it up in front of me, but 200,000. 200,000 was for either the ACO dues or the accountable communities for health. And so I think we do need to clarify which they're talking about. And if it is for the accountable communities for health at that dollar value, then I want to know what it's for. I'll just note that one of our follow-up questions to them was, if it was the accountable community for health, how would they be measuring success on that? And we did get some follow-up from Laura Robles like at 6 a.m. the morning after she was here telling us, you know, with a set of measures that they are using to look it out. So what are they actually using them for, was my question. Okay, yeah, that's a different question. The other thing that you should be prepared to come in with for next year was to think about what it is, this was one of those hospitals that we gave in last year's budget orders I tend to call it currently the ability to exceed last year's guidance in the ring back here again this year. And I think that that would be important information for us to have when we're making these decisions. Yeah, I think there's a few others to fall on that hold, at least one other. Anything else on Northeaster? Okay, moving on to the last of the North, Northwestern. They did propose an adjustment. They did propose an adjustment to the base which again was a transfer that was approved the origin of their occupational health into the hospital. So with the proposed adjustment that would be 3.2% NPR growth requested without that adjustment which has been approved previously would be 6.3%. Can I clarify, they had four or five adjustments that were proposed somewhere early or one was approved which brought me to describe there were three others and among those three others some of them, this is why I brought up earlier some of them were for new services and they didn't exist in the community already. Both are not. Yeah, this is an area where I think we have to do a deep dive. Definitely, so we'll get that to you as well. For health reform investments they did request 0.4% increase there and they are participating in all three ACO programs in 2018 and 2019 as well. For F.19, their rate request is 2.0% and the estimated value of a 1% increase in rate is just under $530,000. The decision points there would be whether or not to accept the proposed adjustments to the FY18 base NPR, whether or not to accept the proposed health reform investments, whether or not to accept the proposed NPR and whether or not to accept the proposed rate increase. The proposed adjustment to the FY18 rebased budget which was rebased, we did make a note back here is an increase for the ACO accounting change which is similar to the CBMC change that Pat described earlier. For NPR growth without the proposed adjustment would be 4.5% and the NPR growth with the proposed adjustment is 3.2% for health care reform investments. They did request the full 0.4% for FY19 and they are participating in all three ACO programs for 2018. For FY19, the rate request is 2.8% for commercial only and negative 1% overall. The estimated value of 1% is just under $397,000. Your decision points here are whether or not to accept the proposed adjustment to the base, whether or not to accept the proposed health reform investments, whether or not to accept the proposed NPR and whether or not to accept the proposed rate increase. I would just add that another potential decision is what to do with the ACO risk as Maureen articulated earlier that has sort of suppressed their NPRs. Yeah, this one would have a significant change at three points to their request and can go up at $2 million. Yeah. Another thing I want to throw out for discussion and they've put it on the chart for the two hospitals that we rebased. We rebased because of over performance in 2017 and we made some adjustments for that 17. When we rebased 18, we didn't do anything as far as, we rebased them but we didn't talk about any overages that may occur with that. So I'd like to at least see where their operating profits are for 18, what their budget was and what they were projecting for the two hospitals that we rebased for 18 without doing anything on their bottom line. So I just want to clarify because we didn't rebase for 18, the motion that we voted on rebased it for 19. So they're still subject to that half a percent variance on what we actually approved for the 18 budgets. And that's what Justin's motion had been when we made that vote was to rebase it for 19 after 18. It's all the same request. Look at what they're doing on their own for both of those. You can just throw out something that this might be crazy so. But it relates to what you're all talking about with UVM Medical Center quartered on CVMC. And I'm just wondering, this is the first year that they actually presented an entire budget together. You know, it's sort of a system wide look. And I just, I want to just throw out this concept of, do we treat them as a system in our budget order? To the degree that, I don't know that we can even do this this year, so this is why I'm making it crazy. But to the degree that the UVM Medical Center is trying to push back care to the CVMC and quarter, we're going to see higher NPR and those hospitals if they're actually trying to move the care to the local communities. It should be offset by lower care at UVM Medical Center that can all be accomplished if we actually treat the entire network as a system and impose an NPR for the whole system and actually have them manage to it and impose a rate increase to the whole system and have them manage to that. I'm just wondering if it's too late in the game to do that or we'd even think about that or is this just crazy, Jessica speaking? Well, I would say that at this point with two weeks left to go, I don't see how we change the rules of the game for this year. But it's certainly something that should be discussed next year. I mean, my sense is it's to stay the course because that's what we've been working on. But it might be helpful if we had the information as to what it looks like system-wide because obviously that's a track that I think they want us to be on and we want to be on. And we can at least start the UVM. And I think it is easy to blend three but we can start to see what it looks like as a guitarist. I would just add that the board would certainly consider that as a factor when making decisions. I think that what's not too late to say, we'll look at the system-wide. I mean, you can do it. It could be a mitigating factor in some of your decisions if you wish to do it. What I like about the idea is that it promotes moving the character to the lower cost setting. By the way, I think we could look at it as consideration. Okay, thank you. As next is Rutland Regional Medical Center. They came in with a FY19 the growth submitted with 3.2%. They gave us a revised MPI growth of 3.1% with their presentation this week. They had, and part of that is because of the ACO information that they received later in their submission. They had health and form investments of the 0.4%, and they were not participating in ACO programs in 2018, but they're in 19 for Medicaid. Rutland submitted a 3% rate request, but their presentation told us they now have a question of 2.6%. The decision point for Rutland is do you accept the proposed health and form investments? They're in here and they're waiting for us. No, I mentioned it earlier. I'll just say again, my only question on Rutland is I think we do have to discuss their inclusion of the deductions from the FPP act, which is their health care reform investment, part of their health care reform investment. Southwestern. Southwestern came in with a proposed adjustment for their FY18 base, which included the dental home of 581,310, because we approved their CON last year right in the middle of our hospital budget process. So their proposed adjustment was 3.6% rent care growth with this adjustment brings it to 3.2%. Their health and form investment? Is the staff prepared to make a recommendation on the dental practice? Yes, so accepted, please. Is anybody disagreeing with accepting? No, because I think, quite frankly, we approved it in their CON, so. Exactly. We approved the NDR and we did that. So you can take that decision point away. Thank you. Back to the health reform investments, their request is 1.1%, which is equal to a little shy of 1,800, but their allowance was only worth 638,000. They are participating in the Medicaid ACO program for 2018, and I'm not sure if they're 19, I don't know. I can't remember if they've sent off from the air. I don't think they've decided yet. I think they're still waiting, if I recall. Yeah, that's my recollection, is they'll stick with Medicaid, but then they'll consider it the other way. That's what I, for dollars, don't look like Medicaid from November, see? Their FY19 rate request was 3.2%, and the estimated value of 1% rate increase is a little more than $800,000. Your decision points if you want to accept this budget would be, as we already talked about, the adjustment to the NPR, health reform investments, the NPR rate percent, and proposed rate increase. And I think they were going to get back, Robin had some great questions about reduction in total cost of care related to their health reform investment in the tele-ICU, and they were going to get back to us with data, so that was the answer. Well, that was the answer after, wasn't that going to be quite the after? Steve Majetic said that he had a slide that he could share, and we sent that question out yesterday morning now. He went on vacation today. I can't say I saw anything in my email, but hopefully he delegated it. Thank you. And the only other, on their health care reform investments, that as you know, they have, their request is larger than the allowance, so this is probably less of a big deal, but we did talk with them about their planning costs for the IT, and I think we could have a larger discussion about IT as a health care reform investment. And to me, if it's directly connected to changing the operations, like upgrading to include a shared care plan, or something like that, that to me is very connected to the operational change, that makes sense. In this case, it was improving their fiber optic cables and sort of prep costs that you would need to do with any IT change, so I personally wouldn't allow that million, but quite frankly, they don't need it to reach the point for. So I don't think it necessarily would impact that, depending on what happens with the tele-ICU. I would concur with that, Rob, and I think it would maybe a little sweet. Upgrading their electronic health records can have major impacts on your ability to do care management, quality improvement, population health. So there is an argument for IT to particularly work around electronic health records to be considered health reform. In this case, while that's their ultimate goal, this was really a $1 million planning expense, as Rob had said, it really sort of get the system prepped for that ultimate, I think they're planning to migrate to Abbott. And again, there's some compelling arguments that are partner organizations aren't that have health uses Abbott, and it certainly could enhance their imaginer, but because of this planning phase, I think that's why the staff felt like it didn't really rise yet to a health care reform investment. And as Rob indicated, they don't need it to reach the zero point for. For Springfield. Frankly, there is also going to be a discussion on their risk reserve for risk, but they had proposed FY19 NPR budget growth of 1% and they have health reform investments of zero. They were allowed $238,000 and they participated in all three ACO program for 2018, and I believe for 19. And their FY19 rate request is 5%, which is estimated value of 1% rate increase is equal to close to 319,000 dollars. Your decision points would be to accept the proposed NPR and the rate increase. At least UVM. UVM was one of the hospitals that we based for FY19 purposes. We re-based their 19 budget and they also have a accounting change for the ACO worth close to eight million dollars. So they proposed budget without adjustments. Their growth would be 1.7% of NPR. If you accepted the adjustment of NPR, it would be worth 1.1%. The hospitals health reform investments, they requested 8,572,000, which is equal to 0.7%. But they were allowed only $5,9,188,000. They are participating in all three ACOs for 2018 and 2019. For their FY19 rate request, they requested 4% for commercial and 3% overall. We estimated the value of 1% commercial rate is equal to $4,500,353. The 1% overall rate was equal to 6,337,346 million. Your decision points are to accept proposed adjustments to their 18-based NPR, their cost-reform investments, their proposed NPR and proposed rate increase. So again on the health reform, we're talking about a number that's below what the guidelines were, I think that's kind of a viewpoint. What is the staff recommendation on the proposed adjustment to the NPR? We need more time because of ACO adjustments. Okay. So I think that blocks us through all 14. Just on NPR, we did request more validation on their NPR growth because it will be about 13 million when we, even if we reset them back, you know, when we reset the ACO back, it's a year over year increase of 13 million. And the past four years, I think you guys ran, they've done between 40 and 60 million a year. So my concern on this one is we're making decisions, including rate and things like that on what I challenged is gonna be really difficult to hit only a 13 million dollar increase when their rate increases alone are 25 million. So they're going down year over year, we checked it in the past four years, they've had like a 40 or 60 or 40, you know, so I don't know how it looks like they're being very responsible, but the challenge is are we gonna be here next year and they beat this number on the top line quite a bit that we had to approve rates to fit into that. So I know we did ask them for some support on that. So that's gonna be important to help make this decision, you know, the largest hospital in the network. Right. If we're asking them that, I'll provide that information on that. Yeah, I would just say that they were obviously not gonna vote on this region, census on this this afternoon, but clearly I'm not prepared to give them the rate increase that they asked for. Actually, can I jump in on that? Sure. The rate increase vote. So one of the things that I've been looking at and thinking about how we deal with the commercial rate increase, I've realized we've just given off of this QHP filings where we cut, you know, the commercial rate effectively there, the premiums there for the idea that we're actually gonna come in lower on our hospital budgets than were submitted. And I think that we will in various places. But I've been looking at hospitals that have a little past their commercial rating increase from over 3%, just as a kind of, okay, let's look at everybody over 3%, which there are many. And one of the things that I'm doing that I thought maybe might be helpful if you share with other board members as part of the pack of where you all can look at as well, is I've been looking at the data on the charge master from the Department of Health. You know, what is the charge? You know, what are the gross charges for various procedures in patient and outpatient? Trying to look at whether or not the hospitals that are asking for very high rating increases, are they already above the average, at least in gross charges? So for example, if you look at Gifford, Gifford is asking for a relatively high commercial rating increase. They're really above the average in gross charges by a lot, sometimes double the average for the state. So to me, that raises a very large red flag. The other piece of data that I believe it was Robin that pointed out, which is I found helpful, is looking at the total cost of care by HSA in the blueprint profiles. And again, for example, Gifford is an outlier there being really expensive. So for me, I'm concerned about giving them another rating increase when they're already an outlier. So I think that data might be helpful for the board to have in front of them or for everybody to look at is, what are the gross charges? And I realize gross charges are not the actual prices, but they're correlated. And as we heard, they're usually a percentage off of gross. So I think it's just another vehicle and information and it's available online. And I think it's helpful. But just to remind you that just in today's two hospitals, we heard once a 85% of their charge sheet and the other said 70%. So that is a huge difference. A lot of them were coming in at the 70%. I am, Springfield, I mean, because when you asked the question earlier, most of the hospitals were saying around 70%, it made me wonder if Springfield's charges are lower or something. They're lower. Yeah, gross. So one of the hospitals though that said 70% is also one of the hospitals that I, at least non-anidotally, has one below us percentage off of charges in their negotiations with at least one of the insurers. So the things didn't reconcile on my brain. I just think it's, yeah, it's just another data piece. We'll see what we can do to hold that thing again. Or at least send a link around. Under the blueprint as well as the public care. Yeah, the blueprint is right online, if we have time, we'll get it and we'll try to get it into a table. They're also in the reference library by your side. So we have lots of access to that. So that's, I mean, we really today want to lay out the decision points you've exceeded our expectations by actually taking all the decisions. I'll lower your expectations. Well, yesterday, well they all say you, yesterday, I wasn't even thinking that we were gonna have a slide deck. You and yesterday, very fast though. Yeah, and you guys are starting the same, so. I would just say that the hospital budget team has exceeded our expectations as well. And it makes our job a lot easier when we're getting such great information from you. So thank you very, very much. Thank you. So with that, is there any old business to come before the board? And can I just add to, just as a, maybe we just want to discuss the next steps and calendar and just make sure everyone. So the next steps that are gonna be available because I've just realized that the next board meeting, which is December, September 5th, is before the close of. The bottom, yeah, exactly. So my whole timeline has been thrown astute because I truly hoped to make some decisions on September 5th, which I clearly cannot make now. Could we make a, you know, a preliminary decision or a conditional? But it still leaves, it still leaves all 14 of them. Don't follow who you're talking to. Yeah, the last day you go through the list again which is what I exactly did not want to do though because I felt like we made some hurry decisions last year. So that's why I tentative. And then if you need the ones you'd make on the 12th, you, oh, we've got to go back and choose the other ones. The same sometimes it gives you that. You know, if you don't probably want to hear that it might change your mind for what was decided on a little bit. That's what I'm afraid of. That's what's happened in the past. Yeah. The other thing, I wonder if we'd want to maybe think about doing a longer board meeting on the 12th because that's also Khan's memorial. So we're not going to have a lot of questions. Oh, so do we have the information on? Yeah, but. On the 5th and the 13th, on the 12th, they're not feeling it. It's up to the 12th. So that goes, so we could schedule, I mean, we could plan on staying here. Well, we have to be out of this room by the end of the day. The other thing, I don't know how the people don't want to even have this suggested, but maybe we should schedule a board meeting on the 11th as well. Works for me, that's fine. Wouldn't you, buddy? I teach in the morning, I have to be at the end of the day. Definitely could be in the afternoon. What time would you be able to be here at night? My class ends at 12.15. I get out by 12.30, the earliest I'd be here would be at 2. What about the 10th? Well, unfortunately, it's the public office. What would you start in the morning? You could start in the morning on the 12th as well. We have a room all day. It's a long day, but I don't like the easiest. You don't have to do all 14? I think we could make some preliminary decisions next week. Either it's going to be like this one, we're yay-nay on the top line, or the raid, or where we get some discussion points. And then maybe we do all day, the 12 or 15. What time does the public comment officially end on the 10th? It's usually closing business. That's how we usually, that's how we usually count it. That was open to the postulates. I know. One of the things that we went through had some preliminary discussions that anything changes our mind in public comment, and we don't make any, we don't vote or anything on the 5th, but we sort of go through. Do you want to do a strong hold? I think we're just going to have to make our best efforts. And at the end of the day on the 5th, we'll have to make a decision whether or not we need to come in on the 11th, that too, or not. But I do think that irregardless of what we decided up until that point, we still should schedule that meeting to begin in the morning on the 12th, because I don't want anything to interfere with the service. What time did you say it started, Rhonda? 5.30. I'm just not sure that we would need additional time on the 5th, because we can't make final decisions. But it may help prep for what we do on the 12th. We have nothing else on the agenda on the 5th. On the 12th, we have internal staff giving a data analysis presentation, and then the rest of the time is the hospital budget discussion and potential vote is already noticed on our calendar for the 2nd of October. You said the cast will be out there for that timeline, doesn't it? The internal staff discussion has to be out there for a long time. We can look at the schedule. I think it may have to stay, but let me check on it. On the 12th. Well, Maureen's asking if that discussion from the 12th go to the 5th. I'm not sure it will go to the 5th. I'll look it through. OK. Yeah. So I don't think it makes sense to start in here earlier on the 5th only, because I don't think that we're going to have a day-long worth of discussion at that point unless you, if the rest of the board, I mean, I'm going to be here anyway, so I'm happy to be starting in the morning on the 5th. That's what everybody wants to do. I don't care. I just need to know, because I don't mean I need to reschedule, which I could easily do. So I'm fine with it, or I'm fine with your back. I just needed a nothing fancy to reschedule something. What's everybody else's preference? I think we have accomplished on the 5th enough. And then if we have the morning from the 12th, through the afternoon of the 12th, I think we'll be able to. So what time do you want to start on the 5th? You still want to start at 1? Yeah. There's nothing else on the calendar. That's all we have to talk about. It's just, I mean, we have. Is there anything in the staff's plate that is up to you guys? Everything we just gave them is on their plate. Yeah. That's what I was asking. I'm sorry, I'm sorry. Christina, we have this room until what time? We have it every day from 9 to 4.30. Every Wednesday, sorry. That's why it's easy to get in here. Earlier on the May 9th, you were available to date. Is there a suggestion? Could you just at least try to schedule 1 for the 11th in case we need it? Yeah. OK. OK. Is there any new business? Is there any new business? Anybody want to make a motion to adjourn? I moved to adjourn. I just didn't move to a second to adjourn. All those in favor, sign the sign. Aye. Any opposed, say no.