 Good afternoon, everyone. Welcome to the Green Mountain Care Board. The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you, Mr. Chair. I have a couple of announcements. First is I wanted to give an update on the special comment period that was opened for the technical changes that we reviewed at the board meeting on February 26th. Sixth. Thank you. The comment period closed yesterday. We do not receive any public comments. We are working with CMMI on a final review and with their Office of the General Counsel. And we'll ask for the board's vote on this proposed technical change in a couple of weeks. It is currently scheduled for March 25th as a proposed vote. So that's the update on that item from the 26th. The second item that I wanted to update you on is we had an open public comment period for the sustainability plans. I've been told there is a public comment coming. But to date, we have not received any comments. I want to say that we will have a further discussion on the sustainability plans with the board. And I propose we put that on the agenda for next week's meeting. It's not on there yet if that works with the board on the next steps for six years. Just a technical question because I do believe we had a comment. Oh, we did? Yeah. OK. Thank you. I stand corrected. So we will make sure that that was on the agenda for next week and that will be noticed properly. And then the last item on the agenda and I think the hospital team will likely review this as well, but just to let folks know that we will have a special public comment period for today's topic of the meeting, the 2021 Hospital Budget Guidance. That special public comment period will start today and will go to March 23. And then we expect to have a board vote on the final guidance document on March 25. And then additionally, a preliminary vote to approve the NPR-FPP growth limit on March 18 for this board to vote on that subject and that subject to final approval with the final guidance document that we're reviewing today. Does that make sense? And I would just encourage folks to look at our website. Our schedule is posted for the month of March. I don't think I have to go through each item line by line, but we will have that meeting schedule updated with some of the additions we just spoke about today. And that's all I have to report. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, February 26th. Is there a motion? Still moved. Second. It's been moved and seconded to approve the minutes of Wednesday, February 26th without any additions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor signify it by saying aye. Aye. Any opposed? And with that, we'll shift right into today's discussion about hospital budget guidance. And Patrick, Gloria, and Agatha, whenever you're ready, take it away. Thank you, Mr. Chair. Good afternoon, board members and members of the public. Welcome to the first installment of the presentation of the fiscal year 21 budget guidance created by the staff for the board's consideration. We're going to move you through a few slides here to give a brief overview of our process so far. The process yet to come as far as where today's presentation will go in the weeks to follow. And then we will begin to move through the components of the guidance and supporting materials to better inform you as to the rationale behind that and where we're going. So the first slide here lays out the next few weeks for us as the Green Mountain Care Board. Today, as I stated, we'll review the overview, the appendices, and the overall guidance document. Next Wednesday, we will review some policy updates, any changes that the board has recommended to the guidance, and a new element that we're considering health service area cost and patient origin data that our data team has compiled. And they're going to present that information to you for consideration in this year's budget process. Another bullet point that we'll add on that, following the executive director's comments just a moment ago is a vote on the NPR growth and the projection limitation range that was set forth last year. That should also be considered in that as well. And then on March 25th, again, any final adjustments to the guidance and a vote by the board. So for this year's guidance, this is the project path that we followed and our priorities were given the current state of the hospital's financial health to keep that in mind as we've worked through this. Realign the guidance more along the lines of what the ACO guidance looks like and to streamline that. Use data-driven analysis and decisions, consider data-driven analysis and decisions and reasonable schedules and turn around times for the work product that is to be approved. The process involved a subset of CFOs, the healthcare advocate and VOS representative throughout the meetings that we had. There was collaboration between the GMC legal team, the data team and the ACO policy teams and a public process as well. The outcome is the fiscal year 21 guidance draft. We're leveraging a two-part submission schedule and we'll get into more detail on that. Align the narrative and the presentation for consistencies and ease of board usage and update of appendices to support narrative presentation and again, focus on consistencies throughout. So here's the two-part submission schedule. Part one, formerly was known as non-financial reporting, we've synonymously called it off-cycle. We've added a few items to that this year. So we're moving the due date to the 15th because of that. That's our recommendation for your consideration. Part two is the actual fiscal year 2021 budget materials that, of course, is July 1st. That will not change. The time period regarding the part one refers to previous fiscal year and calendar year materials that are informative but weren't utilized to create the upcoming budget for your consideration. Part two is obviously the upcoming fiscal year that the hospitals are going to be presenting to you. The content of part one involves quality and patient access and wait times. That's familiar to you from past years as well as community health needs assessments for those hospitals that that applies to. A more bolstered ACO section and the bad debt and salary information, we've shifted over there. Again, it's all information that comes from previous fiscal or calendar years, but it's still important for your consideration and that of other stakeholders in this process like the HCA. And then part two, back to that, is the actual budget submission itself. And with that, we are going to begin to walk through the appendices first. We've taken a lot of consideration in reformatting these to, again, as I said, create more consistency throughout. And we're going to let Agatha take that away. Great. Thank you. So this first, we're going to go through two different workbooks. This first workbook is part one, what we refer to as non-financial reporting. And as Patrick said, we are going to recommend that this be moved from an April 30th due date to a May 15th due date, simply because it has expanded. And by expansion, it means we took stuff from the July 1st due date and put it in this first part. We didn't expand the amount of information being asked just when it was being asked. And so just to reiterate what Patrick said, everything in this workbook shows previous year's data. So this is coming from FY19 or calendar, year 19 or calendar year 2018. So this is backwards looking data. So the first is, and what I'll do is I'll feature to you what's been changed and what's been added. So this is the access to care wait time appendix. This is familiar because it looked exactly the same last year. And the only thing that we did was add some services that were reported to us last year. So if it wasn't on the regular template, the hospital added some service lines, and so we've added that into this template. And that is all that has changed from this template. Chairman Mullin, I plan to just whiz through these, but please, anyone stop me if there's any questions along the way. This next tab is about the all-payer model quality measures. This will look exactly the same as it did last year, just with the new information from calendar year 2018. Community health needs assessment has been shrunk. Last year we asked some questions about Schedule H of the 990 and community benefit investment, and that was a one-year question. We were trying to understand how the hospitals use their Schedule H to report community benefits or how they don't use Schedule H to report their community benefits. So no need to ask that question again. We've looked back and looked which hospitals are scheduled to update their community health needs assessment, and we think it's only two hospitals that have a new community health needs assessment that would have impacted the analysis we did last year. So we're trying to make it clear to the hospitals in this red text to please only fill out this table if your community health needs assessment has been updated. And that's sort of a general theme that you'll see through all the appendices that we're presenting today as we really tried to take a step back and think, what information do we absolutely need the hospitals to proactively report to us? And what information can we just ask them for an update with? And the community health needs assessment is one, we just need an update if you had a new report published since the last time you communicated to us. The next slide is about ACO reform payments. This is new. So this is an attempt for us, again, to align our processes between hospital budget and ACO. And this is a question to the hospitals for the previous fiscal year if they can identify the kinds of reform payments that came in by category. We already know that it will be challenging for some of the hospitals to report this to us by category. Nevertheless, we'll ask the question with specificity and how those funds were used. So this is a new question. And this question was developed in collaboration with the free mountain care board policy team and was discussed with the CFO health care advocate work group meeting that we referenced earlier. This next appendix is new. And this represents one of the pieces of information that we pulled. I'm sorry, the appendix is not new. But what we did was pull the question out of the narrative and it is now an appendix prompt. So the hospital does not need to reply to this with a narrative. They don't need to supplement this with a narrative. It's simply the appendix. This next tab on collections is new. So this was a question that has existed in the narrative asking the hospital to respond in narrative form to who are their collectors and whether or not they adhere to patient-friendly billing. This was one of those things that we as staff felt like, there may not be much change from year to year. We can just take the information they've already submitted, put it in a table and ask the hospital, has any of this changed? If it has changed, update it and indicate to us that it has been updated. So again, an attempt to sort of reduce the number of questions that we're asking. And then the bad debt table is a previously established table. What we added this year was a question about, and this comes from the CFO conversations that we were having is a question about observations about bad debt as it relates to commercial insurance. So we're hearing from the hospital's one-off that there is an increase in the amount of bad debt that's attributed to commercial patients. And so we're asking for observations on that. This next table is a new table. This was in the narrative last year asking hospitals about sort of compensation policies they use and whether or not they use a consultant to set their compensation benchmarks. And so we felt a staff, this is something that we can put in a table and ask the hospital to confirm whether or not it's the same or to update it if something has changed from last year. So again, our attempt to kind of make it a little bit easier for the hospitals to answer and for us to interpret. And then this last tab is really just a placeholder. The total cost of care by health service area chart was included last year in the budget guidance. And this is that chart right there going up to 2017. So part of what you'll see next week from the data team presenting with us is an update to this chart and an additional supplemental data set that shows patient origin. Where are the patients in each HSA getting their care? Are they staying home for their care or are they traveling for their care? And if they're traveling, where are they going? And so that will have the data team to present to you next week, but this is just the placeholder for now. So those are the contents of the part one non-financial part of the budget guidance that we would recommend be due on May 15th. And are there any questions? Jess. I took a small request. On the all payer model quality measures, we have the data on calendar year 2018. Since this was in the last year's budget guidance, it would be really helpful to have last year's results and this year's results just so that we can see if there's progress at the time you're over here. Jack. Thank you. On the bad debt table, is that something that you've had any conversations with the health care advocates office so that we can try to get as much information on that as possible? The only conversations we've had was I believe it was Kayleigh was on the phone when we were talking about moving this over to this off cycle version or part one of the budget process. We wanted to make sure that they didn't have any objections to that, but that's about as far as the discussion went on that. So if there's any feedback from them after they see this, we'd be happy to hear. So yeah, I would just ask if you could take a look at that and maybe there's a way that some of your questions could be built into that table as well. Thank you. Go ahead, Maureen. On the community health needs assessment slide, just some clarification on, I think question five should be answered again, even if they haven't updated their CHNA. It's really saying what are you doing as the next year progresses. So I would just be careful about saying, update this only if you had a new CNHA. Right, because they have a new implementation plan. Right, so hopefully each year, they may be doing some more programs. They didn't get it updated, but the following year they may be doing different things. So I would just make sure we put that into point. Any other questions, Tom? Just like to make an observation on the information on bad debt. One question that you might ask, and it was asked a few times, I think in the budget cycle last year, was whether or not after a debt has been with the collection agency for a period of time, is that the end of the process if it remains unpaid or does the hospital then send that information to a rating agency? And I think most hospitals don't send it to the rating agencies, but there was one or two that did last year. And so that distinction might be important in terms of understanding or getting some kind of insight as to what might additionally be collected if the process was more aligned with, didn't stop just at the collection agencies effort to collect. One other thing I'll just mention before moving on is at the top of each of these tabs, we asked for the hospital name, but also for the name of the person who prepared this, because unlike the second workbook you're gonna see, which is mostly financial, this could end up in many areas in the hospital. And so we would like to know, like, is it a CFO filling out the quality stuff or is it, you know, and for the hospital themselves to keep themselves organized, so you'll start to see the names of the people who prepared the documents on those. That was a suggestion from the CFOs. All right, so shall we continue to the guidance appendices? So now we're moving on to, and you'll notice we're doing this little backwards. We're not going right into the guidance document and that's because so much of the guidance document is built on these appendices, so it's easier to interpret the guidance document once you've seen the appendices than many of these you have already seen. So now we're looking at the appendices that support part two. This is the information that's required on July 1st. The first appendix is the bridge table, which we are all familiar with. There's been a couple updates to this. The first is that we have two bridge tables. The first is the traditional bridge table that shows the budget to budget. This is the year to year comparison of the drivers of revenue and the drivers of operating expense. This is the traditional way that we look at the bridges, but down below there's a new bridge table and this is a projection to budget bridge table. It is identical to the first in the categories that it's asking for, but instead of looking at it as last year's budget, approved budget compared to the upcoming request, it's the current year's projection compared to the request. The reason we're doing this is because last year there were a few hospitals whose projection variances, so their operating performance for that current year were substantial, which made their budget to budget bridge not a very useful or relevant analysis. And so we're asking this year, trying to be proactive and ask for the bridge to also be represented as a projection to budget. Now modifications that have been made to this are in the past we've asked for this information by payer, Medicare and Medicaid and commercial. In this year, this was feedback and discussion we had in the CFO meetings is that we wanted to start to see this more in terms of the types of revenues that are coming in, not just by payer, but by what we are calling traditional revenue versus reform revenue. So what are the traditional revenue? And I'll say, so we don't have a standard definition for this. We are asking the hospitals down here to tell us how they identify it, how they are defining those buckets. Because even with the subset of CFOs we had, it was very challenging to come up with one definition. So traditional revenue would be, for example, fee for service. Reform revenue would be, for example, FPP or fee for service under the all payer model. So we're asking the hospitals to start to parse this out so we can understand better where the drivers of revenue are coming from. Any questions about that? No, but I have one comment on this one, which is having them somewhere put us what their projection is from. So we know often it's based on April year to date, but it could be at a later time. Did they update, because they submitted at a certain period of time. So trying to understand, obviously we'd prefer it to be the most recent data, but what are they basing it on? That's very helpful, Maureen, because we as staff, we struggle with that too, because as you know, during this whole process, we're still collecting the monthly reports, which have projection updates in it. So identifying the month of the projection is an important part of it. It will also tag, because when they do their presentations, we ask them to update where they are in their projection. So sometimes there's been no update. It's still as of the April other time too, because at that point, when we're meeting with them in August, they only have two months left of their year. But we know when they put the budget together, because when they have to go to their finance committees, things like that, they're basing it off and on six months of actual data, six months of projection. So trying to be really clear both here and then also in the presentation of what is it, at what point did they update it? That's great. Lori says we ask multiple times, including in our staff analysis. Okay, well then, we'll move on to the change in charge table. Oh, I should have mentioned from the very beginning that we have specific instructions in these worksheets, whether or not a worksheet can be modified or please don't modify. The reason that's an instruction to the hospital. And the reason for that is, for example, bridges says do not modify. It's because we will create a system look from this. Like we will be able to, we will tabulate this. So we'll have 14 spreadsheets. They'll all be summed together. And if hospitals start to insert columns, then it throws off all of those. So we say please don't modify, except for these areas that say other. Change in charge is another one that we say, please do not modify, except for words as other. This is an existing chart, we've updated it. In the past, we've asked for just to show us your change in charge, the dollar value of the MPR. And it's very interesting because half the hospitals would report the dollar value of the MPR. And the other half would report a percentage change. So we had kind of a mixed bag. And so what we're doing this year is proactively asking for each of those looks. We're asking in this first part to show us the change in charge of the percentage of the categories of service. And then down below, we're asking them to show us the change in charge as a dollar value of MPR. So we will see it in both ways. We've also added this one question at the end, which used to be part of staff analysis, those questions that went on at the end of July. And I should say that one of the focuses of this staff was to limit the number of questions that we are sending to the hospitals after that staff analysis. So what that means is we know that there were standard questions that we were sending year after year and at the end of July, we've now tried to bake it into the guidance or the documents that they get in March. So this is a question that we've moved, which is the dollar value of 1% overall change in charge. And specifically, what is the fiscal year 2021 value of the 1% change in charge? So are there any questions on the change in charge? I just thought I have a new chart, but... So I know we may not get to do this one, but actually just if we did this chart after their change in charge, right? If we had another chart next to it that said percent of gross, right? So if we had percent of gross, so change in charge, they're up 5%. That's all well and good, right? But if we knew after all the changes in charge for each of these areas, right? If gross is 100 and gross is the same for everybody, right? And then if you knew for a hospital inpatient, the commercial was 70. Medicaid is 35, Medicare is 45. And I know we may not be able to do this for now, but it was just a thought of, they should have that information if we know what we're changing our rates. And I really did just think of it because I know I've been in the CFO meetings and everything almost so that we may not be able to do, but I think that helps to get to that other point the relationship between Medicare to commercial and Medicaid and it's somewhat meaningless to everybody when rates go up by three, four, or 5% when we don't know what the base is, right? So here it's doing it a different way in saying reduction, but it just might be a thought for the future. I know I can see if I'll meet you tomorrow. We have, so next week, we have it on the books and traditionally what has happened is those CFO meetings when they finish, the work product is what you're looking at today is a draft of the guidance. We did schedule an extra meeting so that if there were any developments from this presentation right now, we could go back to the CFO group and discuss it with them. So you're right, we do have something scheduled for next week. It's tentatively on everyone's calendars and we'll use it if we feel so, there's a need to use it. It is maybe more of a discussion of is it possible? Can we do it? And it may be for the next year. So I'm not trying to throw it on to say, okay, let's throw this into the guidance, but as looking at this chart, I do think that would be helpful to understand that relationship because other than a self-pay and even there, pretty much nobody's charged 100%. Okay, thank you very much. Probably this observation or comment was for the previous chart, more than the charged chart. But I'm just wondering, as we're looking down the road here, where 2021 would be the fourth year of the all-payer model and the whole transition from what we might call traditional revenues to reform revenues is an important part of that. And I'm just wondering if we have thought about a metric to determine whether or not we're on a schedule that makes sense, that gets us to scale in by 2022. And because it's okay just to collect the information, but what does it mean? And clearly this revenue categorizations means something in the context of our all-payer model. And I'm just wondering if you folks working with hospitals kind of thought about a metric that might help us understand the information that we're getting. Yes, and I'd say that work is actually starting in our office as well, that we're trying to figure out what is the appropriate measure for, to measure participation. It's not enough to just look at FPP as a percentage of the net revenues. So that dialogue has begun in our office and we'll work as a topic that we're pursuing. So let us know if you have any ideas. I mean, I do want to just add to that. It's my understanding that FPP is not an accurate measure of reform revenues because within the risk corridors that hospitals are striving to live within is also the fee-for-service associated with that. So there is a regulator of sorts. The more strident one is on FFP but on fee-for-service because that's tied to the overall risk corridors that hospitals are seeking to live within. One can consider that money, that revenue pass-through money as reform money as well. Yeah, that's correct. Move on to Tendex number three, which is utilization. This is a new tab, not a new concept in the new tab. And I will say that the change in charge tab just reviewed and utilization tab that we're about to review, they all relate back to Bridges table. So in Bridges, you'll see here, there's a line called utilization. We want to know more about that. And then these first three lines here, that are shaded in blue, those are all about the change in charge. So we're really trying to get a better understanding of this. The reason is because there's usually a lot of questions from staff and from board about the utilization. When a hospital is using, if a hospital exceeds the guidance limit and is attributing it to an increase in utilization, we would like to know more about that. Even if they don't exceed it, we would like to know more about that. So in some of the hospital presentations last year, there were some excellent examples of how the hospital presented to the board where their utilization, they're assuming it's going to be coming from. Some hospitals are able to do that even down to an MPR level. Ideally, we would have been able to get this information on MPR level, but we're going to use gross revenues as a measure of growth. So what you're looking at here is a tab that the hospitals can modify. And the reason for that is because the categories of service that are driving their revenues will likely be different for the 14 different hospitals. And so we want them to be able to select their categories of service. It could be surgery, it could be major categories. So we don't need specificity, but major drivers of the utilization. And we want to see it by payer. We're indicating to the hospital that this does not need to tie to the profit and loss statement. This does not need to tie to other documents. This is really just kind of a general, where do you think, when you put together your budget and you sat down with your departments, where do you think your drivers of utilization are coming from? And I should also mention that this is not taking the charge into consideration. This is truly, and that's one of the instructions, this is truly a utilization look. So any questions on this? Yeah, wouldn't this one be more helpful if we had what the utilization is now at gross? And I do believe gross here is a good measure because it's not clouded with that's, everybody is on the same playing field. It's just gross, but it does go by payer type. And then you have the change and then you have the new total. Because this is off of a change where we're not really comparing it. I think isn't that on some of the other charts, like on one of the other charts maybe? So you're saying give a FY20 baseline and then show the change between FY20 to the FY21. And then show it. Okay. It would be more helpful. Even just the change because I don't know what we're working from. We know there's gonna be a change of X percent, right? It might be 3% of revenue. Yeah, so it would look more like the bridge document with the- Yeah, but kind of tie things together. That would be without the change in charge. But there should be, they should be working from, this is my days. Change, this is the new number. And so that it ties together if possible. One moment, Marie, just for clarification. The change in charge, the top part of that particular chart is supposed to have been percentage of growth. That you're changing. So the charge- Yeah, I mean they may not be able to do it this way, right? Because they may not have utilization just by- In, yeah. Right, without everything else. But it's kind of at, without the, right, without those increases. So we'll have to think about it. But you see what I'm saying, I mean it would be good to be able to understand where are we starting from. That's right. Yeah. The next is a new tab. This is inflation. So we've asked for it in the bridge table what are your drivers of expenses. But that's a combination of the increase in the price and the quantity. And we really wanna look at the inflation. So recognizing that it will be different for every hospital. So again, this is one of those charts that can be modified. We spoke, we've been speaking for several years in the CFO group about this. And so what this tab represents is in the hospital's opinion and perspective, what are the expense categories that are really driving inflation. And we wanna see here the percentage increase, but also the dollar value increase. And so in the instructions, it's saying that identify key categories of operating expense inflation and provide the estimated inflation factor. This is not an assessment of overall growth of the category. For example, it does not need to tie to the P&L. So if they identify MD salaries as an expense driver and they provide an inflation number here, there's also that same line item on a P&L. Those two will not tie because they're measuring different components of the cost. So this is our attempt to kind of really understand a little bit more the cost drivers. We put a note in here to say that this is not intended for a system-wide look or comparative analysis. So with information like this, it would be interesting and easy to start to compare hospitals, but that is not the intent of this chart. The intent of this chart is to look at what the expense drivers at our particular hospital. And if we collect this over time, we can start to see over time at a particular hospital how those trends are changing. And so this was the work product that came out of the CFO group. Question, comment from the new table. Would be good to add a comment, column as well. So because it's based on individual hospitals and what they're doing, and they might not have a comment on each one, but they might say this is why they say that's the inflation piece. So I think just to give that opportunity on this chart would be good. This next is the ACL participation. This is a previous chart that's just been updated for the dates. And then this last really isn't an appendix, but this is just an edit feature for staff to use and the hospitals can use it if they'd like. So that concludes the appendices. Any questions? Excellent. With all of that wonderful background, thank you Agatha. We're going to move into the actual budget guidance narrative document and we will continue with our trend of highlighting the changes to it. And I'll say before we get started that we reformatted the guidance this year for an organizational change and tried to front load the expectations up front and then from there trickle down some of the changes. So one on the reporting timeline that has changed as we highlighted earlier is the April 30th date. That relates to an ACO reserve and settlement table that we're currently working on with some of our consultants and that table is still a work in progress and we still have to work through that product. There's a couple of hospitals CFOs to make sure it's actually a usable product. So we've set a deadline in there for April 30th for us to deliver that. So that is not ready yet, but we have added it to the timeline. In the introduction section under instructions, we've created more explicit directions this year around the documents that we expect to have delivered from the hospitals, specifically page numbers on the narrative and the presentation and supporting materials, citations, if you're using outside sources, providing a link and supplemental information as an appendix and consistency through the narrative and presentation data should match their entry. We did have a couple of instances last year that rightly so some of the board members keyed in on inconsistencies and we're trying to mitigate that as best as we can with some of the work that we've done here. Certainly when you're producing a mass amount of material like the hospitals are, there's always room for inconsistencies to occur, but we found that often leads to additional questions and if we can mitigate that, as I said, we would prefer to do so upfront by creating more explicit instruction. So what you were seeing up here with these three bullet points are more specific and the effort is to make the materials easier for the board members to navigate and corroborate some of the information that's coming through. So as you see, as we move through the narrative expectations and the presentations, the format mirrors itself. So as you're sitting there, come possible presentations and you're looking at their narrative and you're looking at their presentation, you can correlate one to the other as you go through the product and it's not, presentation should not bounce around separate from the narrative. So we're putting that out there as an instruction through the upcoming process. And also the intent on the latter point of consistency is to write explanations upfront prior to hospital presentation. So what can we bake in or front load for the board in advance so that there are less questions that go into the process later on or maybe it offers you the opportunity to formulate more substantive questions so you're not having to be concerned bouncing around during consistency on that. So that's a formatting change that we made. On page six, we have our placeholder under section one A for the net revenue and FPP quote that will be set by you. That's a discussion that we'll come back to after this as Susan discussed at the beginning. So that is in there for that. Underneath that, we've made more explicit the bunch of amendments and adjustments and what those mean and the dates by which we would expect to see any changes that may occur. And so we've really outlined more explicitly some guardrails around that to help guide this process through. And so that any changes that may occur the hospital has the advanced opportunity here to make changes either before or after they first of all, that will mean for their budget. Okay, section three, narrative. The second paragraph there. Recognizing the narrative prompts may require related or similar information. Please do not restate your answers and instead incorporate the information data and responses by reference. So this goes back to our prior point about where we recognized inconsistencies last year which lead to questions and can often eat up a lot of time between the staff of both the hospitals and the Green Mountain Care Board. So once you've made your initial information or data point or response, if that is referenced later on, please reference back to the original point and explain further based on that. You don't have to actually restate the entire information block. Again, that's trying to ease some of the back and forth that goes on on both sides here because this process unfolds very quickly over the course of 90-some-odd days. So time is certainly a factor and we hope that the information once stated can be taken as it's stated. And section two here on page eight for utilization, Agatha has already shown you the appendices for that and this is more explicit instruction on the utilization component and trying to get down to the utilization consistent with the state's health care reform and population health goals related to cost-quality access, the budget utilization and consistency across into Maureen's point showing the changes there and the impact on the budget and this part is to again get those explanations of utilization upfront and more robust so that there's not as much need to go back and forth on the utilization component. Section four, sorry, section IV above section four, this again references the appendices and the data around submitting percentages and dollar charge requests. Again, last year we saw a little bit of a mixed bag and we thought it was important to provide you a more detailed outbreak of both people and look at percentages and derive information. Some people like to see the dollars. So that point is essentially getting to the same information but viewing it differently and we've added that to this component. And below that in section four and section five we've gotten a little deeper on the other operating revenue and non-operating revenue. This became a topic last year. Hospitals where they can are diversifying revenue streams outside of patient service revenues. And if there is a growth there that is impacting the bottom line of the hospitals we want the board to know where specifically that is occurring. And we began to move into that arena a couple of weeks ago when we presented the fiscal year 19 reports outlining where we're seeing the largest growth in these other operating revenues. And we wanna hear a little bit more about the impact on the bottom line as opposed to just focusing on that patient revenues. And to this point the board has no authority to regulate any of that. And this is more of an informative piece to help inform their decision on NPR growth for a household. Under expenses, section three specifically the latter half of the debt. Again we are looking to understand more from the hospitals about their major drivers of inflation. And this is the prompt for that discussion. The appendices are very much supporting documents but throughout this we're trying to prompt them to tell their specific story according to their hospital and what is causing their cost to go up. There's our discussions brought out the fact that there are some categories that affect hospitals relatively the same but there are others depending on service lines and whatnot that can cause cost to go up considerably. If that's the case the section is to prompt them to dive a little deeper into that for the board's informative purposes. Below that the operating and total margin. This is a more detailed description of how they arrive at their margins and what it means for their organization. We felt a more global perspective of margin impact was appropriate giving the circumstances that are encountering our hospitals today and we want to keep that narrative moving into the budget process and beyond. We also wanted the board to be informed as to why the hospital feel the budget to target margin they are seeking is reasonable and therefore we are asking for some supporting documentation around that whether it has to do with ratings, agencies, parent companies and affiliates, industry standards or whatever on top of that. How are you getting to this? Why are you getting to this? And what's the justification for it and to build on that more this year than has been done in the past. This section has grown considerably around capital investment. We've actually added a section here around electronic health record systems. We want to begin to find out a little bit more about those. They are immensely complex. They reach into almost every corner of a hospital when they are implemented. There have been implementation struggles that occur but also these systems are beginning to take on complexities that physical building structures used to take and they're probably outstripping back to and especially when it comes to costs of hospitals. So with the capital investment plan instead of just noting what the dollars you intend to spend over the next few years are we want to learn a little bit more about how that's going to impact the future of your organization as far as days cash on hand, depreciation, how is it going to impact your age of plant? Are you going to have to incur any debt? Are you going to sell fund a portion of this and so on? So really building out on that section for prior years to get a better understanding of some of these major investments that hospitals are having to make and what that means for future budget cycles when we begin to look at that and for our regular monitoring as well. Oh, sorry, yes. I was skipping in. Organizational structure, keeping with some of the section one, keeping with some of our priorities throughout this is to address changes where changes occur and not necessarily seek out a full loan document for that. So the organizational structure, we're only asking this year if there's been a change, please highlight that and speak to that and describe what the change was. Section two here, we're talking about related entities and financial pass-throughs and this was another item that came out of our budget hearings last year. We want to be able to understand better how related and hospital related entities and the transfer of funds between them impact the hospital, whether positively, negatively, where it's going, to whom it's going to, et cetera. So we're building that out a little bit more this year as well. Number three, service line assessment. This is related to the sustainability plan conversation that's been going on. We wanted to make sure that that narrative does continue through this budget cycle and into fiscal year 21. So we placed this in there to discuss the considerations for cost quality and community needs around assessment and optimization of service lines. We want to begin to hear a little bit more about that from some of the hospitals. It's not as in-depth as the sustainability plan that at this time is only for the six hospitals that were earmarked last year, but because that potentially has greater reach into the hospital system as a whole, we want to make sure that we're incorporating that into the budget this year. And if the board does feel that that place marker there is not robust enough, we would defer to you on to how robust to make that component, so we did want to note that it is in here as a component of the fiscal year 21 budget. The risks and opportunities, that first paragraph, last year we just asked kind of vaguely describe your risks and opportunities. This year we want to go a little deeper into that in 21, recognizing that risk and opportunities exist on a local, regional, and national level. And please identify hospital's ability to influence each risk and explain how the budget proposal supports strategies in addressing these issues. And that could be CMS reimbursement and regulation challenges. It could be items like an epidemic that is currently in the news and how that impacts your budget. So getting more specific and asking them to think more locally, regionally, and nationally as to the risks and opportunities. And certainly not to just give negative examples, but advances in telehealth medicine and investments and stuff like that would be a great opportunity that they could begin to talk about and be heard some of that last year from the hospital. So this is more of linking them not only to their community but to their region and national industry as well. So this section regards the ACO participation in healthcare reform. We're looking to build this out and we did with feedback from the ACO team to begin to comprehend the current reserve methodology of the hospitals as they participate in various ACO programs. We are acknowledging that there isn't a consistent approach across hospitals or their auditors, but we want to begin to track the information. In part two of this paragraph, we have a plug for a table that we're working on and this is the aforementioned table working with the consultants to better understand now that we're beginning to move deeper into the all-payer model in terms of all-payer model one and the years it's been in existence, we want to begin to track their methodology for that. So as that develops, we can understand how they got to that, why they're reserving, what they're reserving, how settlements are impacting them, et cetera. So again, that's a work in progress and we hope to have something deliverable by April 30th. The presentation section, again, as I stated earlier, the format of this mirrors the narrative section as well and again, this is being done so that as you're moving through the narrative and the presentation, you could begin to develop questions and there's consistency there, there's pages for citation, et cetera. So this is more of a formatting component. We are asking the hospitals to stick to this outline here for that purpose because we want to make sure the board members involved in narrative and the presentation and if there are inconsistencies that pop up, they can make note of that and address those in the public hearing. If there are other additions that the hospitals wish to add because it fills part of their story, we will ask that they please drop that to the bottom of this list here and make reference to that and note to the board members that they are doing so because it shouldn't appear within this framework that's our proposal for the coming year. And really with regard to this part, section three here, one through five NPR, we've built this out a little bit more per the narrative, per the appendices and we expect them to go into greater detail as we've requested so far in their presentations. Aside from that, page please, part B. Part B, additional information, Appendix seven questions from the Office of Healthcare Advocate. We did receive preliminary questions last night from the ACID and as we are ending our presentation here, we will provide them the opportunity to speak to those if they would like to. Okay, so with that, we conclude the portion of the guidance as proposed by staff to the board. After discussion and feedback from you all in a few minutes here, the next parts here will have to do with the due date, the continuation of the two year growth limit around 3.5% set last year and also the projection limitation. Last year there was a 5% range and we feel that there should probably be a vote on that if that is to continue and that was done as a way to mitigate budgeting that was out of sync with prior. So if you have any questions, clarifications or comments on the guidance, we welcome them. So just a comment on the discussion points. I think we're going to schedule a vote for the 18th decision on what the growth target limit is for the NPR FPP and also on the continuation of those that don't reach their budget amounts and trigger that 2%, 5% category. So I guess to kick off the discussion, I would say that unless any board member disagrees, I think that really what our motion would be next week is to set that target at 3.5% and also to follow through using the same for those that are missing their budgets, the same language as last year unless there's a disagreement among the board somewhere. Probably. We have between now and next week to think about it. You do. Okay. It'd be much better to start a discussion now if you think that there should be a significant change. Do you need comments on this too? Yeah. Do you want to go first? No, go ahead. I don't disagree. I think part of the point of coming up with a two-year construct was to give people more certainty. So if you don't stick with your two-year constructs, you're sort of quite frankly shooting yourself in the foot. With that said, we do have some exogenous factors that are happening right now. And so I think we just need to make sure that the language from last year was clear to indicate that if there was something else going on, the hospital should vary. And my recollection, I didn't go back and look at last year's language yet, which I will do, but I think that it was allowed some flexibility so that people could come in and say, you know, I'm asking for this because of the ex-Y or C. Things could be very different in 60 days, but. Yeah, exactly. So I think as long as our language from last year is allowed for that variation, I would stick with it. That would be my inclination. Can I build on that a little bit? Sure. And then I actually have some comments also on the guidance. Yes. Which is, I'll build on Robin's first and then I'll go into the guidance. And I just, I thought about this a little bit, particularly in the context of the last few days. And I think I just want to reiterate the comment that Robin just made, but budgets are just estimates. We know that. And they're based on the information available at the time. And even in normal times, I think we expect that there are error bans around people's budget estimates. And so I think I just want to caution folks to say that these are not normal times. And the error bans, I think, have just widened significantly for our hospitals. And we don't know what's going to happen, as you just said, Kevin, in the next 60 days. And my worry is that some of the headwinds that I think are facing our hospitals now are going to be exacerbated, potentially in the next few months, depending upon how this coronavirus unfolds. And I could go into economic analysis of that. I was very well of that. But I think the point being that I think we can, maybe we stick to the cap as it was imposed because we gave him the two-year cap, but I think we should acknowledge that we're in a new world with a lot of uncertainty. And I think our first priority is to make sure that the hospitals can serve communities that meet those needs. And so they may exceed the cap, they may not. And I think we have to make sure that in lay enforcement, there is latitude for a recognition that these budgets were made under high degrees of uncertainty. So I just sort of want to put that out there because I think the times are changing. And I just don't know exactly what's going to happen. And I think the hospitals are putting together the budgets with the information that they have now. And that information is constantly changing. About the budget guidance in particular, first I want to say I really appreciate the work that everybody on the team did working in the CFOs to try and streamline the process and get rid of duplicate questions and reduce some of the burden on the hospitals of duplicate kind of reporting or questions and aligning our regulatory asks. There's two areas that I have concern about that we've struggled with in the past. And I don't know how I'm wondering if we can still think about how we might approach these two areas as we enter the new budget season. The first one is we've had in the past different hospitals coming in describing patients and the numbers of patients, whether it's unique patients increasing in a particular community or it's out of state influx of patients. And I don't see, I want to know how we might be able to address getting data perhaps from boss or perhaps using the discharge data, just some proxy for patient flow into the hospital system. I know we're going to hear next week about some data that the analytics team has put together but my understanding of that is that's just where the care is being received. I'm trying to get a sense of unique patients flowing into the hospital, whether it's in state migration or out of state influx. And so I think thinking about how we can get a proxy for that using discharge data or maybe getting some data from boss would be helpful. The second is I don't know how we can move towards a better understanding of the baseline for commercial charges. So I want to understand if there's a request for a 10% rate increase. That is at a high cost hospital that's very different than a 10% rate increase at a low cost hospital. So can we use some of these proxies that we tried to use last year around the average commercial to Medicare ratio as a proxy for where the hospital's starting point is. So I just want to throw that out to you. I don't know that that needs to come out of the hospitals but I want to put that on the table for information that will be helpful in the hospital decision making process and whether that's straight up our team can put together and we can get some help from boss on that. Okay, Maureen. Yeah, sure. Thanks. I have a few comments on the deck. So one I thought for potentially for the, when we talk about organizational structure, if there's been any C-suite changes in the prior year and what their plans are to fill them if there are any openings right now, I think kind of specifically calling that out. And then I think in the non-financial package, including the structure of their board and this can be something that then each year they would just update, but understanding who's on their board, what their qualifications are, what the tenure is of the board chair and things like that. And then each year it'll just be just changing, we have a new board chair or what happened, especially since we're starting to ask the board chairs to sign on these and the board, their boards at the hospital is kind of after the hospital executive management approves their own budget and prepares it, their board is kind of the next line, right? And then it comes to us after that. So at least understanding who's on their board if they have board openings, whatever. So we might be able to set up a format for that and that can be in the non-financial piece and just update each time. And then on the ACO piece, trying to also get at for the fixed perspective payment that the hospitals receive, how they perceive they're doing against that, right? Because we'll hear, we hear more about the entire attributed lives and what happens with those attributed lives both in and outside the hospital, but those that they get a fixed perspective payment for, they could be trending ahead or behind on services as far as if they had shadowed it with fee for service. So just kind of understanding how they're doing there as well, maybe in that ACO explanation piece, I think would be important. And then as far as on the looking at the guidance for next year, I'm also supportive of putting in the 3.5% that we had last year and then also putting those guidelines on if they're falling below because there are only max of 5% above. So I think that's, that we did that last year. I'm also supportive of not setting one for a two-year trend right now for like the next year and just looking at this year ahead, particularly with the uncertainty that we have, but I feel that might be a question that hospitals may come back with about if we're gonna give a two-year guidance again and something still the board can discuss, but I think we're talking about just really putting one out for next year. Anyone else from the board, Tom? So like Jess, there's an area that I struggle with that is more structural in nature, I think, than it is focused on each hospital as kind of a tub on its own bottom. And that has to do with the cost shift and the payer mix. I think that all hospitals are not born equally. And some have relatively a silver spoon in their mouth and others do not. And, but I don't know how to, I don't know if that's true and I don't know how to integrate it into this process when I'm looking at individual hospitals and thinking this hospital struggles has to struggle more and it's, in my experience is somewhat analogous to the property tax issue in Vermont that for generations every town was a tub on its own bottom and they raised their school spending out of local resources. And some towns like Stratton had $900,000 per kid, you know, supporting their school system and standard, these were the poster child back then in the 90s had like $9,000 per kid. And so, you know, and that system went on for a long time with people trying through state aid and things of that sort to amend it, but it never really fixed it until Amanda Brigham took it to court and they went to the Supreme Court. And in 1999, you had the Brigham versus the State of Vermont Vermont decision that leveled that playing field. And I know, I don't want us to be because we're not charged to be the kind of regulator of all of the landscape for healthcare, but there is a landscape for healthcare out there and you have an institution like UVM that has a commercial payer rate of 60% and others like Brattleboro that are down in the low 40s or high 30s. And so, when Medicaid costs shift, some hospitals can make up the difference more readily than others. And I'm just wondering if as we move forward and head toward the end game here, whether or not we can look at the data that we're collecting and some of the data that I think I saw in the healthcare advocates letter, which I just saw today, but seems to be related to cost shift and the relative asset that a commercial payer base might be. So that as we get to the end game, we won't have anything definitive but when a hospital CEO or CFO says, as they did in the rounds last summer, that for example, the head of Brattleboro Hospital said that the cost shift was an existential threat to his hospital. That's a serious charge. And I just wanna make sure that we're doing the best we can to understand that relationship and to mitigate it wherever possible. I have one more question. Actually, I have two. So on the page eight, net patient revenue fixed perspective payment utilization where we're asking for an assessment consistency with all-pair model goals related to cost quality and access. And this may be a question for you to ask at your CFO meeting. Do we need to be more explicit and quite frankly, I'd be shocked if they can know what that meant, but do we need to really tie that back to the quality measures which are included as an appendix, the access measures which were included as an appendix and the total cost of care measure that we're shooting for? So what I wouldn't wanna get back as an answer is a non-answer basically. So if we need to be more explicit there, we should just know and do that. Robin, you're on page eight? Yeah, in two, number two. Okay, yeah. And then I just wanted to note that I didn't, so in the HCA's questions, it refers to tables, but I don't think I didn't see the tables in the email. So I was wondering if we can get a copy of the tables. Julie, shout out to the healthcare advocate. So we did not submit the tables, so it seems to be a draft. Happy with the questions, you know, it's in the system, I'm on tables with the final draft, but if you were to simply see the draft, it would also be fine. I would love to see the draft tables, but that's okay. The other thing that I would just ask the HCA, which is consistent with what I think we've asked our staff to do is that if you're asking for information that we collected last year, pre-populating that in the table, since it's already in a table that we have, in my mind would be preferable, so that we're asking for changes and not collecting the same information year for year for year, because that just seems like a disease. Julie, shout out to the healthcare advocate. So can I send your reach out to VOS just about what's possible for our front-run now on the board of their front-runs for us, populating their month and data that we have? I can only speak for myself, but I think it's like, for me, I don't, I prefer to be able to just, if we have it, let's pre-populate it, but that's just my preference. And I would be shocked if VOS didn't want to pre-populate it. Right. But we'll see. Yeah, I'm happy. If the hospitals want to redo the work, then that's up to them, making not themselves up. But thank you, that's all I had. Anyone else on the board? Not at this time, I'm gonna open it up to public comment. Yes? I'm not in the hospital, but okay, I just wanted to say, first of all, I'm sure there's a dialogue, and I'm sure there's an answer about the operability of creating a budget and influencing to adjust to the factors that the industry continues to throw at us. Hospitals continue to be at a moment's notice when we prepare for it to come our way. I've been in healthcare for 25 years. I ask myself more and more frequently, how much time and energy do we put on budgets that we always try to seek, set, make promises, and follow through on? And when it comes down to operating the hospital, I look at basically two or three things. I look at how do we compare to when it comes to our operations? I'm always looking at really a 13-month cycle. How do this month compare to last year's same month? And how did this month compare to last month? And what is it going forward? How does the next month look? And I find myself putting more resources in trying to find that out and how to react to it rather than how do I compare, how do I look at this month compared to the budget, because the last year's budget was created at the time that we didn't know all the factors that played into it. So just I thought we'd add that to the conversation. Thank you, Brian. Any other public comment, Jeff? Yeah, Jeff Thiemann with the Hospital Association. Just a couple things. First of all, we do have an official comment later coming from Vaz that will be emailed to you, actually in just an hour or so. It's signed by every hospital CEO in the state, so it represents a consensus view on behalf of our hospitals. Second, I'm encouraged by the conversation today, too, of both around budget awareness that Brian talked about, but also around where our current public health crisis to Jessica's comments is showing about how things can change so rapidly and require hospitals to stretch quite quickly. And then third, you know, there's more detail in our comment letter, but there were new ideas that you raised here today, and as we say in the letter, I would just always encourage a very careful cost benefit analysis of how new inquiries and ideas match every man's potential benefit. I think if we're not constantly asking ourselves these questions, then we're putting new requirements by hospitals without really getting a return on that. And so I think it's worth always making sure that it's part of the consideration of things. Okay, is there other public comment? Mark. Mark Stanislaus from the University of Vermont Health Network. As we think about growth, growth is actually, in my opinion, more with the actual to actual changes from period to period, not so much budget to budget. So, you know, so I would just put that out there. That's what the true rate of growth is. That's what the individuals of the state of Vermont are actually paying from year to year is the actual to actual change, not budget to actual. So I think we're consistent with the previous comment there. I think that we need to understand those trends. If you really wanna understand what's changing in healthcare, it's the actual to actual trend, okay? The tables might be informative to inform budget to budget, but is that really telling you what is actually changing? And those are actually the current challenges that the hospitals have today. The next set of comments are just more general statements. As I was thinking about the presentation, someone comments from the board member. As we think about what the 1% change in charge is, what we need to remember, there's a difference in the change of charge and the change in reimbursement. And there's really no such thing in healthcare that I'm aware of in my 25 years of experience is what's the effect that 1% across the board, you really need to break it down, pay your categories specifically. The hospitals have no control other than the critical access hospitals that are paid differently. The Medicaid rate is handed to them. The commercial rate is handed to them. That's more than 50 to 60% of their business. So, I think there is value in collecting with the 1%. I think you just need to think about it differently and on how we talk to it, okay? The second piece is tracking how well we are doing against what the reform effort, okay? I think all the hospitals are in the all payer model to some extent, either all the plans or some of the plans, okay? So, advancing the all payer model forward, the hospitals have done as much as they can do. It's those plans that need to bring more attributed lives to the model and getting more providers under that plan to sign up for that model. Under that same thing is that there is no plan under the all payer model that is functioning as a fee for service. I think I heard some of that in the comments. There's reconciliation to the comparative of what the fee for service payments were, yes. Okay, now that being said, I wanna share what one of the struggles that all the hospitals are having is those lights that are covered under the commercial payment, they're still processed as a fee for service and then there's a reconciliation and that is very difficult on the hospitals to show those numbers as FPP when they're coming through a fee for service because there's a large variance. I mean, every month when we get a question from our board members, what's going on with the all payer model? How come we're missing the payment mark on FPP? Well, that's because we budget commercial under FPP but it all comes through, we don't fee for service. So that's one of the challenges that the hospitals are having. And as we think of utilization, there's two types of utilization. There's the inflation utilization and then there's the creep in utilization. Well, from the current budget. So we talk about understanding the impacts on the projected revenue but there are expense inflation components that are flowing through the hospital's expense site that's just a pass through to the payer. So as we think about how we look at regulating the target whether three and a half percent is the number or not, that just needs to be taken into consideration because if that's not taken into consideration, the hospitals truly aren't receiving a three and a half percent increase. And the last thing I wanted to say, I mean, I cannot help but to comment that the services that the hospitals provide are significantly different than the school system. There's a national criteria for each grade level of the standard, okay? And that might be able to apply to the hospitals if every hospital provided the same amount of services, the same amount of primary care, the same amount of specialty care, the same level of trauma service. So it is completely different as we think about whether the payment models, when there's a national standard that every school system, regardless of where you are, that there's a national benchmark compared to the individual services that the hospitals provide. So as you think about the budgets, I hope you take that consideration. Thank you, Mark. Is there other public comment? I just want to comment on that. Sure, go ahead, Maureen. Use the mic. Yeah, I just wanted to address one of the things that you said, which I agree with, which is it's very important to be looking at actual to actual. And that's one of the reasons why we have the bridge that goes from projection to the new budget, right? Rather than budget to budget. And that's why we give a second opportunity during the budget presentation, which is several months later to go against your projection again to budget, to the new budget versus budget to budget. So I strongly encourage the hospitals to really look at that, because when we look at actual performance, though, against that projection, when we get to the year end, there's still quite a variance on most of the hospitals. So, you know, we'll be looking at that when we look kind of at those kind of discussions of where 2019 came out, right? And we know for 2019, 10 hospitals were missed their budget under, so they were lower, four were above. And when the other comparison will be to compare that against where their projection was at the time we did the budget. And again, we're gonna see there were a lot of misses. So I totally agree we should be focusing on that. What we need to really look at is how good are those projections, right? Both when you do the budget, when you come in and prepare them, which may be off of April data. And then when you actually do your presentation, you know, we meet with people in August. So there's only one month left of the year. And I think you know, every time I'll ask, how are you doing right now? And a lot of times hospitals are still referring to data of actuals through April. And you know, we know you should have a really good outlook at that point, August 20th of where you might be ending the year in September. So I think that is very important. I'd also say the capabilities at all the hospitals vary too, right? So some of the smaller hospitals don't really have the staffing to be updating that all the time and they don't make those adjustments. So it's a tough thing. But budget is obsolete day one. I've always said that. So, you know, budget to budget, when you prepare that budget, you know, a year and a half, you know, prior to when the year, you know, in April from the prior year is tough. But you know, really looking at your projections and what those trends are and making sure you're adjusting them and then doing that comparison is really important. And it's something we do factor in. But again, it's only as good as the information that everybody has and that we're looking at. So I would say, you know, even if you look at where UVM ended up at the year end, it was quite different than what was in that last projection because things happened, right? In the fourth quarter and stuff. So it's very important, but it's, you know, again, you have to really look at are you guys adjusting those numbers and do you have good information to then track it forward to the next year? Tell. Okay, other public comment. Yes. Great. Jeff, this is the state office. I have a brief question. So in February 26th presentation, it was a large increase of the operating and I think it was mostly from drugs. 340D and specialty drugs. I think you guys presented that exactly. I'd just like to know whether there have been any modification to the budget guidance or reported requirements in light of that trend. No, there's a line item under other operating revenue that's the 340D program. So we're tracking that as a category. Anything else to add? I would just add that there is a section here for other operating revenue in which we are trying to flesh out exactly that. We're trying to get a little bit more into it. It's never been a focus before, but the growth of it and the impact that it can have to potentially subsidize that patient service revenues that may be coming up short needs to be considered by this group here today. Okay, other public comment. Mr. Chair, can I have it, provide an update from the original executive director for this report? You may. We apparently have had two public comments on the sustainability plans, which I failed to share and I believe we're having another one from Bas so that will be three public comments. And I also wanted to add regarding the sustainability plans. I've also been hearing quite a bit from legislators in the health committees about their concerns around sustainability at the hospitals and we sent some information on the actuals that was presented last week and also updated many of those committee members with our sustainability plan planning. So I just wanted to add that as well. Okay, with that, I want to thank the team here for some very thorough work. I want to also thank the participation of the CFOs and others from Bas, especially like to thank Mike Deltreco now that he's no longer here, we can say nice things about him. And if we may, we'd like to thank our colleagues back at the office because we took up considerable amounts of time for the data team and the ACO policy team and our legal team in putting this together this year, probably more so than ever before. So if they're listening on the phone, thank you all for your help with this. Okay, with that, is there any old business to come before the board? Seeing none, is there any new business to come before the board? Seeing none, is there a motion to adjourn? It's been moved and seconded to adjourn. All those in favor, signify by saying aye. Aye. Any opposed? Thank you, everyone. Have a great rest of the day.