 Chair Mullen and members of the Green Mountain Care Board. I'm John Bromstead, CEO of the UBM Health Network. You probably know that because I've been here a couple of times before. I do wanna start by thanking you for the opportunity to present our 2022 budget. Up to imagine that it's a 2022 budget, but it is. And I also wanna take the opportunity to thank the staff, both at the Green Mountain Care Board and our staff for taking the time to respectfully have back and forth up to this point to question each other, to begin to come to a mutual understanding of what's a very complex budget produced during and covering a very, very complex time in our history. And our aim through the presentation this morning and likely answering questions late this morning and this afternoon is to provide any further clarity that you on the Green Mountain Care Board need to facilitate your decisions. We'll take the next slide, John. So here's the team that's available today. Those folks have sworn in. I will take a second to brag on the team because it's a spectacular team that has helped guide the path through some incredibly difficult and tumultuous times to make sure that Vermonters and folks in Northern New York continue to get the services they need. All of us on the team are well-known to the board, maybe with a couple of exceptions on the finance team which has had a makeover over the past year. Rick Vincent does have a track record but has moved up to being CFO of the entire network after years of training in our network. Judy Peek Lee has joined us over the past year and is the CFO of the Medical Center in Burlington, Kim Patnode at Center Vermont, and Scott Como, some of you may know Scott at Porter Medical Center. I would like to call out that we do, I believe have some of our trustees from around the network that are listening in today and I wanna thank them for their time. I believe we have Maureen McLaughlin, John Dwyer, Tom Little, many of you may know Tom, and Collins, Pat Dunn-Hauer, Allie Stickney who actually is the incoming board in January will be the board chair of the UVM Health Network and Allie Richards. So next slide. What we intend to cover today, I'll run through this quickly and at a high level, our mission, vision and major initiatives that support that vision and that our mission and vision have not changed. Quickly who we are and where we are in our integration as an integrated health system serving the region. And I'll take those two pieces over the next 15 plus minutes. Then how we weathered the challenges of 20 and 21, and they have been many, many of those. I'll ask Al to speak about those. Our continued plan and march towards financial recovery and how we perform against external benchmarks. You know that I and our team always seek external validation to keep us on the straight and narrow. And we believe that that's important in this context as well. We'll go through some of those. Our net patient revenue growth compares to our population growth. In other words, how net patient revenue growth is a function of both expense growth, what we call expense inflation and population growth. Both of those factor in. And particularly because of the population growth piece, we must be measured and judged and evaluated on a per capita basis. To do otherwise, we'll continue the potential and actually the likelihood for significant untoward consequences. We'll take the opportunities through each of our presidents to talk about the challenges at our Vermont affiliate organizations and we'll summarize the budget. And again, the bottom five bullets will be covered by Al Gobey, who's our chief operating officer, chief financial officer, Rick Vincent and our presidents. And again, our CFOs at the entities will be available to answer questions. Next slide, Jen, please. So UBM Health Network, our entire reason for being is to assure access to high quality healthcare services for our region, Vermont and six counties of Northern New York. And we're here not just for today, but for the longterm. So we have to be sustainable and we have to provide those services at reasonable affordable costs. And obviously that reason for existence rolls off the tongue, you know, and we live every day how incredibly difficult it is to realize that. Next slide, please. Every year I present our mission and our vision. These have been durable over time, they have not changed. And we're a mission driven organization from the top down. And this can be seen in the persistence, the drive, the innovation that's been on display over the past months in meeting our mission as we've had obstacle after obstacle thrown in our path. And I believe being mission driven is the necessary ingredient to being resilient. And if there's one word that characterizes our workforce, our organization over the past two years, it's resilient. And so working together, we improve people's lives always a very collaborative, respectful model. Next slide. So who are we? The map hasn't changed, same geography. There are some updates here. Relative to other organizations in our region, I know we know that it's really difficult for folks outside of the organization, outside of our system to get their heads wrapped around our scale. And it's really difficult to translate that scale then to the accountability that comes with that scale. And that accountability for delivering services and the health of the region is born by every single person in the organization, not just the leadership. So a couple of examples of that scale, if you go from Center Vermont Medical Center to the East and you drive to Malone, New York, Elliside Medical Center to the Northwest, on a day like today, nice dry roads poking along, you make it in a little over three hours and there's a ferry ride in the middle. And when you do that drive, there's a huge expanses of rural real estate and that impacts everything that we do, our decision-making, how we deliver care and what's expected of us and we know that. A few of the factoids that are here were the same constellation of providers. Some of the statistics in 2019, which was the last semi-normal year, there is such a thing. We had more than 41,000 inpatient discharges and 1.3 million outpatient encounters. And not that many fewer if you jump up above that to 2020, which was a very bizarre year, almost the same amount. Also, we contract or employ, mostly employ, more than 1,400 physicians and almost 300 of those are primary care physicians. So, big scale, we absolutely understand that and particularly when you start talking dollars and cents, there's many zeros after the numbers. It's because of our size, but again, that translates into us knowing the accountabilities that come with that scope and scale. So next slide, Jen. So progress to date, we actually began our journey 10 years ago, October of 2011, with the formation of then Fletcher Allen Partners. Now, blissfully, a much better name, the UBM Health Network. And we started that journey with two core strategies, just two, becoming a tightly integrated delivery system to maintain access to high quality health services for the region and shifting to payment and delivery arrangements that reward high value care. We've made significant progress along this journey, but it's clearly far from over. Through the presentation, you'll get a lot more detail on what's on this slide and we're certainly open to questions on what we've accomplished and where we're going. But I'll just tick through some high level thoughts here. On network integration, we've lived through, as have all of us, we specifically have lived through an organizational stress test over the past two years. And if we had not been a highly integrated collective of healthcare organizations, I am absolutely certain that we would have lost one of those organizations, the way of Springfield or EJ Noble in Northern New York, if they had been standalone organizations. So we have seen the fruits of that integration through times that we certainly don't wanna repeat. Expense management, we're seeing the benefits of economies of scale and implementing systems and platforms across our network. And this is not just in supply chain. You'll note that the administrative expense from our shared service as a proportion of our revenue has gone from 13.7% in the 2021 budget to 13.4% in the 2022 budget. And certainly Rick Vincent can deconstruct that for you if you'd like. And care management, we're pushing hard on our provider side to make our care management consistent, well-functioning and well-resourced, good provider side care management is a prerequisite to high quality care. It's also a prerequisite to us taking financial risk. We will not repeat the foibles of the 1990s when providers took on financial risk, did not have all of the levers to pull on the care management side. That was disastrous. And so we're working hard to make sure that our care management processes are strong. The EHR installation and integration epic, hard to believe, but within a year of completing that, Vermont entities will be totally done with the implementation phase in November of this year and our New York entities will be completed in April of 2022. Value-based payments, you all are well aware of the progress that we've made and continue to make in the all-payer model space. Our latest payer partnership with MVP to launch a Medicare Advantage plan is very consistent with our core strategies. It's a step along the pathway of realizing those strategies. And this plan is very complementary with the all-payer model and is in no way in conflict with the all-payer model. As providers, we're taking accountability for a population to provide cost-effective, high-quality care. Access to care and workforce. These are both huge issues, huge issues that we're all grappling with. And unfortunately, there are no silver bullets. Everybody wants to say, if we just did this, everything would be okay. There's nothing that simple. There's lots of very complex factors to deal with and to address. Just one example, access to mental health services, which have been difficult since Irene, probably before Irene, but definitely since Irene. Now, every single point on the care continuum for mental health services is stressed beyond breaking. It really is a crisis in any way you define it. And we on the healthcare delivery system side can't and we won't run away from that problem. We're gonna run towards it. That and the other crises around workforce and the impacts of COVID and pent up demand on access in addition to the mental health really are difficult to deal with. We need to have that discussion together. We can't do it alone to address these issues. We have to have our budgets and the resources to address these issues. And we need timely, I would say as rapid as possible, approval of the certificates of need that we've put forward to have the facilities to attract the workforce and to meet the demands of our growing population. In academic integration, we've made great strides with the Larner College of Medicine, the UVM College of Nursing and Health Sciences, SUNY Plattsburg and other higher education organizations to help us on the workforce front and to provide access to clinical material for their learners. Next slide. Leading healthcare delivery and payment transition the past two years as I've said repeatedly have presented real challenges to achieving our goals. Al is gonna speak with some specificity to what we faced. Those challenges have also showed us that we're on the right track in our move towards value-based care and really has stiffened our spine that's created renewed resolve to continue down the path to really realize the benefits of that transformation. We're continuing to lead the region in healthcare delivery of high quality and affordable care. A few of the things are listed here on how we are doing that and how we propose to do that going into the future just to pick a couple to dive a little bit deeper on investing in our staff and facilities so we can recruit, retain and support a first rate workforce. I said that ties directly into our certificates of need also to our budgets. We've put in things like workday which provide a lot of support for our employees to be able to access issues that they may have. We've worked hard to make wages and benefits appropriate. We now are like many organizations moving into the non-traditional. How do we provide flexibility for our workforce to work from home, to have non-traditional work hours and work weeks and we're thinking out of the box as others are on how we can differentiate ourselves to recruit and retain and in many cases train our own healthcare providers of the future and you'll hear more about that in the coming months. Investing in Better Access to Mental Health Services I've already pushed on that one quite a bit. This is one of those issues that we can't succumb to just nibbling around the edges. We need to dive in and we need to finally push on this so that we can start approaching with a straight face that we're providing parity to those that have mental health needs. That means an inpatient site capacity on our Central Mont Campus. It means an emergency department redo at the UBM Medical Center and it means doubling and tripling down on the workforce needs. So in our communications of late, we've had a consistent theme. I'm sure you've noticed that you and the external world judge us based on well-established external benchmarks. And Rick's gonna show some of our recommendations. They were in the presentation. You've probably already looked at them. There certainly have been discussions between our staff and the Green Mountain Care Board staff. Excuse me on these recommendations. But I just wanna run through some high level measures to start with because we need to be cognizant and reminded of where we are with healthcare delivery in our state because that is a good news starting point. It doesn't mean that there isn't a lot to do, as I've said throughout the past few minutes, but we need to remember where we're starting from. So next slide, Jim. So this comes from the Dartmouth Atlas and you all know that the Dartmouth Atlas is a time-tested source of truth for healthcare utilization and cost. And the header says it all. Vermont is the lowest cost state in the nation for the Medicare program on a per capita basis. The lowest, not the fifth, not the 10th, not the middle. We are the lowest cost state in the nation for Medicare. And look at the legend there, we're almost $3,000 less than the national average on a per capita basis. So anything that we're doing is improving on best in class status. So there's lots for all of us to be proud of on this slide. I am no way I'm saying that the UVM Health Network is the direct cause of this. We certainly are a participant, but so are those that work in state government and that regulate healthcare. Next slide. A little bit closer to home. Our home counties in Vermont of Chittenden, Washington, and Addison, lowest cost counties within Vermont. It's not a mistake or just happenstance that our three organizations in Vermont have come together. We have a very similar approach to delivering healthcare that's highly efficient. We're the lowest cost counties within Vermont and Addison County is also among the lowest five counties in the entire country. And again, the legend shows in this relative to the Vermont average, what the per capita, again per capita cost is in each of those counties. And I will point out when I've shared this before, folks say, well, that's because there's bunch of young college students diluting the needs in at least Addison County and probably Chittenden County. These are age adjusted. So this is about as close to apples. That's why the Dartmouth Atlas is the source of truth. So these are age adjusted. Next slide. You might say, I've heard this too, if you're such low cost, you're probably not producing on the quality side. This is complex slide, so I apologize for that. But this is the Commonwealth Fund that puts out a state by state report card, scorecard. I think on an annual basis, they might skip a year or two here or there. This is the 2020 report card using 2018 data. And this shows that overall, Vermont ranked sixth out of 50 states and the District of Columbia on their composite ranking. To dive a little deeper, affordability and access, just characterize this as a huge complex issue that we're all dealing with. Access here, if you look at the measures that underlie this rollup, they're really talking about access to health insurance and ability to afford healthcare in that access and affordability. And since we have had health policy that makes the vast majority of Vermonters have some form of coverage, that's how we end up fourth. So this doesn't take into account what I've acknowledged is a huge access issue. And then the next five that have to do with quality are composites of 60 measures that are bunched here and you can see our ranking. And again, this takes a village. I'm not saying that the UVM Health Network is the cause of this, but again, we're certainly a participant. And if we weren't hitting on all cylinders, Vermont wouldn't rank this highly. And I would say that my recollection is that we've been in the very top tier of this ranking every single time I've seen it. And a couple of years ago, we shared this report widely with every Vermont legislator and many in state government. Next slide. Network focus on diversity, equity and inclusion. And this is the last thing that I'm gonna speak to in the presentation phase. I'd like to thank the healthcare advocate for asking questions specific to our diversity, equity and inclusion efforts. And I'd refer you all, the board members to the answers that we've provided to these questions because it gives you a little bit, a lot more granularity on the resources that we're providing. I would say that like many organizations and in my view, particularly organizations in Northern New England were late to the DEI game in many ways, embarrassingly so. And since the murder of George Floyd, we are experiencing an organizational awakening. And this is across all of our subsidiary organizations across the UBM health network. And we've chosen to not just talk about the deep issues of diversity, equity and inclusion but actually to begin taking substantive actions to make progress along this journey. It actually starts, I'm going off my script here. Our network board over a year ago looking around the room and saying, we've got gender diversity, but we need a sense of diversity actually expanded our board and brought on four members that have added great diversity of experience, of thought, of lifelong lived experiences. So it started right at the top with our board taking substantive actions. Some of the examples of things that we've done at the management level, we've established an anonymous hotline for our employees to be able to call into if they believe that they've been subject to discrimination or exclusion in any way. We've completed a DEI workforce assessment done by a national vendor and we've shared the results of that back to each organization from the board down to the line staff. We've asked each of our organizations to create action plans based on those data and those action plans, many of which are being acted on today. We've designated the DEI leader at each of our subsidiary organizations and they have led the effort to set up multiple employee resource groups. Every single one of our organizations has at least one of those and most of our organizations have several and those continue to evolve. All of this has been based on not just top down, hey, that sounds like a good thing to do. We've had listening sessions, the academic medical center and Dr. Lefler have been real leaders in this open listening sessions where our employees have a safe place to go to talk about these issues and they've been a great source of learning for what we can do on the management side to actually have an impact and not just pay lip service. We have a three phase network plan that's informed by those listening tours and by a DEI advisory committee that I meet with personally every two weeks to float ideas, they bring ideas and before we implement anything, I test it through that group to make sure that what we're doing will be impactful and will resonate. We've had leadership training in implicit bias and also in anti-racism and how to be an anti-racist organization and I will tell you that the personal journey through those learnings is tumultuous and that self-reflection is really tough and we don't have that knocked in any sense of the word but we're continuing to work on that and we're also recruiting a Chief Diversity and Inclusion Officer, we're in the final phase of that with four finalists identified and I will tell you that it has been amazing the national interest that we've generated by that search and I believe we will have a leader that will come in and help us not only in the UBM Health Network but in our broader community as well. So in the face of all of these obstacles and all of the difficulties in healthcare delivery, why would we focus on this and put so much energy and resource into it is because it's the right thing to do at the end of the day for a caring and compassionate organization to focus on creating a place of belonging for everybody but if you look a little bit deeper, you know, we tout ourselves as a population health focused delivery system. We need to recognize the disparity in health outcomes that come with disadvantage and we need to measure along the path and we're just scratching the surface of how we measure and track our progress and also there's a great business case for focusing on diversity, equity and inclusion. Study after study shows that organizations that have a diversity of inputs, particularly at the leadership, make better decisions, do better in recruiting and retaining high quality workers and do better in meeting their missions and financially. So again, I thank the interest of the healthcare advocate for this. You'll be hearing a lot about this from our network and it's very much at the top of our priority list at this point. So I'm gonna be available for questions. As I said before, we officially got started and I'll help to farm the questions around but now we're gonna go into the bulk of the presentation. I'm gonna turn it over to our chief operating officer, Al Gobey to get us started on that. So to you, Al. Thanks, John. Good morning and happy Wednesday to everybody. Chair Mullen, can you hear me loud and clear? I can, thank you. Next slide please. We wanted to start the operational and financial briefing today with a conversation about some of the challenges that we're facing. We've written in the last two narratives about the good work that folks at the UVM Health Network have done, basically combating the pandemic. The update I wanna give you this morning though is where we're at as of today because in our narrative, we talked about the aftershock of COVID and we probably shouldn't have called it aftershock because we're still in the middle of it and I wanna be very clear on what I mean by that. We are seeing incredible patient volumes right now in our EDs, in our med-surg units and in our ICU's but they are patients that delayed care or have higher acuity than normal. It is not due to the Delta variant. We certainly have COVID positive patients in-house in our facilities but the volumes that we're seeing are really about the healthcare that was delayed when you saw our revenues go down. So that is presenting itself as the mental health challenge that John discussed and it is presenting itself as the med-surg and ICU challenges and ED challenges we're facing every day. Just a couple of examples and the presidents will elaborate on this. Our med-surg units at CVMC have a census today that is higher than almost anyone could ever remember it being and that is literally due to delayed care and our ED at UVMMC had one of the 10 hardest days yesterday that anyone could remember in terms of the number of patients and the acuity of those patients and so again, not COVID positive patients in totality, certainly a few, but the main issue here is delayed care. And again, the presidents can answer questions on this or comment on it, but I wanted the members and staff of the Green Mountain Care Board to know and understand just what we're dealing with right now, today, this morning. I'll also touch on a few of the things on this slide. We've talked in our budget hearing last year and throughout the year about the impact that revenue has had. Later in the presentation, I'll show some slides that go through the volume impacts of the second COVID surge and where we think we're at as of today and how that works into our budget. I want to be clear that COVID is an accelerator. So anything that was happening and sometimes bad, it may have happened faster. And so we've had to work really hard at controlling our expenses and managing our expenses. Anyone who's tried to buy anything understands that the supply chain is completely disrupted globally, not specifically to healthcare, but inclusive of healthcare. And so in the early days of the pandemic, the question was, do you have enough masks? We worked with the state, we worked with Dartmouth, we've secured enough PPE and we feel confident in our supply, but there are supply chain disruptions that cause us to work hard every day to make sure we have the equipment that we need and the supplies that we need. And we can talk about that in detail or have a future conversation if you'd like to hear more about that. Testing, for example, we've seen testing scale back. Now we're gonna be scaling up testing as our vaccine mandate takes effect with our employees while other employees do the same and as the Delta variant causes increased demand. And so what we thought was slowing is now growing in response to the needs of Vermonters. The last under COVID-19 that I'll talk about at this point in the presentation is vaccinations. Vermont is probably the best place in the world right now in terms of the population percentage that is vaccinated. We are incredibly proud of our teammates that work to help make this a reality by both giving out vaccinations but also a willingness to be vaccinated and we'll continue to lead on that. John's been very clear that we will mandate vaccines for our employees in both states, on both sides of the lake or that we will have regular testing. So I can't talk about challenges of the past 12 months without talking about the cyber attack and I'll get into that a little further in the presentation. If you take one thing away from this presentation today, it's the next bullet other than of course approving our budget. And that is staffing shortages. This is an incredibly serious nationwide problem that we are in the middle of. We are spending an incredible amount of money on travelers and locomtenants in order to staff our facilities. We are also partnering with organizations such as Birchwood to pay for travelers to staff skilled nursing facilities in order to get patient flow out of our med surge units because we have long-term stay patients that we need to find a bed for outside of the hospital and the flow of patients in the system, not just mental health but also skilled nursing facilities has been impacted by the pandemic and remain so. But staffing shortages is the key problem in my opinion that we face on all levels, central sterile, cafeteria, doctors, nurses, med techs across the board. Last, Fannie Allen and I see Steve in the frame here. This has been a really hard thing for the UVM Health Network and the University of Montt Medical Center in terms of the way we want to provide access to our patients. Both rehab and our surgical center have been impacted by the closure and we're working hard to try to address that both through planning our outpatient surgical center and with things that we can do in-house to make the situation better. But that has been a significant challenge. Next slide. This slide takes my breath away and put together with the next slide that shows the federal and state money that we received. I can't say it any simpler than we are grateful. We're grateful to the state, we're grateful to the federal government because if it wasn't for the money that we received close to $197 million, the $300 million in revenue that we did not earn in the two years, in the two fiscal years would obviously have driven these margins much lower. The 3.4% that you see for UVMMC on the green line is completely due to this federal and state intervention and would be headed towards $30 million in loss if we did not receive those funds. And so it's a good story of support. Without margin for capital, we simply cannot remain modern and that is important for everyone to realize it has sweeping implications across each of our facilities if we were to have lost the amount of money we would have lost, but also the $197 million from the federal government did not close the $300 million gap entirely. We did a lot of work on expense control and also capital spending to keep our days cash where it is and to also help offset some of the margin losses. Next slide. This is the chart that I just mentioned. I'm not gonna go into it in detail. We offer it as an exhibit of what we did receive over FY20 and FY21. Next slide. I've touched on many of the points on this slide and we've certainly talked about them in our narrative this year and last year. When I think about this slide, I think about our people. I think about our leaders and I think about what they've done for other human beings. I can't say again any better how proud I am of our teammates. Next slide. So on October 28th, we were attacked and we were the victims of a crime and just looking at this brings back the memories of that day and the subsequent weeks. We're grateful again to the state of Vermont for partnering with us with the National Guard. Grateful to the FBI and grateful to our IT folks who worked tirelessly to get us back in business. We could talk for literally hours about the response that we put into this when we had to basically rebuild our infrastructure and get to every endpoint, which is every laptop, if you think about it that way, in the network, 5,000 of them and basically re-image them. We have taken decisive actions since. When you think about the virtual private network that we were hacked through, that is a direct consequence. Believe it or not of the pandemic. As people no longer went to the office, they didn't go through our normal access channels and used alternative access channels that were not as secure. And so the decisive steps we've taken are to protect our network from any offsite access by employees. And so we feel the steps we've taken have been prudent and are protecting us today. But this is an arms race. We worry about PPE, we worry about vaccines, we worry about med-surge patients. These folks wake up every single day trying to think about how to hack us. And so we have people that think about that as well and we are trying to stay one step ahead. But we are not alone in this as has been seen over the last year. And this is a worldwide problem. Next slide. This is the structure that we use to secure our network. And so we have built a shared service meaning each affiliate doesn't do this on their own. We work together under one leader, Doug Gentile, to have the three pillars of engineering operations and risk and awareness all work together, but also to have the tough conversations about where we need to invest large dollars and where we need to frankly change our business practices to remain secure. Next slide. So from here, I'm now gonna turn it over to Rick and he's gonna talk about how benchmarks are guiding our return to solid financial footing. Rick. Thank you, Al and good morning, everyone. So as you heard in Dr. Brunstead's opening, Athena, I think you'll hear throughout this presentation is how we're trying to use benchmarks to highlight both where we need to be financially and how well we're doing at taking care of patients from a per capita basis and how efficient that we're being with our internal resources. Again, all looking and all being guided by external benchmarks. In this next section, I'm gonna highlight how we use benchmarks to guide our path back to solid financial footing. So the key financial metrics that we look at and we've had a discussion with the Remount Care Board staff that I think the staff are also starting to look at these metrics, which is great to see because these really are the key levers that guide us in terms of making sure that we're getting back to solid financial footing. The key with these metrics is they really need to be looked at together in concert. You can't focus on just one of these metrics because if you do both for us internally or for you as regulators, there could be something that you're missing in the story there. So just to give you an example, if for example our long-term debt was quite high and our day's cash on hand was quite high, that should tell you that we're too leveraged. We have too much debt and we've essentially financed our cash through borrowing versus having a good balance between borrowing and also generating cash through our operating EBITDA margin. So that's really the key here. I think the board and the staff know what these represent, the operating margin is what we generate from our core operations. We need to generate an operating margin from our core operations. We can't rely on non-operating revenue to support our needs. The operating EBITDA margin is a key metric. So this is our operating margin but highlights how much cash that we're generating from core operations. So it takes out the non-cash items related to depreciation, interest, and amortization. The last one on here, average Asia plant is a key, also a key metric. It highlights, are we keeping pace with the investments that we need to make both in terms of facilities and equipment so that these capital assets do not become obsolete. Next slide, Jen. So today we're here obviously focusing on our 22 budget for the health network but it's just important to point out that internally we take a longer term view of our finances. We have what we call our financial framework where we look out for five years. We update that framework every January based on the prior year's activities and what we know will be happening in the years ahead. Some of the ways that we, this really guides our finances and guides our path back to a solid footing. One of the very tangible ways that our framework is used is it actually sets the operating and operating EBITDA margin targets for us for the year so that the operating margins that you're seeing in our budget this year actually come directly from the framework. It's the number that we need to hit on that path. It projects our days cash on hand so we know where we are at compared to the target that we need to be at and how much money we'll have in that particular year to spend on capital. It also tells us as we look out, if we have debt capacity that we can borrow money to help support capital spending. But when you put all of this together, what the framework does for us is it ensures that we're on a path to continue to provide the access to care that those in our region in Vermont need. It's our scorecard, if you will, to ensure that we're on that path to meeting that need. Next slide. So this again, back to the works that we use. So we do have three mark sources that we use for these key metrics. They're also the same A side of the chart here. You can see that the benchmarks for these metrics are slightly different across the three agencies. So we look at that range in terms of setting our internal targets. So the operating EBITDA margin, for example, S&P is at the lowest at 7.3 with Moody's being at the higher end at 9%. So we use those to guide our internal targets. Our internal targets, as you can see on the right hand of the chart actually has a higher expectation for the UVM Medical Center. That's because academic medical centers that are part of a system have higher financial metrics than their non-academic affiliate system. Those benchmark ranges that you see there for Fitch, Moody's and S&P is the combination of the entire system. So it includes the academic medical centers that are part of those systems. The way to clearly see this is down on the bottom of the chart there. We've included a double AMC benchmark for, which is the double AMC CAUTH benchmark is all academic medical centers across the country. They don't have the same level of financial metrics that the rating agencies do. They focus primarily on expense related metrics which you'll see a couple of examples of that when Dr. Leffler gets to his presentation. But they do have a metric on operating margin. And you can see that the median for academic medical centers is 5% compared to the one and a half to 2.8 that you see there for the rating agencies. So based on that, our internal targets do have higher targets for the academic medical center. But when you look at the weighted average of our internal targets you can see that they very clearly line up with the benchmark ranges. So operating even a margin, the target that we have in our framework is from seven and a half to 9%. And you can see the S&P to fit ranges from 7.3 to 9%. So they pretty much all line up after you've done that weighted average. Important to note that these ranges that we have in our framework, the lower end of those ranges puts us at risk for a downgrade. So that's not the place that we want to be. We need to be at the higher end of that range to ensure that we're financially stable. And then the last piece that I've highlighted here in yellow because there is a deviation from our internal framework compared to what you see in the benchmark range has to do with our operating margin. So currently we have a higher target for operating margin than what you see in the S&P and Moody's. And that is directly related to the fact that we haven't spent the amount that we should have been spending the last several years on capital. Which means when you look at our profit and loss statement, we have less depreciation on our profit and loss statement than what you would find in other organizations. So hopefully, assuming our budget gets approved and we start getting on a path that allows us to spend more capital, that internal target will go down over time as more and more depreciation expense starts to become a part of our P&L. Next slide. I just included a quick example just to kind of show how that will happen. So this is, if you assume just static revenues and expenses, so no change there, but you start spending more on capital which will drive up the depreciation expense that we have. You can see that that doesn't change the operating EBIT of margin, but it does over time start to drive down the operating margin. So that's what will happen to our internal targets as well. As we hope we're able to increase our capital spending on much needed investments, our internal target will start to go down for our operating margin. Next slide, John. So this is a look at where we have fared over the last few years when you look at the internal targets that we've had. The yellow highlighted numbers are numbers where we're below our framework target for that given year. Green is, sorry, yellow is we're within the framework target. Green is we're exceeding the framework target and then red we're actually below those targets that we just took a look at at the previous slide. So the story that this really tells when you look at from 16 up through our 22 budget is we were on a good solid path back in 16 and getting into 17 in terms of our operating EBIT of margin. You can see that our cash still wasn't within range but was starting to climb as a network. It went from 188 to two or one. But from then on, our operating EBIT of margin started to decline, which caused the cash to decline and the decline as we'll highlight as we move forward through the presentation. Really the key missing piece there is our revenue rate increase did not keep pace with our expense inflation during that period of time. So that's kind of the key messages to take away from this slide. What this does show is we are in a, if you take a look at our long-term debt to capitalization ratio, we are in a good place there in terms of how we compare to the benchmarks and where we are compared to our internal targets. Once we are on a path where our operating EBIT of margin is consistently back into the range we need it to be, that's an area that will have more confidence in being able to take advantage of that debt capacity that we have there. Finally, if you take a look at the budgeted, the FY 22 budgeted column, you can see that we're the target that we've set for the operating EBIT of margin for this year is still at the lower end of that range. But if we can start to make some progress like we did last year, where our rate increase did come very close to covering our expense inflation. If we can continue to make progress there, you can see we'll at least be at the lower end of the range and hopefully in the years ahead, we'll be able to focus our benchmark targets on that A rating. The rating itself is not what we're essentially striving for, it's more about what the rating says. So first of all, 90% of S&P rated hospitals do have an A rating or greater. So the targets that we have set are not targets that are unreasonable, they're very reasonable that they're where we should be as an organization. The A rating indicates the financial capacity that we have to care for our community. It indicates that we have the resources to pay competitive salaries, to recruit and retain the people that we need to care for our patients. It signifies that we can keep pace with advancements in medicine. It signifies that we have the financial stability to weather unexpected events. Back to the deep appreciation that Al shared when he was talking about the federal and state stimulus money that we received. The fact is at the beginning of the pandemic, we were in not the greatest financial shape to be able to weather an event like that and had that not been for the federal and state funds that we did receive, the impacts of the pandemic and the downturn and in our finances would have been even more dramatic and even more impactful to us continuing to meet our mission. So we wanna get back to that place where we have the financial stability to be able to absorb those unexpected events. Something very tangible that the A rating means is that it ensures that we have access to capital markets. So when we do need to borrow money, we have that ability and it also ensures that we have low interest rates on that, on those funds. The rating agencies and their meetings with us this past year made it very clear that they're expecting the health network to be back into that seven to 9% operating EBITDA margin range or that we were at risk for a downgrade. They've seen even before the pandemic that our finances were starting to deteriorate. So they're really expecting this next year that we're back into that range. Then finally, what that would mean if we were to receive a downgrade, it really would mean that we don't have the financial wherewithal to continue to make investments in our people, in our facilities, in our technology, that the organization would seriously be at risk for not being able to continue to meet the needs of our community. So I think that's it for, so I'm gonna turn it over to Mark who is gonna highlight our net patient revenue growth and then also go into detail on our commercial rate increase. Thank you, Rick. So as I go through these sections, Rick and I are gonna be sharing some of the talking points back and forth. So there are a couple of slides he'll be doing. There are a couple of slides up. I'll be doing, but I'll be pausing at the end to see if Rick has anything to add. Next slide, please, Jen. So this is just an idea of how we go about constructing our net patient service revenue budget. It is very consistent. It is very system-driven. There are nuances that need to be factored in for the three different hospital types, but this is basically the practice that we've been doing for many, many years that has gotten our NPR rate, I think, fairly close to target each year. Understanding the last two years to Al's talking point earlier, there's about $300 million worth of less NPR coming into the system over FY20 and 21 for our hospitals. So the first column, you know, this just highlights what goes into the 21 budget, all of those same general assumptions. And so what we attempted to do here is to say that these are the components of how we break it down and speak to the major items that drive it. And there's some notable items at each one of the bottom. That's more there from an awareness perspective, but I can't overemphasize how important that base period of the year to date, October to January is for this overall model. I mean, that is really, really the foundation that establishes all of those relationships of payer mix, service mix. So in the emphasis is probably more important than this year than ever before. As Al spoke to those challenges earlier on an earlier slide, all of those challenges hit in that October to January period. And so the challenges that we had as a network is that we take that October to January base period and then we say, what sort of adjustments do we need to make to that? To basically get the simple example that I use is that before you look at any rate changes, you know, how do we make September look like it's a 12 month budget? How do we align? All of those dollar values that happened in September as a 12 month budget and as you're going to see in a later slide, you know, from Al on volume that also presented a little bit of a challenge this year, I shouldn't say a little bit, a significant challenge on how to predict where 22 is gonna fall. For some of those challenges he mentioned earlier and some more that he will mention later, so here's how we went about it. October to January still served as the base but we had to go in there and do more adjustments than we have ever had to do and I've been doing this more than 20 years, more adjustments than we've ever had to do and basically what we had to do is we went back and we looked at 2019 actual, that was the cleanest year that we had and we basically looked at 2019 actual and then we looked at October to January and then also all of those adjustments that need to happen or be taken in consideration and we put our best work forward taking all of our expertise and this goes all the way down with a revenue chain by the way of saying how is this gonna impact us as we go into next year? So like I said, there was a lot of considerations, there was a lot of changes but we took a mix of 2019 actual, the October to January base and the known adjustments that we would have and then we said, is there any changes in utilization? It's very difficult to come to a single utilization statistic that say this is how revenue changes. So the proxy that our model uses is gross revenue. It's not perfect, but it's probably the best that we have. The imperfections with it is that it really doesn't give the credit to each type of volume of how the value of that payment may change. So there's some fluctuations there. Then there's the physician, acquisitions or transfer component that needs to be considered. And then we take a look at what is our 22 expense inflation? And that's purely on rate, that's purely on unit cost change. And we're gonna get into this calculation next and you total those all up, that's how we get to our 22 budget and you see like the same list of base assumptions that you saw starting with 21. Next slide, please. Okay, so these are the numbers that go along with it. And so, and I'm gonna speak first to a little bit of that scalability that John spoke to earlier that it's important to keep in mind that when you look at some of these numbers, they are big numbers, they are large numbers. But when you put it in relativness to the base in a very complicated payment model of how close that we are actually able to get these numbers, it is pretty remarkable. So, but I'll go through and I'll speak to each one of these at a high level for each one of the facilities. There was the most variation at the University of Vermont Medical Center. The starting budget was $1.4 billion. Through that base period and through those adjustments, there was almost $47 million of changes. I can tell you there was a pair of mixed change where that took that down by a significant number. And we did see a change in our budgeted collection rates by payer. That was attributed to a shift in the mix of services. And Al spoke to this earlier, meaning the acuity or the treatment levels that had to be provided to patients were at a higher level. And it is just the way our payment structure works, okay? Those higher acuity services, like a surgical case compared to a medical case, even if the gross revenue is the same on both of those cases, the surgical case is usually paid a little bit higher. So that acuity mix was a large, large driving factor of that $47 million change. There was a little normalization in there of transitioning like the hospital rate year to a calendar rate year, so on and so forth. That accounted for about $9 million of that $47 million. But the major part of that was a change in the type of services that the patients were seeking out. The utilization for the University of Vermont Medical Center was basically a push, I would say. And keep in mind, Al's gonna speak to the volume later. There was a physician transfer between two of our organizations. Well, the rate increase that was necessary to cover expense inflation was $42 million. And that's what brings us to the $1.5 billion. The rest of the two organizations, CBC and Porter, they were a lot more normal of the year. And I also should say this too, is that that $47 million, I look back that past year's filings, it is a little bit higher than past year's filings. So that's probably that volatility that we had to do in that adjustment period. But when you look at CBMC and Porter, the adjustments were much, much smaller through the base and the adjustment period. You can see through their utilization that we are predicting a utilization increase. Al's gonna speak to those volumes later. Their expense inflation was respectively $6.8 and $2.6 million that brings CBMC's NPR and FPP budget to $251 million and for Porter $94 million. And then if you break that change down in totality, that for the University of Vermont Medical Center, that's a budget to budget NPR change of about $85 million. If you look at after the physician transfer column, you know, respectfully, the staff still need to do their work with the Green Mountain Care Board to calculate those percentages. But if you look at it after the physician transfers, that's about a $6.3 million change and 3% of that $6.3 million is related to the 22 rate change that is directly tied to expense inflation. And Rick's gonna talk a little bit later on the difference between those two slides and how you break all of this down when you look at it on a population basis. But if you look at it at CBMC on the surface, it looks like they had a very large NPR increase of 6.5%. But after you factor in physician transfers, it goes down to 4.5% and their 22 rate that's related to expense inflation for 22 is 2.9%. And then if you look at Porter Hospital, it is 4.9% and 2.9% respectively. Next slide, please. Yeah, so this slide is meant to just highlight a couple of things, but primarily because you'll see in a minute as we did last year, our commercial rate increase is completely being driven by the need to cover the inflation on our expenses. And so when you think about volume or expense increases, there are expense increases that are generated by volume and then there are expense increases that are generated by inflation. And when we look back at our finances over the last several years, if there was no expense inflation in our numbers, and we just had a volume increase that then had a corresponding expense increase. With all the fluctuations in terms of the types of volume changes that we've had over the years, whether it was admissions or radiology exams, different payer mixes, different amount of fixed versus variable expense on that particular volume metric that was increasing, you take that all into consideration, essentially our margin would have just been essentially unaffected by volume changes over the years that the revenues and expenses essentially were pretty much in line. Meaning if we had no expense inflation, we would need no rate increase because all of the moving dynamics within our finances of changing volumes and the things that we've done to help manage expenses all essentially brought us to a kind of a level kind of margin. What has been missing is that rate increase to cover and keep pace with the expense inflation. So that column B that you see there and that small grid down the bottom, that's been what our struggle has been, that because we haven't been keeping pace with that expense inflation, we've been losing ground in terms of our margin. Last year we made great progress where the revenue rate increase came close to covering our expense inflation. So hopefully we can continue to make that progress, but that's really the missing piece. And as you'll see here in a minute is the piece that as we've done the last couple of years that is how we build our commercial rate need. Back to you, Mark. Next slide, Jen, please. Okay, so this is how we went about our commercial calculation. It first starts with what the expense inflation was for all of our payer population. And when we say expense inflation to be very, very clear, we are only referring to FY22 expense inflation. So we're looking ahead, we're trying to pick, we are trying to predict what that looks like. And that's what we're building into our ask. We're not doing the look backwards. I mean, as we all know that the expense inflation Al spoke to earlier in 21 was probably higher than most, if not all hospitals budgeted. So this is only 22. And you're gonna hear at the end of our slide presentation what some of the risks are. One of the risks is this expense inflation that we're building into our 22 budget isn't high enough based upon what we're currently seeing in the marketplace. But this is what it was based upon. So we first start with the expense inflation number. We take away all of the other payment increases from the non-commercial payers. That equals with the remaining expense which needs to be put onto the commercial payers. We divide it by the per 1% and that does the solve for the commercial rate. So that's basically how we do it. And we'll go through the numbers for each one of the affiliates. Okay, okay. So the first thing I will say this is where the expense side really matches up with the NPR side, okay? And the numbers might not match exactly because we're trying to go after it from a payment level and an expense level. So there's a little variation in the rounding here. But basically, if you take a look at the expense inflation for the University of Vermont Medical Center, the total expense inflation was $41 million or 2.5% from an expense level. We did have to back out a portion of that was related to our other revenue activities. So basically the net starting point of how much fell into the expense inflation that needed to be funded by NPR was the $38.6 million. I'm just gonna go through these categories and just kind of share what the change was. So on the salary inflation in this one, it was 3% or 3%. On the med surge, it was 3.2. The pharmacy, it was 2.8. The other category was 0.9%. And the expense inflation on the provider tax is purely related to the unit cost change in the revenue. That's one of those categories that it's just not one calculation. It's a three or four step process that you need to consider as you go through that. And we're happy to talk to that further at the end of the presentation or with the Green Mountain Care Board staff after. But it's very important that you consider those three or four steps. And another way of looking at it is how is the expense changing if the volume doesn't change? So that's another way of looking at it too. But basically, if you go down below the first column, well, that says if we were to out and by the way in the little assumptions after Medicare, that just shows the Medicare inpatient assumption was 2.5% outpatient to professional was 0%. It looks like it was cut off. The basic assumption in Medicaid was zero. It says a minus here, but that's where we're getting to some of that rounding aspect. In the model, you need to consider other payers and bad debt and free care and then commercial. But if that 38.6 million and I'll know this is part of the rounding, it's off by 15,000. But that's just the multiplier on large numbers is if the expense inflation was to be funded equally based upon the current mix of business, this is what it would look like for each one of the payers. Medicare would be at 11 million. Medicaid would be at 4.5. This other category would be a little bit over a million and the commercials would be about 22 million. Based upon those assumptions that were shared off to the left, these were the rate calculations in the model. Medicare funded 4.2. That was basically zero bad debt and free care, which was the main driver and the other payers went backwards. And that meant to balance out the solve for to the end that the commercials ended up with $39.5 million. You can see the difference off to the right. And if you take that $39.5 million down below, the per 1% on a budget year is $5.6 million in that calculated 7.05% rate increase. So next slide, please. So going through the same mechanics for the central Vermont Medical Center. Their total expense inflation is 2.3%. Once again, it is fairly modest if you look across the individual categories. A salary infringes 2.5%. Med Surgeon Pharmacy are 3% and 4%. All others under one in the provider tax is about 2.4% compared to the unit cost change down below. This just speaks to the same thing. Their assumptions were 2.5% for inpatient Medicare, 2% out and zero. Medicaid was zero. Here's the impact of bad debt and free care. If you allocate that $6.1 million across all of the payers, it is 2.2 million for Medicare, a little under 800,000 for Medicaid. The miscellaneous category is 250 and commercial payers are 2.8. Once you factor in the cost shift, it brings us down that the commercial payers have $5.8 million. You go down below, you take that $5.8 million, divide it by the per 1% of the 791,000, and that's how CVMC comes to their 7.41% commercial rate. Next slide please. Okay, so as we look at Porter Hospital, they had a pretty low cost inflation total. That's about 2.4%. Their salary in fringe was 3%, well, the mid-surge was in the 3%. And then the other thing that I should say is all of these numbers tied to the appendix table that we submitted under the inflation category. So if you wanna reconcile those numbers, that's exactly where they come from. So on forth going, all other was under 1%, whether the provider tax was 1.8% that was in line with their unit cost inflation. As you go down to the rate assumptions, Medicare inpatient, outpatient had a 2.4%. That's a little bit different because they're cost-based reimbursement. So on the hospital activities, so it makes sense that 2.4% is exactly in line or very close to being in line. With what their cost inflation is. On the professional, since they're not paid that. Way on a cost basis, it was 0%. Medicare was zero. So just to kind of outline this, I mean, where you can see going across, there's 800,000 for Medicare, 200,000 for Medicaid and 1.1 million for commercial. You can see that Medicare for cost-based reimbursement comes a lot closer to funding that inflation cost. It's a much smaller number. So the solve for there was a little under 1.9 million dollars for commercial is 321,000 per in. And so that calculates a commercial rate of 5.86. I would just like to say that, this is just one aspect of the NPR change. Rick's going to be talking about the next aspect of the NPR change. And how you start to transition this look of an NPR change and start to look at the impact of it, of when it's evaluated across the population base in our service area and exactly what that means. So I'll hand it back to Rick now. Thank you. Next slide, Jim. So yeah, as Mark was saying, so what we just went through on those slides is the rate component of our NPR. The other component is the utilization piece. So what I'm going to take you through the next few slides is how that rate and utilization compares to the population we serve and make the case that when you look at it from that lens compared to the denominator, which is the population we serve that we feel we're within the 3.5% net patient revenue growth guidance. Jen, next slide. So in asking that our net patient revenue growth be viewed in that light on a per capita basis, obviously I hope we're agreement that we're not asking the board to go beyond the bounds of the statutes that regulate us. So hopefully that what we're about to go through makes sense to you. Next slide, Jen. So when you think about total cost of care as I mentioned, so it's a combination of the price for the services times the utilization that we're expecting. So our total NPR is essentially that total cost of care. It's what we're projecting for the price of the services that we have, including the commercial rate increase that we're requesting in this budget, times the utilization that we're projecting for all the different volume metrics, admissions, radiology exams, the everything that we have in terms of utilization. The next piece of that equation is then taking that net patient revenue number and dividing it into the population that we serve. Since as one of our key and core missions is trying to keep our population healthy, we're actually trying to decrease utilization. So you need to look at that denominator because that indicates the patients and the population that we serve that haven't received services, which is obviously part of our goal. Next slide, Jen. So some of the bullets that I have in here and some of the talking points have changed even in the last two weeks here, but we submitted our presentation a little while ago. So I'll just highlight some of the things that have changed. So overall, as we've highlighted the last few years and as I'm sure you've seen, the population in Vermont has been flat through 2000 or was flat through 2019, but that our primary network, the counties that surround Chittenden County, so Addison, Grand Isle, Franklin and Washington counties have been growing even though through 19, the population of Vermont has been flat. We saw in mid-April, the newest census data that came out that showed that the population in Vermont had grown from that 2019 estimate of 623, almost 624,000 people up to 643,000 people. So a very unexpected result and that's even before we've seen any kind of data on what's happened in 2021, which I expect when we do start to see some data, we're gonna find that that number has grown even beyond that number. At the time that we submitted this, we did not have the census data available by county that did come out a couple of weeks ago and it has essentially validated our sense that our market area is growing. Al later on in the presentation is gonna share some of the results of an independent study that we had commissioned that will show you a little bit more detail on where we think that that's headed in the years ahead. Like the rest of the Vermont, the UVM Health Network's primary market area has been aging. In 2018, we were fourth in the country as a state where we had 19.8% of our residents that were over 65. And this newest 2020 census data that's grown to 20%. The reason why that's important as we all know, the older that you are, the more you utilize healthcare services in this chart at the bottom of this slide highlights the data that has been put out there by the Department of Health and Human Services that shows that those 45 to 64 use healthcare services at two and a half times those under 45 and those over 65 utilize healthcare services at almost four and a half times those under 45. Next slide, Jen. So this model that we have built to adjust our net patient revenue on a per capita and age adjusted basis, we had in our narrative, we've condensed it here in the presentation just to highlight the kind of the key pieces of information. But if you're looking for more detail, the chart is a little bit more expansive in the narrative. Starting at the top is our market share over the years. So for FY21, for example, it's that 325,000 figure and this is the market share for all three of our Vermont hospitals. Again, just as we're going through these numbers, just to remind everyone these numbers that you see for 2021 and the 22 budgets are before we had access to the most recent census data, which shows that these numbers actually should be higher than this. So when we update our model, it will change these numbers because the population is actually higher than what we have in here. One of the factors that we've used as again as we highlighted in our narrative is to adjust the population for the age of the population and to use those utilization factors from the previous slide to make those adjustments so that we factor in as population, to the age of the population changes that we can measure the true impact of that when you look at net patient revenue so that we're comparing apples to apples. We've taken our UVM health network patient revenue and we've taken out all the New York based net patient revenue so that we're truly only talking about the net patient revenue that's been generated by Vermont patients so that we can compare that to the population numbers. This next section here on the slide we've added, we didn't have in the narrative because on the next slide, I'm gonna compare this number to some national trends. Again, trying to use benchmarks wherever we can so that we have some external look on these numbers. But when you look at the last five years at our net patient revenue per capita, not adjusted by the age, we've averaged 1.2% increase in net patient revenue over those per capita over those five years. When you look at our budget to budget change, we're at 3.9% per capita. Again, these population numbers are lower than what we know today. So both of those percentages with updated population numbers would generate lower numbers than what you have here. And then finally, the grid at the bottom that is the age adjusted number over the five years, the net patient revenue per capita adjusted for the age has increased by 0.2% over that period of time. And then finally, from the 21 budget to the 22 budget has increased by 2.6%. And it's that number that we feel strongly fits within the 3.5% guidance that has been set by the board. Next slide, Jen. So here just to show again, how this compares to some external, not necessarily benchmarks, but data. As I just went through the UVM Health Network from the non-age adjusted per capita growth from 2016 to 2021 has been 1.2% over that period of time. The national growth rate, if you look at the chart at the bottom over that same period of time has averaged 4.4%. The non-age adjusted per capita MPR growth rate from our 21 budget to our 22 budget is 3.9. When you look at that 22 increase again on the chart below for the national projection, it's 4.9. Again, both of those numbers will be lower when we update with the newest population data. And then finally, not something for necessarily this budget hearing or to use for today, but just looking ahead a little bit when you look at the data, the national growth projections, and you look from 2022 to 2028, the national per capita growth projections are 5.5% per year during that period of time. So just putting it out there that we know that the Vermont population is growing faster than the rest of the nation. And we know that utilization of older folks generate more utilization that looking ahead that 3.5% growth target number, even when it's adjusted on a per capita basis based on these projections that are being made may be difficult to achieve and just something we need to consider in the future. With that, I think I'm now turning it over to Dr. Leffler to share a little bit about the EVM Medical Center. Thank you, Rick. Steve, before you start, at some point in the next 45 minutes, we would like to take a 10 minute bio break. Is now the logical time for that or should we wait till after your portion? Sounds good to me. Let's take a break. Yeah, I think this is a right breaking point, Kevin. Thank you for bringing that up. Thanks, John. So I'm going to recess this meeting until 1020 and we'll see everyone back at that time. Thank you, Kevin. Next slide, please, Jen. So I think it's an important point that the EVM Medical Center serves both our local community and the entire state. We're the Academic Tertiary Care Center for approximately a million people in Vermont and upstate New York. We're also a very large community hospital and our employees serve almost 170,000 people in our local region. That's critically important for everything we're going to talk about today that we have this dual function. I can tell you as a provider and educator, that's an amazingly great place to be to have both a community hospital and academic medicals on COVID-19 and we committed using all the resources that we had to support Vermont's pandemic response, whether that was testing Vermonters, vaccinating Vermonters, standing up surge sites, one of our infectious disease providers, concessions to underrepresented Vermonters to help them make good choice to be vaccinated. So across the organization, people were very committed on using the resources of the Medical Center to help Vermont, I think have the best in country response to the pandemic. This slide was put together when we were optimistically saying we're going to return to many pre-pandemic capital projects, but the pandemic, even though we wanted to be done with it, it's not done with us. We have 13 people in the hospital day with COVID-19. We have five in our ICU who are quite ill. That's down from 15 over late last week. And we have 54 people waiting for discharge who can't leave the hospital, but are ready to because we don't have safe places to send them. That's mainly pandemic related and staffing. We do need to get back to the other important work that we do and we are very focused on projects around staffing, equipment needed, like MRI machines and space. I've outlined some of the things that you're very aware of because we've put a ceiling in or I've told you we're going to, we're working hard on a staffing collaborative with our union to make sure we have safe staffing on all of our floors that's worked very well. Our emergency department, I've been here for 28 years. We've set our top number 10 days over the past three or four months. Yesterday was a day of 210 patients. I'd only seen that a couple of times before in my entire career and we're breaking 200 almost every day now. We need another 3T MRI. We have backlogs for MRI right now. We have the only 3T MRI in the state of Vermont currently. It runs 17 hours a day. We do our inpatients during the nighttime so we can make sure we get out patients in. 3T MRI is the state of the art for diagnosing cancer, another complicated complex illnesses and we desperately need another one for access for remoners who need that study. And you've already heard a lot about the FANY, a huge challenge for the medical center, but we need a current modern flexible outpatient surgery center for the patients that we serve, for our providers and for our learners that can understand as more surgeries move to outpatient care, how that would work for them and the future careers they're gonna have. Next slide, please, Jen. Our challenges, and once again, you've already heard this in the presentation, but I have to hit on this. We have a significant access challenge right now. As great as any challenge I've seen as long as I've been here, I think that the growth of Chittenden County as well as the aging of the Vermont population and the coming out of the pandemic with people being, having delayed care has put us at a critical time right now. Last Thursday, we were in near crisis mode in terms of trying to care for everybody who needs our services. The whole United States right now is having staffing challenges no matter what you're doing, healthcare, particularly is having huge challenges. We are having staffing challenges right now and working hard to make sure that we are an employer of choice, that we are recruiting well, that we're retaining well, that we are pipeline to the colleges that are training our next generation of providers. But staffing I think is gonna be a challenge for the next five to 10 years and we have to make sure that we are a place that people choose to work. Space, right now at the medical center, we are using every available space we have. In the early spring of 19, I came to Greenmont Care Board and we asked for permission to use some space and since that time, we're using all that space every day right now. We recently asked to add 15 more beds and even that right now is not meeting the demand for patients that we have. In our emergency department this morning, we have 22 psychiatric borders. We have 43 total patients and we have three people, this is actually a very low number, three people in our ED waiting to go upstairs, but we have five people outside hospitals that need to be transferred to the academic medical center that can't come. That's ideally a occurrence as a physician that really bothers me. I wanna get people to where they need for care. So we're very focused on that in trying to have space and staff to care for people across our region who need us. Next slide, please, Jen. So I wanna make sure that people realize that the pandemic as Al said has been an accelerator, we are having issues before the pandemic. If you look at the medicine volume up through 19, this is pre-pandemic and the surgical volumes, they were both already increasing. Then we get a dip from COVID, people stopped seeking care, we stopped doing a lot of care, but since about April, we've been back at least on these two curves if not greater. So we were already experiencing challenges around having space and equipment needed to care for people who need us. And since about April, it's been at an unprecedented increase. Next slide, please. So we break every single day at the medical center into three levels of capacity. So green is level one, that means operations as normal. The way I think about that is we have enough staff and space and equipment for everybody who needs us. No problems. Blue means we're challenged, but we'll get through it. Blue as we call it level two. And blue is not an easy day, but we have, we'll get through. And the upper level here, the orange or yellow, is we're at census level three. It can't be operations as normal. It means you have to divert people away from normal activity to figure out how to care for everybody who needs us, both with staffing and space challenges every day. You can see that for the month of May, May and June, we were in either level two or three every single day. We've been in level three right now for seven consecutive days. We project to be in level three all the way through at least mid next week. That means that the staff here is working exceptionally hard trying to manage patients and trying to get everyone what they need in really difficult circumstances. Extremely challenging. On top of that, I just will tell you that we're gearing back up for another major testing and vaccine campaign, the medical center through the fairgrounds through a lot of great partnerships, vaccinated, you know, 83,000 vaccines through the fairgrounds. We believe almost all those people are gonna need boosters now and we believe that with the challenges you're seeing in front of you in terms of managing the high census at the medical center, we're also gonna be doing another huge testing and vaccine campaign that we believe is gonna last through at least February. We look eight months out from everybody's first vaccine. So through what looks to be a very busy fall, high volumes of COVID patients, sick patients otherwise, high volume of transfers, site crises, we're also gonna be running another major COVID campaign which is the right thing to do, but we'll be challenging. Next slide please. This I already hinted at this, but you can see that from March 21 through June 21, there's a gradual but steady increase in patients or I would say outside facilities requesting transfer of their sick patients to the medical center. I wanna be clear, this is our mission, this is what we're here for. We need to be in a situation where we can accept every one of these patients as soon as the outside hospital says they need to come. So that we maintained for the whole pandemic even during the cyber attack that we would accept critical patients, emergent transfers, and we've done that consistently even today. But with already multiple people in the ED waiting for admission, some of these people have to wait for a bed. There's just no place to put them. So that's a critical issue we have to address. Next slide please. I wanna make sure you know that even during these challenging times we're very focused on being efficient and making sure that we're not using resources in ways that don't make sense and that we're controlling the cost in every way possible. This is a slide from what's called AAMC, the Association of Academic Medical Centers. It's about 130 medical centers including this in this chart, including the UVM Medical Center. For as long as I've been here, we've always been an extremely low cost academic medical center. This is directly with our peers. You can see that on this chart, we never even hit the midpoint 50th percentile or oftentimes at the 25th percentile or lower. So we are doing everything in our power to manage expenses and actually not to over utilize resources. When I tell you that our MRI machine is running 17 hours a day, we're one of the lowest utilizers of MRI in the United States on data. Next slide please. Another slide just to highlight that. Supply expense for adjusted discharge. You can see that we consistently are extremely low cost compared to the College of Teaching Hospital median. And finally, if you look at our compensation ratio, so that's basically our cost of staff per budget. We maintain right at A rated median right there, if not slightly below. I think that's my last slide, Jen. Yes, thank you all. Thanks, Steve. Morning, everyone. I'm gonna give a brief overview of Central Vermont Medical Center. Next slide. So just to reground us, Central Vermont Medical Center employs 1700 staff members and we serve over 66,000 people in the regions across our 24 cities and towns. On our main campus, CBMC provides a range of inpatient and surgical services as well as our long-term care and short-term rehabilitation at Woodrich Rehab. I do wanna note that since the beginning of the pandemic, we launched our incident command center on March 9th, Woodrich Rehab and nursing has had zero positive COVID residents, which is almost unheard of in the industry. So I just wanna credit the team for all the work and making sure we kept our residents safe through that, this very challenging time. CBMC also has 25 medical specialties and 23 medical practices across our HSA. We as all organizations in our network have been acutely focused on our pandemic response, doing all we can to support our community. We gave 34,000 vaccines in our hub in the Berlin Mall and we as UVMMC are preparing for testing, for our employees again, as well as the community and vaccine boosters. We are seeing as Steve mentioned a dramatic increase in the complexity and the acuity of our inpatient admissions. Most of our inpatient admissions are medical and most are over the age of 60. We've also seen high volumes in our ED, again unprecedented for us, as well as extraordinarily high volumes in our express care, some of the highest volumes we've seen in my tenure of the last four years. And again, the number and severity of our borders in our ED have increased through the pandemic, both for the adult and pediatric mental health borders. We're also experiencing medical borders in our ED, significant volumes increasing there. And as Al mentioned earlier, our acute care census is the highest that we've seen in my tenure. Next slide. Just wanna go over some priority areas for CVMC. I'm gonna spend some time talking about workforce a little bit later in the presentation, but I do wanna mention that for us as with Porter, we're gonna be going live with Epic Wave 2 in our acute care setting as well as our revenue cycle. We're looking forward to being on the same platform across the entire enterprise. And we are anticipating that with the increased census and staffing challenges that training for that will be a bit challenging, but I think as a network, we've been proactive in trying to secure additional staffing to support a successful goal live. The other focus areas for CVMC are in margin improvements. We've used a variety of lean and rapid cycle improvement methodologies to enhance efficiency of all of our operating systems. I'm gonna focus on a couple of projects in particular and those being optimizing our surgical schedule. So in collaboration with the UVM Health Network team and UVMMC specifically, we've opened up an allocated OR space and resources to provide OR time to UVMMC surgeons to come here and provide care for patients who live in our catchment area. I think that's a strong example of the effectiveness of the network. The other area focus for us is in our OR supply chain management and optimizing of our supplies in that area, reducing inventory and cost of limited use items. Again, just to reduce our overall expenses in that area. In the diversity, equity and inclusion area here, again, Dr. Bromstad shared a lot of what's going on at the network here specifically for CVMC. We've charted diversity, equity and inclusion steering committee in August of 2020. They meet monthly. That team reflects the diversity of our employees here. Very engaged team. As Dr. Bromstad mentioned, we have a lot of work to do. We did get support from our board of trustees for DEI commitment statement, which we've launched and is now part of sort of the grounding foundation work for all of our DEI efforts. We have declared Martin Luther King as an observed holiday, switching from a traditional Christian holiday of Christmas Eve to keep it budget new control, but that was an ask from our employees. So we wanted to move forward in that direction. And DEI content now as part of the education is part of all employee orientation, including our physicians that are part of our medical group. Dr. Bromstad sent a letter to the board in mid July, describing a large number of facilities projects within our network. And obviously core to that is our inpatient psychiatric capacity project. That project is essential to address a severe shortage of inpatient psychiatric beds that we're experiencing across the state of Vermont. We've already talked about the border issue and these patients, as you know, wait in our EDs every day of the year. And that is only increased in severity since the pandemic. We've done a detailed analysis of the statewide need and we acknowledge that we think that we can address that need to some degree by adding 25 additional adult inpatient psychiatric beds here on the CVMC campus and relocating 15 beds that currently exist for a total of 40 beds. Dr. Bromstad has reconstituted the PIC Steering Committee, which he will chair. That committee is picking up where we left off when we paused our planning efforts in April of 2020 at the beginning of the pandemic. We're beginning to explore more affordable options for creating more inpatient psychiatric beds here on our campus. And once we've determined the most efficient location for the beds, we expect to be able to take full advantage of all the planning that's happened to date. And that occurred prior to our COVID related pause. And we're looking forward to providing Green Mountain Care Board an update in late fall of that project's progress. Related to the pandemic response, I think we've already talked about what we've done to address it. And we are now working as a network to talk about how we address the booster needs, as well as the mandate for vaccinations going forward. And so that work is underway and we expect to be able to provide those resources as part of a network response. Other key initiatives that I wanted to mention, and the first one is the Central Vermont Prevention Coalition, drug, alcohol and tobacco use are leading causes of death and disability in the Central Vermont area. And that was as a result of both data we receive nationally, statewide, and as part of our community health needs assessment. We've launched a Central Vermont Prevention Coalition, which is an interdisciplinary collaboration of organizations and agencies that are working specifically on primary prevention, harm reduction and disease prevention, treatment, recovery and restorative justice. CVMC serves as the backbone organization for this effort in Central Vermont. We received a three year federal, rural communities opioid response program grant of $1 million. And over the next 18 months, this team will analyze the impacts of the COVID pandemic on substance use disorder recovery and ways in which we can really strengthen our treatment pathways. Another focus area as Steve mentioned is access for us. We've rapidly expanded and we continue to invest in telehealth services as part of a joint partnership with a health network and their patient access and service center. We're a pilot for some of that effort here and we're working hard to try to expedite referrals throughout the network for some specialties like urology and more locally rheumatology and endocrinology. So access is still a focus, though again to Steve's point, access is challenging with individuals having I think delayed some preventative health measures during the pandemic. The other area of focus for us is our accountable community for health that's called Thrive here. CVMC serves as the backbone organization for all that work and we're focused on improving the social determinants of health. This team's goal is to optimize the health and wellbeing of our community through informed, collaborative and innovative solutions. CVMC has worked collaboratively with 54 partners and they were essential in our, I think a robust community health needs assessment that we completed in 2019. And we're continuing to use those data to drive our focus areas as part of our strategic plan. The other area I wanna mention is the working community challenge. This initiative was launched in 2019 and it supports diverse local teams tackling complex challenges facing their communities. It's a three year grant that is cosponsored by the Federal Reserve Bank of Boston, the state of Vermont and national and local philanthropy and private sector employees. Eight communities in the state of Vermont received a grant and Barrie was one of those communities. And we're really grateful to be able to leverage our accountable community for health to do this work. So our focus area here in the Barrie community is by 2030 there will be 15% fewer single moms living below the federal poverty level than their counterparts in 2020. CVMC is a core partner in this program working with Green Mountain United Way. And we're specifically focused on expanding a program that we've been using here at CVMC called Working Bridges with Green Mountain United Way. And we're looking at how we can bring resources to those single moms that have dependent children and how we can really optimize the supports they have to allow them to really fully engage in the workforce. So that's work that's underway. And again, I wanna highlight our work on food security and wellness. This is work we've been doing for a number of years. That collaboration was more critical during the pandemic. As we know, food security was a huge challenge for many of our community members during this pandemic. So we've continued that effort serving over 300 households every month. And in addition to 150 households getting weekly healthcare shares with a very strong partnership we have with the Vermont Youth Conservation Corps workforce. Again, you're gonna hear this repeated, I think from all of us. And I know you're all aware that the Vermont Department of Labor noted that Vermont's workforce has shrunk to the slowest level in 30 years. So our workforce peak was in 2009 and now it's down to that same size as it was in 1994. So much of that decline has been in the last 18 months. And we're certainly feeling the ramifications of that in the healthcare systems. Reasons for that a challenge is an aging out of the workforce. Not only are our patients demographic shifting, but so are our employees. Availability of affordable housing is also a challenge. And then again, the pandemic impacts. So the staffing challenges that we face here are all over the board entry level positions but particularly acute in the RN sector, radiology texts are also an area that in the past we've not had challenges with but we are today. So one of the things we're doing is exploring EB3 visas to place foreign nurses into permanent positions here at CVMC. The goal is to bring talent into Vermont expanding our pipeline and also at the same time diversifying our community. What the early analysis of this program would show a significant reduction of cost and shifting away from traveler expense. It would be a three year commitment for those individuals coming into the US and Vermont specifically. And we're working with companies that have done this all over the US it's just more unique for us to be exploring that today but we see that as an opportunity here at CVMC. And then probably the area I wanna focus the most is the programs we've had growing talent locally through our nursing career pathway programs. So our LNA programs are strong and running. We've run four cohorts of LNAs in the last six months. We streamlined that program to two weeks. We have a lot of churn in our LNA employees. And again, bringing LNAs on board reduces our reliance on travelers. The piece that I probably wanna highlight the most is our LPN program which we launched prior to the pandemic. The first cohort was launched in 2019 with a strong partnership between community colleges Vermont and Vermont Technical College. These employees who are LNAs or MAs here at CVMC are screened and applied for this program. And if they're accepted, they're supported in completing the program in an 11 month cycle. Our own staff serve as faculty for this program whether they're BSN, baccalaureate or doctoral prepared nurses. They all support the program which has always been a challenge for nursing programs around the state of Vermont is the lack of faculty. They work 48 hours. They have 12 hours of paid study time and work life balance time. And their program starts Friday afternoons. They do the program on Saturday and Sunday. All those classes are offered here on site and that transportation was identified as a barrier for these individuals. And the first class graduated in June with 13 LPNs, which in another month will get us out of the traveler business at our Woodridge rehab facility. VTC recently shared that they're actually getting calls to their organization asking how they can students can enroll in the CVMC program, which is wonderful to hear. And of course they tell them they first have to be an employee at CVMC. So the good news is we actually have gotten a few folks that have come through that channel looking for employment specific to CVMC because we offer that program. And obviously we're trying to replicate that across the network. We also are now offering an RN program which is a graduated program from the LPNs being able to move on to the RN program. That just launched this week. And for the LPN graduates are now part of that program. So I'll pause there and hand it over to Tom for Porter's update. Chair Mullen, directors and staff, Mr. Fisher and Mr. Peesh, thank you for considering the fiscal year 22 budget of Porter Hospital. My name is Tom Thompson. I'm privileged to serve as the president and chief operating officer for Porter. A year ago at this time I was presenting this budget with Jen Bertrand as an interim president. I've obviously since accepted the role on a permanent basis. And I just want to let you know that a key factor in that decision for my part was the health networks focus on high value care and commitment to how care is delivered or changing the nature of how care is delivered and funded in our state. I'm joined today by new Porter CFO Scott Como. Scott has significant healthcare and private industry finance experience including 12 years with the university of Vermont Medical Center's medical group. A quality I very much appreciate Scott is his perspective of finance as a means to an end in supporting our mission. And he's a great partner with our team here to help advance that end. I would also like to recognize new medical center, CFO Judy Peek Lee, who was serving as our interim CFO during the budget preparation. So I'd like to take a little bit of a different twist in our presentation. Tom, your video isn't coming through. At least it isn't for me. I don't know if your camera's up there. There's your smiling face. Thank you. Thank you. I won't start over. Bless you. Chair Mullins or Steve, this technology thing, it is infectious. So again, thank you, John. We'll take a little bit of a different twist in our presentation today to highlight how Porter's plans advance a focus on high value care in our market and as a member of the UVM Health Network. So for just to recall a little bit more about Porter, we consist of a series of primary and specialty care clinics and post-acute and long-term care services in addition to the acute care and swing bed services of Porter Hospital. This care continuum obviously presents a very effective platform to support high value care. And I do, if you would, Jen, flip the page for me or flip the screen. On your screen is our strategy map. Its goals and objectives are designed to advance the Institute for Healthcare Improvements, triple aim, as well as a fourth aim to provide for a fulfilling work environment. All work within this plan is designed to lead to one or more of those four ends. And while events of the past year have caused us to moderate our plan's expectations a little bit, I would like to highlight some of the areas of progress that have, particularly have high value care impact in our plan. So this past year, one of those is that we've moved away from a leadership model that was organized by site of service to an integrated model across our care continuum that features physician and administrative dyads and triads working in a team-based leadership approach. This group is actively pursuing priorities to integrate care and work processes across our continuum. We also started our high reliability journey by training leaders in improvement science, creating process improvement expectations within each department, and recently recruiting a new director of quality safety and performance improvement to help us advance the safety culture and process improvement approaches in our work. We are redesigning our primary care clinics to operate in what many refer to as a team-based care approach with a focus on a blend of professional roles working at the height of their credential to deliver the right care at the right time and at the right cost. And as Dr. Brumsted indicated in some of the opening conversation, we have conducted a survey of our organization to understand perceptions of diversity, equity and inclusion issues. Results have been shared in dialogue with all departments across the organization. Our DEI council has been very active in implementing strategies affecting language access, signage policies and organizational communications. And a last thing I'd like to highlight on this slide is our work with community engagement strategies, including intentional collaborations with community agencies and efforts to engage community members in our work and in our mission. Jen, could you go to the next page please? Okay, so we have several strategic advantages available to us to lever and some challenges we need to overcome to be successful in our plans. And I'm gonna start with dedicated staff which have clearly stepped up tremendously through the entire COVID 1.0 experience as well as the recent weeks and months of persistent high patient activity. We have a great community as far as perceptions and engagement with Porter as a treasured community asset. And I think as importantly, we have an atmosphere in our community and area where we have several really high quality agencies that are collaborators in our mission. The UVM Health Network relationship is key in our strategy. It brings scale, unique expertise, support for care transitions, provider resources, shared services for technical support that we could not provide on our own. And last but certainly not least is EPIC. As was mentioned earlier, we go live with wave two of the EPIC investment here in the next couple of months. And there is a lot of activity toward our preparation and our ongoing optimization of that tool to change how care is delivered, both at Porter and across the network. We do have a number of challenges in our plan. Also a numbers one, two and three seem to be workforce shortages. And then it's again, it's a repetitive theme. Right now we're at 150% of budget on agency support and we are significantly past all other previous years tie water marks in that need for support. We have managers who are routinely staffing shifts. And I think probably what keeps me up most at night is a concern that our organization's compensation is be low market in a variety of areas and concern whether or not our budget that we have put forward can adequately address the needs that we have to keep up. A second challenge also an opportunity, our capital needs and funding, as one of the previous slides indicates we have ticked over 15 years in our average age of plant. And this year we'll be putting in place, hopefully some progress on our master facilities plan and investment in some of our areas where we want to better meet community need that of course will however place pressure on cash levels and margin pressures as we make those investments. To go along a common theme here, patient access constraints. I'll take a little bit of a different twist in that our recently completed community health needs assessment did cite affordability issues as one of the top three concerns expressed in the assessment process. At Porter, we have significant primary care access concerns and are looking both at traditional models as well as alternative models to pick up the slack and being able to introduce new folks to our practices and starting care relationships with us. The network here has also been of tremendous value in extending specialty support and outreach relationships to ensure local access to care. The capacity issues are highlighted by again, persistent high volumes, higher acuties, longer length of stay, mental health folks and mental health crises. And as Dr. Lepler mentioned, the dispositioning issues that we face across our health system within the network across our state, across our country, finding the right place for folks to receive care. At Porter, one of our additional challenges are facilities that are appropriate to accommodate these types of care volumes. Several of our facilities are quite dated and outmoded for the types of care we deliver today. In the last area, I'd like to say it is a challenge and an opportunity also our care inequities. And I think it starts, the challenge part starts with not knowing what we don't know. I think we have a lot to learn about those who are underserved and best means to reach them. Progress, however, is an organizational imperative. And we have been doing great work to date to start addressing some of the issues of the marginalized. Jennifer, you wanna flip the page? I would like to conclude with some critical success factors for our plan success. We have a very ambitious plan, even if it's had to be moderated a little bit this year because of a lot of other activities, our focus is on the IHI's triple aim and to realize those outcomes in a fulfilling work environment. I would cite some of the items on this slide as critical to our success. First is that we accept the responsibility and obligation to be a market leader as both a large employer and as a critical community resource. We are organized and are implementing priority plans to break down system barriers, to optimizing work and care integration, and thus advance a high value strategy. We recognize that Porter needs to be a provider of choice for Addison County residents for that care, which is clinically appropriate in our setting. Our plan focuses on improving access through value added programming and new service development to achieve this end. A role model of mine once said that progress consists of several small steps and an occasional great stride. Epic is a once in an organizational lifetime opportunity to revolutionize care locally and regionally for Porter and within our health network. We believe that continuous quality improvement investment leading to high reliability in our work is a required path for sustainability and high value. We are making those investments and setting those priorities. The needed capital investments I mentioned earlier, we are hoping to begin that work with our master facility plan this coming year to support both our work and care environments and address community need. As mentioned earlier, this is both opportunity and challenge for our organization. Finally, building on our community engagement. Our community engagement is pivotal in our plan, both in maintaining ongoing dialogue with our communities and in programmatic relationships with organizations of like mission, as I mentioned earlier. In sum, the budget proposal that we have put forward is our best effort under difficult planning circumstances. We appreciate your receptiveness to our approach and we look forward to updating you as our work pencils over the year. So thank you very much. Thanks, Tom. Strong work. Next slide, Jen. So we hope that the data and analysis that we've presented today has been transparent, accurate and in the spirit of collaboration. These are four points that I wanna highlight about the three affiliate budgets. First, we believe our net patient revenue growth is below national growth and within the 3.5% guidance when treated as a total cost of care per capita assessment. Second, most of our expenses are outside of the control of Vermont, of our network and of the Green Mountain Care Board. You've heard an awful lot this morning about workforce and the pressures that we're feeling in the workforce area and we are competing in a national marketplace for talent and that is just a fact of healthcare in 2021. Next, our commercial rate increase only covers the cost of expense inflation. And last, we think we've done a good job this morning of showing that we are efficient when compared to national benchmarks. We look forward to having conversations with the board and the staff about that. Next slide, please. This is just a picture. We included this in our narrative last year and this year of a breakdown of the total expense growth of the three affiliates combined and just how much salaries and fringe and pharmaceuticals and provider tax comprise those increases. You can see here that 3.9% of the 6.1 is an increase in salaries and fringe. And that goes back to our point that we're competing in a national marketplace in an incredibly dysfunctional labor market where we are seeing expenses rise faster than anyone would have thought a year ago. Next slide, Jen. So I wanna orient everyone to the next three slides. They're a breakdown of UVMMC, CVMC, and Porter Medical Center's volume as seen through billing when compared to a 2022 budgeted monthly average. One weakness of these three charts is that we did not seasonally adjust the 2022 budgeted monthly averages. It is a straight average. We use these same charts when presenting to the rating agencies because if you go back and look at October, November, December and January of 2020 and 21, you'll see that we presented to the rating agencies in March and we basically only had red to show them. And we were trying to figure out where volume would go by basically now. We thought this would be helpful to the Green Mountain Care Board and the staff of the Green Mountain Care Board to understand the volume assumptions in our budget and the volume trends that we're experiencing that we've talked about this morning. As far as how we construct our budgets, we construct them on a conservative volume basis. We do that because to do that in any other way, meaning in a more liberal way, we would actually commit to expenses that we would not be able to reel back in. And so each line of this is done carefully beginning in March. For everyone listening, if you haven't thought through the timing of this, we do our budgets from the bottom up in March and April and they're done in May so that they can make it through our boards and be to the Green Mountain Care Board by July 1st. And so that's what Mark was talking about earlier with looking at the October through January. And you can see here that October through January in 20 and in 21, was no map to estimating the budget in the upcoming fiscal year. And so we had to do a bunch of adjustments to try to figure that out. And that's why we've said budgeting through the pandemic has been so hard and it's hard to know if you're getting it 100% accurate. And so we've done our best, we stand behind our budgets, but these are the inputs. And so when we say that the ED is very busy at UVM Medical Center, second line down on the left, you come across we're at 115% in June. That's just an example of what we're seeing. And if you go back to the first wave of the pandemic, which isn't shown here or the second wave of the pandemic, you can see that folks just didn't go to the ED. This graphically tells the story. If you have questions on these, we can go into detail, but I'm just gonna call out a few things. Please go to the next slide, Jen. So this is Central Vermont Medical Center. One point I'd make is if you come down three lines on the left, you'll see inpatient births in June. People have asked if there's gonna be a mini baby boom from the pandemic. You can see 152% of projected volume that may be pointing to an answer. We'll see how the statistics play out, but it's just interesting to see this at this level. You can also see that inpatient discharges are above where we're projecting for 2022 by the month, but there's a lot of red on this chart. And so volume assumptions here are critical to making sure that we make our budget for CVMC. Next slide, Jen. So this is Porter Medical Center. This does also include Helen Porter. If you come down on the left to inpatient days SNF, you can see the volumes there. Just to be clear, we include all of these when we do our analysis. I would also call out the ED visits for Porter at 107% of the projected FY22 budget, just to also show just how busy we are in the thing that we call the aftershock, which when we wrote our narrative, we thought we might be through by now and we were wrong. Next slide, Jen. Now I'd like to talk a little bit about what we're seeing in terms of population and demographics. BRG did some good work for the Green Mountain Care Board and based it upon, I believe, the 2019 census estimate. We decided to take a look at that and hire some outside folks and really dive into where we think this is going for us because I want to be clear. We are not comfortable with where we are at in terms of satisfying the volumes that we're seeing at this point. I believe Dr. Leffler explained that very well and we were trying to understand where the population is going. So just a few key things to think about. The Burlington Metropolitan Statistical Area is gonna grow by 16% in the next 20 years and that is from the 2019 projected. So we believe it'll even be faster than that. So we think even this is now a conservative estimate. The Medicare eligible population will more than double and Medicaid will grow by 12%. Next slide, Jen. And so this to me is the single most important slide in this whole deck because I asked you earlier when we were talking to really focus on staffing, that staffing was the thing other than approving our budget I wanted you to take away from this. And this is why this is a problem that we need to partner to solve. We, the UVM Health Network, need to partner with the Green Mountain Care Board and with the state of Vermont to be able to have the people and the facilities we need to care for this population. What's gonna happen to the Medicare population in the next 20 years cannot be better explained than this chart. And again, this is a conservative estimate. We've got to begin to get ready now with pace and a sense of urgency or things will only grow worse over time. So again, we need help and we need your best minds on this and we need partnership because this is truly something that we need to face together. Next slide, Jen. We've talked about our people. This is the projects that we've talked about publicly and written to you about, these are. We do not believe that we'll be successful over the next 20 years if we do not invest in both our people and projects. I'm not gonna go into detail on every single one of these we've mentioned them throughout the presentation. We can answer questions once we get to that. Next slide, Jen. I think we should have probably kept count on how many times we've mentioned access being an issue in this part of the presentation because I think it's obvious that we're all taking it very seriously. I just wanna call out a couple of things. We cannot address access without our budget and without a margin. Those things can't happen without happening together and we can't address our facilities without partnership with the state and with our regulator. And so when you look at the bottom bullet here that we are actively recruiting over 75 physicians across our affiliates in Vermont. That should explain physicians if that's the only problem we had. So in order to address access, again, we need people and we need facilities and we need a margin to take care of both of them. Next slide, Jen. So as I said, we put together our budget from a bottom up process in March and it's approved in early May. So there's always risks, meaning we're making big assumptions on the future. So let me go through some that we see and I really frankly like to hear any that you see because anything that'll help us get the ship to port so to speak. First, obviously if we don't receive the commercial rate we've requested that's a risk to our budget. Second, since we put our budget together the topic in the Wall Street Journal in New York Times almost every day has been is the inflation that we're seeing transitory or is it sticking around? And I'm not an economist so I'm not gonna weigh in on that but it seems like it's a little more sticky at least this month maybe people thought so that could impact us. Medicaid and Medicare payment policies. If Medicaid and Medicare do not keep up with inflation it continues the pressure that we put on the commercial payer. This is the cost shift. You've spent a lot of time talking about it as a board. This is a stress to our budget. This is a stress to the commercial payers. Next, if the ACO program rate that is allowed with the federal government under Medicare or if Medicaid were to change its policies and limit that in any way that would be a risk. The next bullet, who knows what's next with COVID? There's been a new crisis rolling right along and so we need to be ready and we are but it may impact our budget. We have not made decisions based on money when dealing with COVID. An example would be vaccinations. John's point on vaccinations was if we get paid or don't get paid, he did not care. He wanted us to vaccinate everybody that wanted a vaccination and we held to that. And obviously we then worked it out with the state and federal government but we were head down trying to get that accomplished. Next, our outpatient pharmacy revenue may be overstated and that is due to the ever-changing and shifting sands of the 340B program. Last, workforce challenges. I think we've said enough about that today. And finally, Epic. Epic implementations at our two non-academic medical center affiliates in Vermont. The budgets could be at risk if we poorly implement and perform once Epic goes live. That's a real risk. I will tell you that the benefits outweigh that risk to the good points that Tom Thompson made about the incredible moment we will have once we get everyone up on Epic but that is a risk to the budget. Next slide. John, do you wanna jump in here? Go ahead and take this out first shot and then I'll jump in and I have a couple of summary comments. Thanks. Yeah, so the great thing about these hearings is we get to talk about more things than just the budget and we get to think through things that are really important to educate Vermonters about that aren't just truly financial. But at the end of the day, this is a budget hearing where we're asking you to approve what we've proposed. And so here's our ask. We have a budget of all of our three Vermont affiliates combined that's about $1.8 billion as proposed for FY22. And we need the NPR and the commercial rates that we've requested to accomplish the mission that we've set out for FY22. We hope you're comforted by the fact that we are not asking for anything more then or anything less than what we need to cover our expenses. Final point, we need the margin to be able to invest, to invest in our people and to be able to invest in our facilities. Thank you, John. Thanks, Al. Our current times, I said they were complex. Sometimes they characterized them as interesting. They really have been put in the context of crises. We have a crisis with a worldwide pandemic that just keeps coming and coming and coming back in various forms. In our state, we have a crisis with mental health access and I don't yell fire in a crowded movie theater. It's just not what I do, but there's no way to categorize what's going on with mental health access in this state other than a crisis. You combine the two and we have a crisis in access and actually in talking with state leaders workforce has been put into the mix as a crisis. And I can tell you, I'll give you a little vignette of what's going on around our piece of the universe. Way back with the first wave of crisis, we had an every afternoon call that had leaders from around the network and then around the region that got together to brainstorm solutions and to give situation representatives of where we were. And we've gone back and forth on that model. We're back. And it's not just for COVID, it's the constellation of things that we're facing. And we've had three or four of these meetings now and they are remarkable happenings. The things that are being discussed by our leaders are just mind boggling. And I would invite any of the Green Mountain Care Board members, if you wanna attend one of those meetings, we're totally transparent, you can do so. I can guarantee you that you will be dramatically impacted by what our healthcare leaders, clinical and administrative are facing and accomplishing every day. I've obviously been around this block for decades and decades and decades and I'm impacted by those meetings. I'm impacted because they are the most difficult situations that I have ever experienced. And I'm also unbelievably proud and gratified by how our people are stepping up to meet those crises every day. Steve said, you know, the Academic Medical Center levels our access and our capacity on a moment to moment and day to day basis. You know, this is just incredible time, interesting time, a time of crisis. And the way we get through that is we all pull together. So what I said right at the beginning, we can't do this alone. We have the people and the experts, if we have the resources and the ability to reinvest in our organization to get through the near term and to be sustainable in the long term. And that's how all of this ties together. It's not hyperbole and it's not crisis. It's a crying wolf or fire in a crowded movie theater. And again, anybody that wants to experience exactly what we're talking about, I'll invite you. Elle runs the meeting as our Chief Operator and I'm happy to have you listen in if you wanna experience what it's like on the front lines today. So with that, Chair Mullen, I'll turn it over to you for the rest of the time. Decide how you wanna administer the questioning. And again, I can serve as a MC unless one of the board members, you wanna direct your question. Of course you can do that. Otherwise I'll try and direct where the question can be best answered. Thanks. Thank you, John. And thank you for the whole team, for the presentation, very thorough work. Just wanna, before I start to go to questions, I just wanna respond to Elle's point that you really need willing partners to solve the workforce issue. And I refer back to 2018 when I testified in the legislature and called it a crisis for the healthcare system and people thought I was being melodramatic at the time. And here we are today. And clearly it is a crisis. And it's something that not only the state of Vermont, but our entire education system has to become involved with in order for you to have success. This isn't something that anyone can accomplish on their own and we'll have to all work through this together. I have had already a request for another bio break. I've asked that person to please wait until noon. I will be very prompt at noon to break for lunch. I'll even interfere with the questioning of a board member at that time if that occurs. And to start the questioning off, I'm going to ask our staff to ask some questions that they have and then I'm gonna start with board member Maureen Youssefer. So Patrick Rooney. Thank you, Mr. Chair. Joanne for the record, this is Patrick Rooney. Title is director of health systems finances for the Green Mountain Care Board. I would also like to thank the UVM health network leadership for their time today and the opportunity to ask some questions. And also I would like to reiterate that the staff have greatly appreciated the dialogue that we've had with UVM health network leadership outside of this budget cycle over the past several months. It's been very informative to discuss some of the complexities that are facing your organizations throughout this year and with the ongoing rise of variants with COVID and some of the other complications that have arisen that impact your providers throughout your network. So thank you very much for that opportunity. And Dr. Bromstad, I'll meet your request to push my questions through you and for you and your staff to leadership to respond to. I apologize for the lack of organization here. I've been jotting these down as we go through the presentation this morning. So from a topic's perspective, I might jump around a little bit. Okay, thank you. With that, Dr. Bromstad, you had spoken earlier about bearing the fruits of integration and certainly it takes several years to integrate or affiliate a standalone organization into a network. For example, IT systems, alignments, supply chain, administrative functions, et cetera. That said, you have several people on this hearing today who can offer some valuable perspectives. Ms. Newton spoke to some of these questions, some of my questions earlier, but looking at fiscal year 22 and beyond, what are some of the remaining challenges and opportunities that exist for management to bring the Central Vermont Medical Center to a financially stable and financially profitable state of operation on a year-to-year basis? Just to generalize that great question, Patrick, we're just now starting to realize the true benefits of what you said, bringing all the organizations around on common systems, processes, IT platforms, and we're just starting to see the spend on administrative shared services to go over the top. And further questioning, Rick Benson, I'm sure can provide value as to how that's gonna rapidly accelerate in a good direction going forward. Specific to Central Vermont, I'd like to start with you, Al, because you can put it into the general perspective of all of our entities, and then, Anna, you can provide some specifics. So Patrick, how are you? It's nice to meet you, even if it's over teams. Pleasure, yes. Absolutely. So CVMC, if you remember the margin chart that I can't ever forget has not had a positive margin in several years. And so the good question you're asking is, when do we see that turning around and how do we see that turning around? Well, one big giant step is bringing together all of the technology platforms that we have that we're implementing so that we will be able to have eyes into everything that's happening in real time and also better manage the rev cycle and accounting systems of CVMC. So specifically, Epic. I'm gonna say this, I think Anna mentioned it last year or in another hearing, but the OR at CVMC runs on paper, just as an example. That's not a goal of any health system. And so that's something that Epic will change and that obviously we've done all the work with Epic and all of the process work that Anna talked about to fix that. But that's just a glaring example of how technology will bring systemness and transparency within our own network as to how we're doing. And so I'm answering your question though, specifically to the question about what I think of a shared services. We can also talk about volumes and changes to the operation there if you wanna have that conversation as well. Anna, did you wanna add anything to what I just said? And just underscoring what you've already mentioned, Al, you know, it's vitally important in today's world that we have information to drive our operations and CVMC has been lacking in that regard for a number of years, which makes it challenging to pivot to address concerns. So Epic is going to be a huge lift for us. And the fact that our perioperative service line is entirely on paper in 2021 is pretty extraordinary for a healthcare system. And I think that just underscores the challenges we have here. Manual is my least favorite one. Epic will be a huge boom in that area. And so I think for us that systematizing by leveraging the variety of electronic advances, work day being one, Premiere is another that we've implemented and now the last one being Epic is gonna be critical to our realizing a positive margin. That along with operationalizing and improving the efficiency of our operations, Periop is a good example of that. So increasing the productivity of our perioperative services. And again, this is a great example. We're coming together as a network is a wonderful thing. So UVMMC has some challenges. We've been able to bring some of those volumes here and keep care local. And still make sure that we're optimizing a pretty invested area like Periop. So that's just a small example of we're coming together as a network is advantageous for us. I'll just pause there and see if that answered your question, Patrick. Yes, it does. As Mr. Gobi noted that past margin has been a bit of a concern for us as we look at the month to month operations of CVMC. So it's nice to have a clearer picture of where you expect to capitalize on some of those improvements. Certainly anything running on paper these days is a bit of a concern. So glad to hear that operationalizing that hospital should provide some improvements and efficiencies to help you suppress cost growth and maximize margin. So thank you. I appreciate the answer. My next question, Dr. Brumstead, Mr. Gobi, you discussed the expense controls undertaken by the network to counteract the financial pressures brought on by revenue reductions largely related to COVID. When I read your most recent Fitch analysis in March of 21 for your network hospital's financial state of being they use your efforts to control costs, 52 million in expenses, $45 million in capital as part of their justification for giving you a stable outlook and thus maintaining your A plus rating. So will any portion of those non-capital expense controls be permanent in nature for the University of Vermont Health Network? Rick, do you wanna pitch that one first and then, Al, if you have something to add? Pretty much all of those things, we put it, hi, Patrick, by the way. Pretty much all of those things that we put into place are still in place today. I think that the key thing that we, and we put this in place even before the pandemic was very tight position review committees at all of the organizations where we're truly making sure that we have the work and the volume to support any either replacements or position additions has been, that was something that was put in place before the pandemic that obviously hasn't gone away. The other really is on the shared service part of the organization. And when I say shared service, that's all administrative services. So HR, payroll, revenue cycle, all the non-clinical services that we provide, that we, even with the fact that we're not yet all on the same systems, we've seen that that is, and that's something that we've been at for a while. We're continuing to make progress in that space and we haven't peeled back anything that we've done in that area either that the rating agencies saw when they reviewed us back then. And once we are on the same systems, that's just gonna accelerate the ability not only to maintain or reduce costs, but also to improve performance in those areas so that we maximize the, whether it's having a very efficient payroll department, a very efficient accounting department in terms of the quality and accuracy of those services. None of that has gone away since the rating agencies reviewed us. The capital spend, Al, do you wanna just talk a bit about how we're loosening the chains on that? Yeah, so before I do that, John, I do wanna comment on one part that did go away. And that is we did reduce the pay of leadership. We did eliminate retirement benefits, any premium pay. And that was a larger, I don't have the amount of money off the top of my head, but that was a huge contributor to that 52 million. That was reinstated, including reduction of provider salaries and benefits, but that was reinstated throughout the first quarter of this fiscal year. So that did go away. As far as capital, we constricted capital to maintain days cash. I cannot adequately articulate what April of fiscal year 20 was like. We basically shut down our healthcare system for elective surgeries, but folks weren't coming for anything else either. I mean, people hunkered down. And in the middle of that, we quickly realized we were gonna break our bond covenants and that we had a $200 plus million hole to close by September. And so we got to work on it. Luckily, the federal government came through with the CARES Act money that I discussed earlier, but the amount of actions that we had to take to even close the gap that wasn't covered by the CARES Act was huge. We were afraid at that point that our days cash would plummet and we would be in a real cash situation. So happy to go into detail offline with numbers, Patrick, but we need to get back to spending capital for the good reasons that Rick made about how it impacts our EBITDA and our performance over time. So... But it's still a very controlled, centralized, controlled process, Patrick, and that's one of the changes we've made over the past several years is that no longer does each one of these entities that were solo really control their own capital spend. If they do have any fungible dollars, those are allocated from a central pool and based on our quarter-to-quarter performance so that control centralized hasn't gone away even as we loosen things up and how we're spending our capital and prioritizing that we're doing as a collective group, but it is centralized. Thank you. And Mr. Gobi, time permitting, I may follow up with you after the fact so we could speak a little more granular about some of those items. So I appreciate that offer. Absolutely, I'll make time. Okay, super. Dr. Bromstead, you had spoken earlier about the crisis point as it relates to the current state of the workforce. So my question is for the health network leadership, as you have a unique perspective being the most active founder of the ACO, you have a tertiary care and academic hospital as well as a PPS and critical access hospital, all participating with one care and in the all-payer model. So with that said, does the current workforce challenge or challenges being faced by providers affect the progress of payment reform for your hospitals and Vermont as a whole? And if so, how does it challenge the overall outlook for progress? Great question, Patrick. Everything is a challenge when you're going through a transformation and you throw a few massive curveballs in and it really escalates things. How it's playing out, and this will continue to play out for Vermont specifically and one care, is that the Agency of Human Services last November put out a how we can improve the all-payer model and our performance and sort of segmented, including the Green Mountain Care Board and the delivery system, but also the ACO, how we can make improvements. And that spurred the Green Mountain, the ACO one care to go through a strategic planning process which really hadn't been done since inception. And what's come from that is the reality that for the transformation for the UVM Health Network to value-based payments in a population health approach, we, along with the rest of the delivery system in the state, can't build the structures, hire the people, have the IT systems to have us be successful in that and have our resources go in and build duplicative systems within one care Vermont. So coming out of that strategic planning process with the support of the very diverse group of providers that are the Board of Managers of One Care, we're really integrating the people and the systems support that one care needs to be successful with the processes, the procedures, the people that are providing the same service in the UVM Health Network. And as we work through that, there'll be a lot more specificity that comes to that, but in the same way that we've done and other industries have done, it's another instance where integration of services is necessary if we're gonna be highly efficient. And what's really changed and I'll be very transparent about this, if we had tried to have providers broadly in and out of the UVM Health Network share systems and we hadn't done that five or six years ago, there would have been hue and cry and hell to pay. And I think what's really happened because of time and relationship building and also accelerated by the crises that we all face, there is much more comfort and trust that we can collectively build those systems, even if they sit on the budget of the UVM Health Network and that we're gonna be able to serve the broader needs of the rest of the providers that are participating. So it's really playing out in that there's a squeeze on dollars coming in, so you gotta be as efficient as you can be to build the systems. And I think as we do that, I'm really bullish on the transformation to value-based reimbursements. And we're doing a huge amount of work inside of our tent with our leadership and with some of the advising of the McKenzie Group to do our part on that transition. Thank you. So more specifically around the challenges for recruiting and maintaining nurses, mid-level providers, physicians, et cetera, and being able to care for those attributed lives under your health service area. Do those challenges pose an additional challenge to the work of the all-payer model in being able to facilitate the quality care for people who fall under your age essay? I hope I'm asking that right. Yeah, I don't think it's directly related, if anything, the prospective payments as long as they're set at a reasonable level enhance our ability to do the predicting of what we need to do with our expenses going forward. Rick, you're on the one-care board and you chair the finance committee. Do you have a comment on that? I think, I mean, we're doing all we can as on the provider side of that equation to improve our recruitment and retention of all the staff that we need. The HR team here at the health network has recently put together some high-level action plans for how we can start to make an impact there to your question factor to ensure that we do have the people that we need to provide the access so that we can still participate in the and be a strong participant in the CO programs. So, but it's as a challenge. I mean, we certainly we're gonna be competing. I'm sure there are many other hospitals and health systems out in the country that have their same action list on how they're gonna try to attract and retain the people that they need to care for patients. So I feel like we've got a good path forward but it will be a challenge for sure. Okay, all right. So my next question here is again for UVM health network leadership. Do you believe your organizations still have revenue growth potential under the current all payer model? And if so, how do you plan to grow those revenues in the coming years? We're seeing a bit of a looks like budget to budget stagnation on specifically fixed perspective payment. So do you believe you're maxed out there or is there room to grow and where is there room to grow? I'm gonna pitch this to Rick in a second but and it might seem counterintuitive that to gain participation, we've had to squeeze down the risk corridor that those contracts through one care have and the real potential is for the providers being accountable is to increase the risk corridor as we improve our ability to manage care and reduce costs because it's in that upside potential that we see growth in 2018 or 2019, McKenzie characterized that the UVM health network left about $20 million on the table because at that point with that risk corridor, we just sort of hit target. We didn't really perform at a level that we would yield the gain. So a couple of core issues there, one is get to a point where we can expand the risk target. Second issue is we really need to address the current mixing in of blueprint and sash into that because it limits the provider side ability to move within that up and down and it's totally on us on the delivery system to improve the care to the point that we can provide excellent care and do so efficiently so that we can yield gains in that expanded risk corridor. Rick, do you have anything to add to that? Maybe one other item that I think we need to address to expand the potential growth in those all-pair model programs is that Dr. Bromsted didn't mention is the targets and the way that they're set right now are looking at historical claims experience. When you do that, essentially all you're doing is chasing, you're chasing your tail to a certain degree because if you do a good job at reducing utilization and that good utilization is then used to set your target for the next year, you're never able to get to the point where you're building up some reserves and actually seeing the benefit. It's essentially a bar kind of keeps moving up every year if you're doing a good job with the way that the targets are set today. So that's the other piece of the programs that need to be fixed. And then finally, I think, it all comes down to attribution. So it's about convincing other providers and insurance companies to participate in the programs. And so you have to make it attractive to them. You have to make financial sense for them to join, but that's in terms of the key number there for us to expand our revenue stream in that area. It's all about attribution. Because one other thing I'll just mention, Patrick, is that I think we need to make sure that the way that we're measuring our participation in those programs isn't just purely about the fixed payment because we do have some programs where we're completely at risk for the population that we're serving, but it's not in a fixed payment model. That is the ideal. And that's where we wanna move to is having fixed payments that are unreconciled. But if you look at our participation in some programs, we are at a risk, it's just that we adjudicate the plans at the end of the year instead of having it be paid through a fixed payment. Okay. Thank you. Kevin, I'm almost done here. Again, for the UVM Health Network Leadership, you'd mentioned in some of the dialogue that the staff has been having that you were planning to have a meeting around the budget hearing date with some of the stakeholders around that Medicaid regarding the cost shift. And I'm just curious if that meeting has occurred yet. And if so, what was the result of that discussion? Great question, Patrick. The meeting hasn't occurred. We will make it very clear the information that we've provided to you today in the cost shift right down to the dollars and cents of it to Diva and the Agency of Human Services in time to impact the next state's fiscal year to have the meeting sort of out of sync with when there actually could be actions didn't make sense to us. So we will be in time to impact this next fiscal year be making our observations and our recommendations known in writing. And I'm sure when we do that, much like the reaction that the Green Mountain Care Board has gotten when they've made those comments, we'll get some attention. Okay, thank you. And finally here, when I look at some of the numbers around staffing to go back to that and recruitment, UVA Medical Center from 21 projection to 22 budget is listing an increase of 363 full-time equivalents and budget to budget 21 to 22, 179. So those are some large numbers no matter which way we look at it. How confident are you that you'll be able to achieve those recruiting aims as we move into the next fiscal year given the current labor market and work shortage amongst providers? Rick, Al and then any president that wants to chime in for your local, your piece of our organization. And really quickly, I'll just speak to the reality is we're already at that number today. The problem as we've shared is that's being, that FTE number is being to a large degree being filled with avalars at a very high cost. So what we're trying desperately to do is attract permanent employees to reduce that cost that we're all incurring. That's always obviously the safety net for us is hopefully that avenue doesn't dry up for us either in terms of being able to have access to temporary workers. Steve, any other thoughts? Patrick, thank you for asking that. And so to Rick's point, we actually are more or less staffing to that level now, but as Rick pointed out it's with expensive travelers in the budget for 22 where we wanna add 75 new nurses. That's part of the work we did with the Nursing Union Collaborative to have for State Floor Staffing. We have about 200 nursing positions open right now. And so it's imperative that we, as I've already mentioned become a preferred employer, the whole network, also so we're not fighting with each other. What's interesting right now for travelers is that in the past, most of all of our travelers will always be nurses. We have a lot of travelers for other positions right now. We have travelers for CSR, we have travelers for others. And I would also add just finally one other significant piece in that additional positions that we're adding is for mental health technicians and sitters. We are running a full inpatient psychiatric service on our ER every single day, every day. And so trying to staff that is very challenging. And we on a daily basis don't have enough sitters so we've added significant to that as well. But most of the positions added are direct patient care positions and that's how we built the budget, thank you. So one of the centers of excellence that we've been building in HR across the network is talent acquisition. And there is a direct relationship between the number of people that you actually have recruiting per the number of open positions to successfully fill those positions. So we are actually staffing up in that area and actually bringing in some external expertise. I don't know, Al, if you've got a comment on that or anything else. Yeah, Patrick, I think my comment would be is there's two things happening right now, right? One, volumes are much higher and the acuity of those volumes is much higher than we would have predicted six months ago. We thought there would be a return after the pandemic. It's just higher than we thought. Second, the dysfunctional labor market that I brought up earlier. The question is, how long will both persist? I have no guess. All right, well, thank you so much for the time this morning, Mr. Chair, back to you. I think you're on mute, Kevin. Thank you, Patrick. And I just want to remind everyone that the statute is specific in the way that the Green Mountain Care Board must look at each hospital. And that's the way the words are specifically stated in the statute. So I think that this is probably a logical time to take that lunch break, given that it doesn't make sense for Maureen to ask one question and then go to a break. So what I'm gonna do is just lay out the parameters for what will happen this afternoon. When we come back, because that statute says that we must look at each hospital budget, we're gonna take a look first at UVM, Maureen will start the questioning. We'll next go to CVMC, where Jess will start the questioning. And then we will go to Porter, where Robin will start the questioning. On each of these rounds of questions this afternoon, we will then turn it over to the HCA and then turn it over for public comment so that someone can offer comment on a specific hospital. And at the end of the day, if there are some more general questions that haven't been answered, we can go back to the more general format, but we'll be focusing hospital by hospital when we commence again at one o'clock. So at this point in time, I'm gonna put this meeting in recess till one o'clock and we'll see everybody then, thank you. So I'm gonna reconvene the meeting of the Green Mountain Care Board and I'm gonna turn the questioning over to Maureen Youssefer. Maureen. Thanks. First, thank you for your very thorough presentation and for all you're doing during this really challenging time and the pandemic. And clearly the network is stressed with surges and with the impact that this must be having on staff as well as patients. And I really do appreciate all the benchmarks that you put in and comparisons to peers and things like that, that's helpful as we kind of move through. So I wanna focus my questions on some of the drivers of the financial statements in 2021 and 22. So starting with NPR in 2021, the forecast is down about $124 million from a little over 1.4 million to about 1.3 million and can you address specifically how much of that decline you would attribute to COVID? How much to the cyber attack? How much to Fannie Allen? So those three components, if you could break out that and then if there are any other major drivers but if you could at least touch base on those three. Rick, that sounds like either you or Judy, me. Yeah, Maureen, we'll have to get you that answer. We don't have that as we sit here today in terms of being able to break that down. It's without the exact number, the largest impact is likely the cyber attack then followed by the pandemic and then the Fannie Allen closure but we'll have to get you exact numbers if you want that number broken out specifically. Okay, that leads me really into the next question which is when we turn to 2022 and I appreciate that the budgets are prepared so early that you really are preparing it on data where you don't really know where you're gonna end up in forecasts for 21 but when we turn to 2022 against the forecast because your comparisons were against the budget we're going from about 1.3 million to just under 1.5 million if you take out the adjustments for COVID so it's up about $200 million or 16% from year over year and we'd really like to understand there as well what the bridge is for utilization you've shown kind of what the rate increases are what is it bringing us back for COVID maybe the COVID catch up or the delayed care and the acuity but really trying to look at that because from year over year we're showing a 16% increase which is pretty significant from budget to budget we know the budget is obsolete at this point so do you have some context into other than the $40 million that's in there for rate there still would be another $160 million of growth year over year yeah so there's two components that's the largest is obviously volumes have come back or we're at least projecting that volumes will continue to be where they are at in 22 compared to what we had last year so that's by far the biggest component of it the other component that we saw a little bit of that Mark kind of touched on when he was doing his chart of the he was breaking out the change from the 21 budget to the 22 budget where he had utilization and how much was rate increase in that that bucket of the change and base we've seen a bit of a change in terms of service mix where we have some higher reimbursed services that are making up a higher proportion of our revenue in 22 again it's not a on a percentage basis it's not a big number it's one and a half percent or so that is contributing to that somewhere in the $37 million range but that is also a piece of what is changing from year to year that is that service mix okay so important to understand you know some of those drivers because it's such a big increase in total so maybe that's something to kind of follow up on and then within the net patient revenue just to touch base on any ACO reserves or settlements I mean it appears that there are no reserves but just want to confirm whether you have an ACO reserve sitting out there and also what your expectation of any of settlements from 20 or any other you know any other things you're hearing either positively or negatively so you're asking about the 21 projection or the 22 budget just what you have you probably still have settlements to come in that aren't resolved yet and so I don't know how you're booking that through your P&L are you expecting to get a favorable settlement for Medicaid and if so how much and is that reflected in the numbers and are there any reserves that you're capturing on the balance sheet it doesn't look like there any but just want to clarify specifically for the ACO yeah for the FY21 projection that includes the reserves that we do have on the books so we're right now assuming that we will get a positive settlement on the shared savings component of the programs for both Medicare, Medicaid and the MVP plan for 2020 so again we're quite a bit in arrears in terms of the settlement of these programs but that's been reflected in our current financial statements at the same time you have a reserve for the fixed perspective payment versus fee for service also called the AIPBP reconciliation we have a reserve that's on the books for that for 2020 as well that will be needing to pay Medicare back for that component so our financial statements includes the most current estimates for those 2020 settlements for 2021, we don't quite yet have enough data we probably will before we reach the end of the fiscal year to book estimates for the 2021 shared savings components of those programs but we do have and was included in the financial statements a reserve again for that AIPBP reconciliation because we've actually started to do that internally rather than relying on one care to provide that projection because we actually have more real time data than one care does so we essentially treat those fixed perspective payments and compare them to the shadow claims every month and essentially convert those fixed payments to fee for service every month so right now we're on the reserve side of that equation where we've had to reserve because our shadow claims are higher than the fixed payments that we've received so far in fiscal year 21 but that we do on a real time ongoing basis. Okay, so is there an incremental reserve that you're posting? Is there a net change from 21 to 22 positively or negatively reflected when you look at the between the two years if you were bridging? No, the net impact of all of those entries my without seeing the exact numbers in front of me are probably pretty close to a wash. Okay, and there's just another question on 21 and the other part I didn't, I don't know if I said on the NPR was also the Fannie Allen and the impact that would have had as well on your revenue but I wanna talk about operating margin. So for 21, you were projecting 40 million was your budget operating margin and it's estimated to be coming in at 52 million. However, if you exclude all the COVID money it would be negative 9 million. And can you talk specifically about what the impact on the operating margin was in 21 from the cyber attack and from the issues at Fannie Allen? So I can give you the number for the cyber attack the Fannie Allen will have to get you that number as well. And so the type of cyber attack we calculated cost us about 45 million dollars in F121. Okay, and I think where that is important is, when you look at, I think it was Al's chart that kind of goes down like this and he said, this is the one that scares me the most but it would have been quite a bit better if that 45 million was dropping to the bottom line both on cash and operating margins. And specifically at one point when we go to talk about cash I think it's been a pretty big impact there. And do you have any insurance claims that you can talk about on the cyber attack that might be coming in the future or have you booked any expected reimbursements there? So we've filed our claim for cyber insurance. We haven't received them. We haven't booked anything in FY21. We've had a little bit of back and forth with the insurance company which I think may be a little bit of a struggle to get the full amount of our coverage which is 30 million. The thing that's complicating the, or what's causing the insurance company pause, if you will, is the same question that you asked earlier is how much of that is cyber related, the loss revenue cyber related versus Fannie Allen versus the pandemic. So it's unclear at this moment yet the full amount of our coverage but with what we're at, there's nothing that's been booked on our financial statements. So if we, and hopefully, hopefully you will be able to recoup some funding there. So if that were to occur, that would happen in 2022 and could be to the tune of 30 million dollars. Is that correct? That would be the highest amount, yes. And where would that book? So that would book as other revenue. Okay. Okay, so now moving to commercial rate and you've kind of gone through the methodology of how you calculate the commercial rate increase looking at the inflation issues and less any increases from the prior, other payers. But to me and all those reconciliations, one thing that's a little bit striking is additional cost saving initiatives. And I know I bring this up every year and I know when you address it, we've done all the low hanging fruit, we really don't have additional, major additional cost saving initiatives, but in most industries, I know this is different, but in most industries, much of the inflationary growth is offset by continued pushing to on margins and cost savings and supply chain. And specifically, Epic wanna understand where all the legacy offsets and the staffing offsets that were supposed to be occurring this year. I mean, those are all things that should be bearing fruit on top of all the work that you're doing on supply chain consolidation, system consolidation. So where is that in the equation to show as somewhat of an offset? Because volume increases are gonna drive top line volume and carry expenses, but should be contributing bottom line. Inflationary increases, yes, need to be covered, but if there are all these programs that are coming in, several of which were, we could go back to the Epic CON, were significant impacts to this year. And I just wanna kind of get a reconciliation on where those offsets are. To start, I think one of the points that I was trying to make in terms of the volume related expense increases, when you look at that over the years, there's no doubt that our expense saving initiatives has played a part in that, in that we've been able to maintain a fairly static margin without any expense inflation because of those activities. The volume in our industry, as you can imagine, the differences between fixed and variable costs across all the types of services that we provide the different reimbursement levels requires that even to try to maintain balance there, you need those expense saving initiatives to play a part in trying to maintain that balance. There's no doubt that we've already started to impact from a total administrative cost perspective, the cost for those services. We've been a little bit delayed with some systems. I'll just speak to Epic specifically just to give you a sense on what that will mean when we're fully on the system across all our affiliates. Right now, we have teams that are tasked with working specific payers. So we have payers that work Medicare claims and Medicaid claims and commercial claims. And that's a function of having to be very hospital-centric. Once we're all on Epic, there's gonna be an opportunity where that work instead of being necessarily based on the insurance will be, this is a particular claim that can be worked by this kind of a level one staff person, level two, level three. Well, that will create significant economies of scale that will be able to do that work with fewer people. And so we're getting there. We're close. The three main systems that really will impact the administrative services are Premier Connect, which is our accounting and supply chain system. So there we're almost completely on the same system. Workday, which is our HR and payroll system, which we're close to being across the network there. And Epic. So we've already seen the impacts of even not having all affiliates on those systems, but in the years ahead, that will certainly start to ramp up the cost savings that we'll see. I just want to add to that, Rick, that I do also think, Maureen, you have to consider that the data that Dr. Brumsted showed, we are right now the cheapest state in the country for Medicare expense. I'm not sure how much you can squeeze further than being the cheapest. If we were like the way up the great craft and you said, well, you have 3,000 per patient, maybe there's some opportunity there, we can always be better. We can always be more efficient. But if you look at the demands right now on services and many people when they're sick or very sick medical patients require more care. They require more oversight. So I don't know how much cheaper we can get than cheapest in the country and maintain the level of quality that we demand of ourselves and that our patients deserve and access. I think there's somewhere, there's a balance there and we might be off on the access one right now, honestly. I think the chart too, that's probably a little bit more direct to the expense side was in Dr. Leffler's section two, Maureen, where when you look at our total cost per adjusted inpatient day, to the point that Steve is making, I mean, we're already as an academic medical center compared to our national peers. There are also AMCs. I mean, we've never gone over that median number, which that's all in cost. That's staff, that supplies, that's overhead that gets charged to the AMCs and we've been bouncing around that 25th percentile. So, absolutely, we still, trying to contain costs and having these initiatives is something that we do every day, but that's a great point that we are starting at a fairly low level to begin with. Just one final comment to add on. When you look at the AMC data, I know, because I talk to my peers across the country all the time, we have one of the most highest challenges in the country for discharge to nursing homes because Vermont has so few. And so I think our costs are actually artificially high because many people would leave sooner if we could discharge them. As I told you, we have 54 today. They're all incurring expense that really wouldn't fall to the hospital part of it if they could go to a nursing home today. So I just wanna add that. Okay, I'll stop now. Okay, thanks. And last year, you talked about improvement and documenting and coding and acuity of patients and that this may potentially have some impact on revenue and just wanted to find out if you could quantify if that is impacting in 2022 and or if there's opportunity there as well. So I'm gonna start, Rick. We just add on, but we just saw some data this week from our chief quality officer that some initiatives we put in place through this spring have returned about 4.5 million in revenue from improved coding. The other piece that we were planning on when we mentioned this last year was this engagement that was looking to help improve coding and revenue recognition. But the other was a system that we had to delay due to the pandemic and the cyber attack that was essentially an artificial intelligence system that would mine the data of our inpatient records to highlight the issues that weren't correctly documented and weren't correctly coded. And we've had to delay that implementation. It's now gonna be implemented in the fourth quarter this coming year. So we won't really see an impact of that system in this, the 22 budget. Okay. So now just going back to the commercial rate and the calculation. So I put my push on the cost savings, but assuming there's no additional cost savings to help offset the $38.6 million in inflationary expenses, having need some help reconciling the chart. I mean, when I look at the methodology that talks about take the expense, the 38.6, take any increase from non-commercial and that looks to be about the 4.2 million from Medicare on Medicaid. Appreciate that you're gonna be talking to Diva and hopefully we can transition some of that cost shift because your relationship between Medicaid and commercial is commercials at least double, more than double. But when I take the 38 million and I take the $4 million roughly that we're gonna get from Medicare, it yields about 34 million. So on the chart, you have another $5 million. And since the chart was done at NPR, so I'm assuming should already be factoring in things like the bad debt and free care on the incremental gross revenue that comes in. That's a pretty big number and worth 1% of the commercial rate increase. So I really need to understand what that is because I don't understand that $5.2 million negative. That's on page 32 on your chart. Mark, do you wanna take a stab at that one? Yeah, Maureen, that's exactly what it is when you touched on it. From a gross revenue perspective, is that every dollar that changes on your gross revenue fee schedule, well, the way you get to net is you subtract all of the deductions and basically whenever you have a gross charge increase, okay, it is not only the bad debt and free care on the payer increase, but it's the bad debt and free care on all of the difference on that charge increase. So we're happy to walk you through that in order to get you to a comfortable level, but that's exactly what it is. Yeah, but what I'm saying is I don't get that if it's at that. So we're probably gonna have to take it off. I'll walk you through it. I mean, happy to walk you through it. This is a mathematical calculation and happy to walk you through it. Yeah, because you're saying you need 38 million, yet you're getting 43 million in rates. And that's actually, that piece I can answer right now, about 4%, a little less than 4% of, and so keep in mind when we say NPR on that rate schedule, that's fee schedule. That's not what we actually collect, okay? So you have to deduct charity and bad debt from that. And that right there is in for commercial is in the range of about 3% to 4%. Yeah, we'll need to go through it. Cause I mean, at the end of the day, you need to recoup 38 million and you're asking for more than that from commercial and getting it from Medicare and that those since they're net numbers, it should already be taking into impact the, bad debt and free care. We're not giving away more, more of what you never got cause we're talking at the end of the day, you get paid. That's my point is that's not a net number for commercial. You have to take bad debt and free care off from that afterwards. So anyways, we can walk you through the math. Okay, so we're gonna need to understand why. Nope, I completely understand what you're looking for. And then just talking about the value of the 1% commercial. I thought when I read through your materials that you were taking an increase across everything in patient outpatient and professional. And I think your commercial base is about 800 million or so, we could look at the number. And so 1% of that is gonna be more like 8 million. So can you reconcile to the 5.6? For 1% commercial. Do you wanna take that one? Okay, well, well, the commercial rate in this model is that's a challenge between the calendar year and the fiscal year. When we say the new commercial rate kicks in, it doesn't start until January. So our inflationary, yeah, but our inflationary expenses start in October, but that's a big piece of it. So what you are referring to is a 12 month impact versus what the prorated impact is in the budget of three quarters. But yeah, we need to go through that too because you got 8% last year. So the first quarter of this year over the year before, you got 8%. But we can't not count it every year. So last year was three quarters, but you got 8%. And then you're getting an additional eight on top of that. I completely get that, but the expense-based changes because of our staffing, which is our largest expense in October, not January. Right, we'll have to look at it. Could you be up to count that quarter? I know exactly what you're talking about, yes. Yeah, okay. And then it's just moving to cash and where you are right now for cash. I think you're at, well projected to be what, 224 million at the end of 21 and 22. I guess, where do you expect cash to be? And it's a little bit of a loaded question for you, but it seems pretty strong. So how do you look at your cash balance now and days on cash from where it's been historically? I mean, going back to the benchmarks, I mean, that's where we're trying to get to. So if you look at slide 23 of the presentation that we just went through, the target that we're trying to get to, to be in that A-rated category, again, the place that we're financially stable is with the Medical Center, we're trying to get the cash balance to be somewhere in the 224 to 269 days. For CBMC, we need to get to 149 to 179 days and then Porter is the same number. So that as a network and take the weighted average of all three of our Vermont hospitals, we're in that 210 to 252 range, which would put us essentially right in the range of the rating agency A-rated benchmarks. And do you have offhand what one day's cash on hand is for UVM? For the Medical Center, it's four million. So you'd go up, if you were to get $30 million more from the settlement, that would increase that by another eight days roughly. I would just make the point because it's come up several times now. There's a large issue going forward with cyber insurance in that we likely aren't going to be able to get fully insured from dollar one. And so there may be draws on whatever payments we get from the insurance company to create reserves until we get back to a place where we can be reinsured again, obviously to go bare without any coverage in the arms race that Al alluded to is not a place we want to be. So I want to be careful. Yeah, we might get that 30 million or 20 million, at least a big chunk of that against any future occurrence. If we're going bare. Okay. And then just the last question is, how much COVID funding, if any, is still on the balance sheet or that may help you additionally this year? All the COVID related funds that we received have been reflected on the P&L, I think the last, so there's nothing left on the balance sheet. It's all on the P&L. I thought that was the case, but just wanted to see. Okay, thank you. You're on mute, Kevin. Thank you, Maureen. Next we'll go to board member Holmes, Jessica. Thank you. Long day for everybody. And in fact, I think it's been a long 12 to 18 months for everybody. So the first thing I want to do is thank everybody on the health network team for the presentation, but also for all your efforts over the past 18 months. I know it's been exhausting. I know it's been rolling. And I really, as a Vermonter, I want to acknowledge that. Also, I want to acknowledge that I think budgets are always built with some degree of uncertainty, but anticipating revenues and costs for next year is a near impossible task. So I recognize that. So I'm hoping we can muddle through some of this haze together. I'm actually gonna start, maybe this is probably gonna be a question for you, Mark, since Maureen asked about it. I think that slide 32, which is the slide where you all are making the effort to explain how you arrived at your rate requests and the impact of the cost shift on the commercial ratepayers. First of all, I really appreciate that slide because I've been trying to understand how the cost shift impacts commercial ratepayers for a while. And so I think this slide helps us get there, but I really want to understand some of the calculations. So my first, I guess, question is, because I think this is a really important, obviously an important table for us to understand. And it may have to be offline, Mark. Maybe we'll have to do a tutorial with Maureen and I afterwards, but let me just try and ask the first question. I understand what you're conceptually trying to do. The first column where you allocate the $38.6 million expense inflation across all the payers to come up with the rate without a cost shift. I'm wondering why you allocated that $38.6 million using the net revenue pair mix. If you're trying to start without the cost shift, shouldn't the initial allocation be based on gross revenue pair mix? As you said in your presentation, you use gross revenues to proxy utilization. Medicare is 45% of your gross revenue, but only 29% of your net revenue. So I would expect the initial expense allocation to reflect that Medicare are your costliest patients. That's where your utilization is largely coming from. So why wouldn't you use the gross revenue pair mix to allocate those initial expenses pre-cost shift? My first question. Okay, so the intent of that slide is to say what portion of the inflationary cost would be related to the cost shift, not to adjust any of the current base. So that's purely to say of the inflationary cost that's new cost to the system through inflation that what's the cost shift related to that. So there's no adjustment to the base starting point. And so at least if we could get to that ground zero, it would be a good place to start. Well, I guess my question is, I mean, most of your expenses- Are you asking me what the total cost shift is for our whole budget? No, I'm saying that most of your expenses, right, you've got some expense inflation. If the majority of your patients or the costliest patients, right, the most expensive patients or Medicare patients shouldn't that first column reflect that more of that allocation is being attributed to Medicare since that's where at least on a gross revenue basis, it seems like most of your costs are coming from, most of your utilization is coming from. So I guess- I understand. Okay, so we'll select, I understand why you would ask that question, but when you look at current payment schedules and rates of change, it's all based upon current payment schedules. So that percent change is all based upon what they're currently paying us today, you know? So what's so that's why? So you're already embedding some of the cost shift in the initial column and then you're looking at me- Yes, this is only the cost shift, yes, absolutely. This is only the cost shift that's related to that 30 million. So then I guess my second question is around, as I look at that Medicare, for example, let's assume that the 11.2 is the correct allocation. The rate with the cost shift, so that means that you're only gonna recoup 4.2 out of the 11.2 expense allocation there from Medicare. Is that right? Am I assuming that correctly? Yes. Okay, so I guess that surprised me as well because when I think about your inflation, right? The growth is about 2.5%. If I look at the appendix, you referred to the appendix, right? The inflation appendix is where a lot of these numbers are coming from. So the overall inflationary factor, the 38 million over the 1.6 billion, is about 2.3 to 2.5%, right? That's the inflation. And Medicare is their inflation, their reimbursements are going up 2.5 for inpatient, two for outpatient, nothing for professional. But they are to some degree covering some of that 2.5% inflation between their outpatient and their inpatient. So I would have expected more recovery of that expense from Medicare than I'm seeing, right? This is only 4 million of 11 million, it's about 37% of those expenses are being covered. But I'm trying to understand this table. And maybe this is something that we do have to take offline and I don't wanna burden everybody with trying to understand this, but this is an important table. One, because I think it tracks the cost shift and two, because it's how you arrive at your rate request. So I am trying to understand that. Think you're muted, Mark. Yeah, okay. No, actually, I was just pretending not to talk. No, actually, so to be very clear, all of these numbers tie back to how we do our accounting in our GL system, how all of the numbers track back to each other. There could be a difference in the thought and how we go about assumptions, but we are very, very happy to take the time and actually welcome the time in order to go through that level of detail. But there's a lot of detail there to go through and it's more of how do we walk you through it from start to finish, not starting at the end and how do you deconstruct it from there? So whatever time will we need to make to walk you through, we are very willing to do it. Okay, well, I'll follow up with you on that. I guess maybe as we plan for that, I would think about, when I think about the expense growth being about 2.5%, then I think Medicare is coming close to covering it, not completely agreeably, but coming close to covering it with what its reimbursement expected increases are. Medicaid not coming close to it at all, huge cost shift there. And then I guess we have to see what happens with the commercial rate for how much that will be covered, but with your 7%, it's clearly with more than cover it on the commercial side. So that'll be helpful, we'll talk about that at another time. And I do wanna talk about, thank you Dr. Brumsted on the topic of the Medicaid cost shift. I'm really glad to hear that you're gonna be reaching out to Diva to discuss the Medicaid cost shift, its implications of commercial rate payers. In your conversations, it would be really helpful. I think if you could maybe with Mark and others' help to share some measure of the cumulative impact of the Medicare cost shift on commercial rate payers, because this is not the first year that we've had 0% increases for Medicaid. So I think understanding cumulatively how this has impacted over the last five years, for example, would be really helpful. My question around that is, I know you're talking to Diva since you serve a lot of New York patients and I'm imagining there's a cost shift on that side as well. Will you also be reaching out to the Diva equivalent in New York to talk about that? And to legislators who ultimately hold the first strings, at least in Vermont, clearly they do. Legislators on the Vermont side, absolutely. And we're already crafting strategies on how to do that. New York state is a whole other kettle of fish. It is the size of, in world economy terms, it's like in the top 15 largest world economies in the state. And so our voice particularly since, and I'm not speaking out of school, there's 250 years of history that support this. The North country of New York is tremendously disadvantaged relative to the South and the East, where huge amounts of the resources go. And so even those that have a strong voice for the North country, when advocating, it gets diluted relative to New York City metropolitan areas. But we do have voices into the Department of Health, which does have a deputy commissioner that is charged with all things hospital. If you've been watching the news, there's been a tad bit of a shift in power there. So all of the people that we knew that I and others have spent a lot of time developing relationships with an appropriate attorney general's report went by by. So we do have plans in the very near term in September to get back and to reestablish relationships with the new set of players. But that's totally different. When we're talking Medicaid on that side of the lake. Got it. And I guess as we're talking about that side of the lake, there was a lot of discussion about the need to preserve an A bond rating. And I can appreciate that on so many levels. And my understanding is that the health networks bond rating is determined by the performance of all the hospitals, not just the Vermont hospitals. And in fact, you mentioned that the medical center actually has to achieve a better than benchmark margin to support the other hospitals. We never really hear about how the New York hospitals are doing, but clearly they contribute to your bond rating and they contribute to the need for the UVM medical center to have a higher than benchmark margins. So I'm wondering if you can just speak to whether or not the New York hospitals are performing better or worse than CVMC and Porter. And that's how they're contributing to the overall bond ratings, the need for UVM MC to generate higher margins than the benchmarks. Thanks and Rick, you can jump in here too and Al, but just sort of looking at trends since say April or May, Champlain Valley Physicians Hospital which really is the lion's share of the activity there has actually been in the black every single one of those months which is a dramatic turnaround and has been a great leadership team there and Al Gobey have really focused on turnaround there. And remember that that hospital and their portion of our medical group are a little bit bigger than Rutland. So it's a large organization. Elizabeth Town and Ticonderoga is our shining star. They just crank along at a three to 4% margin as a critical access hospital that does very little procedures and don't have an operating room. So there's a lesson for you that it can be done. They are eminently sustainable and provide tremendous service to Essex County, New York and incredibly rural county. So that might be a great case study for the Green Mountain Cure Board, a regional case study on what might be. I don't know if anybody else wanted to follow up on that or? Just to add, Jessica, it, as John said, Elizabeth Town has been very financially solid for some time. CVPH has had some improving finances. So when you put those into the mix, it doesn't dilute the data that we showed on the, essentially the weighted average targets would be essentially the same when you put them into the mix. That's great. Thank you. Jess, can I ask a follow up question? Of course. Just because I didn't hear anything about Potsdam, are you still experiencing problems there? We've never really experienced problems. We had many years ago, it was very obvious that there was just a cultural mismatch between their philosophy as a healthcare provider and ours. So it just never came together to be an organization that we could bring into the UBM Health Network fold. Again, they're just a mission mismatch. We still have significant tertiary care referrals from that region and referrals from St. Lawrence County really are critically important for some of our key academic and tertiary-quantinary programs, cardiology, neurology, neurosurgery. So, you know, they're still in our catchment area from a clinical perspective. We're just, we're not affiliated really in any way administratively. Does that help, Kevin? Yeah, so there's no plans to do anything there, John? No, they're formally aligned with Rochester General and it's probably more a funds flow and almost a bank type relationship because that's where their head was at in their philosophy. But there's no other than clinical program development and maybe some transport mutual investments. There's nothing on the docket that I see unless somebody else on the RQ has a difference. Yeah, so John, I just wanna jump in and ask. I'm sorry, this is the court reporter. I can't see who's speaking. Hi, this is Al Govay. How are you, Jim? Thank you, I'm good, thanks. Awesome. Mr. Chair, the one we haven't mentioned is Alice Hyde Medical Center in Malone. And I wanted to make sure that everybody had that in their thinking that is part of the network, so... And how are you doing there, Al? So, Rick, do you wanna describe the obligated group and how that works with our bond rating? So right now, Alice Hyde is not part of the obligated group. So the question that Jessica was asking about the rating agencies and how they view us, that is not yet in the group. So their financial performance, their cash is not part of what the rating agencies look at. I'm assuming that's what you're asking for, Al. Yeah. Are there any funds flowing from the network to Malone? Not per se. I mean, we do at the network level, backstop debt that they have, but as the other affiliated organizations are expectation and what we're working towards is to have them at least be break-even. They're not. Right now, it is one of the areas that I'm very sad that we lost relationships at the Department of Health in New York because we were starting to build up to a place where we could get the same sort of New York state funding as we got to convert Ticonderoga to a medical village for Malone. They're an area that needs restructuring, but right now there's no plans for us to put the capital in that would be required to restructure that organization. There is break-fix capital going in and supportive programs, but again, Rick can speak to this. It's not particularly in total as we've demonstrated many, many times, a negative funds flow from Vermont to New York, quite the opposite. Sorry, I interjected there, Jess. Go ahead. No, no worries. So actually I'm gonna switch gears a little bit and talk about access to care, which at the Academic Medical Center, first I just wanna appreciate your attention to the issue and the presentation and in some of the press releases I've seen of late. And I wanna acknowledge that the Medical Center has taken some unexpected blows, starting with the challenges of epic implementation, the shutdown of Fannie Allen, the cyber attack and pile on to that, I recognize the nationwide labor market shortage and that you're in a county that's the only county in the state that's really growing, one of four counties in the state that are growing. So I have no doubt that all of that is factoring into current waits for care, but I have to convey my worry largely because I'm now hearing from those in the medical profession that are sounding alarms about patient health. And so I wanna talk a little bit more about it, particularly as it relates to the budget for 2022 and what your expectations are around how access backlogs will be alleviated. You submitted some data on the percent of new patients seen within two weeks. And I think that's really helpful as a snapshot, but I actually, I have a couple of worries about that as a metric, I think it may underestimate the true access barriers. For example, I don't think I'm probably included in those numbers yet I tried to make a couple of appointments and was so discouraged by the wait time that I actually kind of hung up and sought care elsewhere. So I don't even think I'm in those numbers. Also, I worry a little bit about tracking the proportion of patients who are scheduled within two weeks. That may tell us that, for example, 30% of patients got in within two weeks, but it doesn't really tell us what happens to the other 70% of patients and how long it takes for them to get in. So I'm wondering about other measures that you might use, you know, a lot of the other hospitals seem to use the days until third next appointment, time until appointment for the average patient seems like it would capture some of that long tail of some people who can't get in. So I'm wondering if you can speak a little bit about the metric you're using. And then that's my first question. And then however we measure it, I think, and you all agree, you did agree that we're in a crisis here. So one of the, I think, strong justifications, frankly, for this year's budget request, which some may say is a little bit high, given that if we projected out of 3.5% from 2019 until 2022, this would exceed that 3.5% growth. But I recognize that there's a need to accommodate the Chittenden County population growth. There's a, we do have a patient access issue. So the second piece of my question beyond just what metric are you using is you mentioned that you're already, you know, although you've budgeted 300 new positions in fiscal 22, you're close to staffed at that level now with travelers and you want to swap out travelers for permanent. So I guess I'm trying to understand specifically how this year's budget, if approved is actually gonna help reduce that backlog. If you're already staffed at the levels that are not necessarily getting us through the backlog. Two-part question, long question. So I'll start, but please jump in others. I'm not sure why we switched metrics. I remember we did it, but I can't remember why we went from third next available, which we had for a long time. There was a reason, but it slips me right now why we do know why, Rick, you're not. There was no way to really benchmark it against other organizations. So that metric that we include, you can actually benchmark against other practices. And the third next available, we had our own internal benchmark that we would use, which was 14 days, but there was no way to see how that compared to other practices. And thank you, Rick, I appreciate that. In terms of overall access, Jessica, I mean, access really comes down to, in my opinion, three big things. It's space to see people. It's the staff to take care of them, and it's the equipment and facilities you need to provide the level of care. And we're working on all those. In fact, a number of them with you. We desperately need another 3T MRI. I already mentioned on this once already, we have the only one in the state and it runs 17 hours a day, seven days a week. The faster the green non-care board approves that CON, the faster we'll have it in place and we'll be able to scan people. I was in our MRI suite yesterday. We're back down to a backlog of about three weeks for MRI, but that's still unacceptable for people who have cancer who want to get a scan quickly so their doctors can schedule their appointments and stage their cancers. We desperately need that MRI machine. That'll help the back for 3T MRI. The only thing that's going to help right now is another scanner. The more difficult one, honestly, is staff, and we've already talked about it a lot. I can tell you that we have an access program going on right now. We have some pilot programs going on to get people scheduled throughout the network when that makes sense. We're doing a lot of work with our doctors to make sure we're scrubbing their schedules really carefully to make sure we use every appointment available. We are aggressively recruiting and while there are challenges, we do have some success. We need 10 neurologists, which sounds overwhelming. We did hire three in July. We have one coming in November. We are bringing on new staff as quickly as we can. But there are other opportunities. I'm not sure how much of them will come into fruition in 22, but there is a program through Epic where Epic can do what's called e-consults and it makes a huge difference in access to specialty care. Not to too dark, but they do it particularly well. We've been down there. We've learned from them. They've shared their information with us. I can't wait to have that at the Academic Medical Center because I know it'll make a big difference for our patients and for our specialists. And so I think we have to keep chipping away at this. I don't think we'll fix the whole thing in 22. I think it's a bigger problem than that. I think it's back to the other things we've talked about making sure that we're a preferred employer. That's wages, that's benefits, that's space to work, that's cutting edge facilities, that's having the right team around you. It's a bunch of stuff. I think for a long time when I came here you took the Vermont discount. You know, it was so great to be in Vermont. You didn't need much else. Those days are gone. And I think we have to make sure that we're competing nationally for the people that we need to care for our population. Jessica, this is Tom. You know, I think I'd volunteer also the team-based care redesign and the primary care practices, which is our biggest challenge for getting folks in. It's particularly new folks, but I think all folks in redistributing who patients see based on the type of care that's needed will help alleviate some level backlogs. You know, even in our practices here in Middlebury we've introduced an ambulatory pharmacist who might even see patients in a panel just to help with that nursing visits and also interjecting more mental health supports into our primary care practices that support primary care. These are, and there's a culture change and a transition period involved with that that does take some time too. Well, I appreciate all that. I mean, I know you're making efforts. I hear the efforts that you're making. I also hear the frustration in your voice because I know, Dr. Leffler, that this is not something that you want, right? I mean, obviously you, you know, your mission is to care for everybody who needs it. And so I know the frustration that you're all experiencing. Is there anything that referring providers might learn from a conversation with you about some of the efforts that you're making? I'm just wondering if they may even have some suggestions for things that they're experiencing as a referring provider that might, you know, be short-term solutions. I'm wondering if a meeting of the minds might be helpful or you're already doing that. I don't know. So Dr. Duchamp who's our medical group president, I don't believe it's on today, but I know that the medical group and all others on this call will welcome that. So we want to be here for our referring providers. We want to make sure that we are getting their patients what they need. And I do think there are ways to probably make it better than it is right now. So yes, we would be happy to do that. Jessica, if you want to send me an email I can help to set that up. That sounds great. I think those are my questions. I really, really appreciate it. And again, just an appreciation for all that you've done and all that you're going to continue to do. Thank you, Jess. Next we're going to move to board member Laundra Robin. Hi, everyone. Thank you again. I'll echo what Maureen and Jess have said about thanking you for your presentation today and spending time with us to talk about your budget for next year as well as all that you've done during the pandemic. I think I'll kind of start where we were, where Jess left off around staffing because in hearing all of the discussion today and reading the materials that you submitted I wanted to see if we could get a little more detail about some of the HR initiatives that you mentioned in your narrative that you've been here today that you're hoping will help with recruitment and retention because quite frankly, based on some of the public comments that we've received it does seem like there could be a morale problem at UVM. And I'm just wondering how, you know a little more granularity about how you're addressing that component of it. Thank you, Robin. So it's no secret that UVM Medical Center has been through a really tough 18 months on President's challenges one after another. I mean, I was going to mention in my comments before that we were not really out of the cyber attack but I was deferring people to start building up the vaccination clinic at Epic. Like even when we most needed to be turned in internally we were still trying to externally support our community. So people are tired. It's been really tough. I will also tell you that we are relying on travelers much, much more than we want to right now. We did use extra travelers over the summer to make sure that our people got some vacation. We knew that was critically important going before the fall came. People mostly lost their vacations last summer. So we are using more travelers. We have been working with the union to try to work on some areas that have higher than expected vacancy rates or longer to higher than we would hope for. We have a pilot going with them in one area right now and they're hoping to work on some more. We just did a salary adjustment for 208 employees that we felt were under what the market would show. And I think we have to do more work around market. I also think that at the network level we're trying to figure out how can we make sure that we retain our staff. So it's more than just wages. I want to say that. It's the whole package. It's having been paid fairly and feeling like you're getting what you deserve. It's having a good benefit package. It's having the support and facilities you need to provide high quality care. And I will tell you right now at the medical center the stress every single day of not having the staff you need for everybody that's here is overwhelming. Every single day when you get here trying to figure out how you're gonna manage the care for everybody who's here that needs us is all consuming. And it goes to late, late at night for the leaders and even more for the people that are on the ground. So I sympathize with the people here. I'm so grateful for them. Thank you. In terms of retention and looking at your turnover rates is that something I assume you normally track in your HR system? We do. We're very on top of our retention and we do know our turnover rates. I believe they're a little higher than usual which is pretty common across the country but not exceptionally higher. Okay, great. And in terms of sort of a longer term strategy because of course as we've all discussed already workforce is not, there's no simple easy fix for that. Could you speak to some of the ways that you're thinking longer term about recruitment and retention? There was just a network presentation. Hal, do you wanna talk about it? Yeah, I mean, I'd be happy to jump in. I mean, I think that Robin, first of all, it's nice to see you. Good to see you too. You know, I think that, so this is a budget hearing. You know, and we're here to say, hey, this is what we need. And what you're bringing up is, hey, maybe you need more than what you think you need. You know, that's really the point here of what I hear in your question. And so I welcome it. I think that when you think about our workforce workforce needs pay, compensation but workforce needs housing, workforce needs childcare, workforce wants parking, workforce wants recognition, workforce wants to be appreciated over time in different ways. And so we are literally trying to think on all of those fronts and then also how we can build internal and external pipelines. I think President Noonan gave a great example of work that the CVMC has done that's been very successful in a micro way that could be made larger. But we need to get better on all of those fronts and we are working on each one of the ones that I've been talking about that I went through with you just now. Most of those are not gonna bear fruit immediately. And I think the Jessica Holmes has very good points on access. That's why I appealed to the Green Mountain Care Board this morning for partnership, meaning the only way to fix access to take care of our people and to have the facilities we need is to get the resources we need and head in a direction we all agree on. It's the exact same thing with our HR issues. We've all got to agree where we're going, have the resources and have the five year plan to make sure that we can get there. But that's where our minds are at. Is that helpful at all? Yeah, no, that's helpful. There's certainly an immediate crisis and immediate access issues, but we have to obviously, to your point, I'll be thinking out into the future, we'll never get ahead of it. Right, and if I could just add, we try to hire people and they come here and hear meaning Washington County, Chittenden County, Addison County, they come here and there's nowhere to live. We bring travelers here and there's nowhere for them to stay. So it's not just simply, are you willing to pay the hourly rate or the weekly salary? It's way more complicated than that. Yeah, I hear you. We've been hearing that from some of the other hospitals as well, particularly around housing and childcare. Yeah. Shifting gears a little bit. In our staff presentation, which hopefully you're familiar with, they did a breakdown of, and actually I'm gonna just pull this up so I get it right. They did a breakdown across the whole system about pressures on NPR. And one of the areas that they highlighted was something that we're calling UVM Health Network Fiscal Year 21 Billing Variances. And my very limited understanding of that is that it perhaps has something to do with the cyber attack and the need to push billing out until the systems were rebuilt and all of that. And I didn't notice anything about that in your narrative. So I was hoping that you could just speak to that a little bit and so that I make sure I'm understanding what it actually is. So I can. I don't know who that goes to. I can start and I think Mark can kind of fill in some of the technical details. Actually, we did speak to it. We didn't I think call it billing issues or variances. When we broke out the net patient revenue change from the 21 budget to the 22 budget in those charts, we highlighted that big base number change that was a little bit of what we were trying to describe there. And the issue is with the cyber attack and the Epic Go Live, our total charges were certainly, we got them in the system, but were they in the right financial class from the beginning? Like was it a Medicare patient? Was it a Blue Cross Blue Shield patient? We did, that took a while to clean that up. And when you cross those two fiscal years that created some noise that typically we don't have in our budget filing. So in totality, we feel like our net patient revenue number is accurate. But when you look from one year to the next because of those disruptions and the cleanup that we needed to do, there was some noise there from one payer to the next that typically isn't there. Got it. Thank you, that's very helpful to just explain that a little bit better. Okay, bear with me for one moment because my questions are a little bit scattered in my materials. So let me just get to my tabs and see if I've covered most everything. One thing I just wanted to mention and this is really a comment so there's no need to respond to it. I'm happy for Jess and Maureen to understand the commercial calculation in greater depth but to the extent that that's not in the record we won't be able to rely on it for our decision. So I just wanted to mention that if there's anything that's particularly relevant in that discussion that should be in the record that that would need to be submitted officially. So I'll just leave it at that. Robin, this is Al. Could I just comment on that for a second? We'll be happy to get something in the record but also Patrick if we could talk about the cost shift report and the way that you do that and the way that we're doing ours and then maybe explain the difference so that the board that is well-versed in your way of doing the cost shift report then understands ours. I think that might be a way to translate. That sounds great. So I had a question around the per capita calculations and some of the data and I wanted to just make sure that I'm understanding it because this is certainly an area that internally we've been thinking about in terms of the hospital budget process as a whole. So based on what you said, it looked to me like you were using the census data presumably on a county level to in your per capita calculations. What I'm wondering about is for the counties where some of that care, some of those people will be going to a different hospital that is not in the network. For example, Franklin and Grand Isle. Did you adjust for that in some way or are you just including the resident population of those counties as unique patients in that per capita count? No, we're adjusting that based on the market share that we know we have based on billing data. So Franklin County, for example, it's currently right around 40% is our patient. So the primary counties that make up that number in the analysis that we had was Chittenden, Franklin, Grand Isle, LaMoyle, Washington, Addison County are really, and so there's percentages of each one of those counties that make up the total population number and market share that you see on that report there. And presumably Washington County, I assume. Do I skip that one? Yeah. Just checking. Since I live in Washington County, wanna make sure I'm in there. So when you are, the other question I then had is like, how do you then know if you're looking at total cost of care that a unique person is encountered twice? Like for example, if I go to, you're just counting me, even regardless of whether I go to CVMC or UVM, like can you tell in your market share that one person is sort of crossing those hospitals? No, we're essentially just counting them once. So the way that we did this is, we're looking at the three hospitals, revenue and the three hospitals, essentially market share. So you can find all that. Thank you. That was helpful. And I think I am coming to a close. Oh, I did wanna ask specifically about the 15 beds that you reopened. I'm wondering how the staffing for those beds is how that's going. Cause obviously the space, as you mentioned, Steven, the space alone is only one component. So Robin, we only have three of them open right now. That's on, those are neuro beds that we could add capacity right away. The other beds take about eight weeks to get ready. We will use travel staffing if we have to. Many of those patients are here now, but they're boarding in the ED or other locations. So it'll just be basically able to get people out of hallways and into rooms. So not all the staff, but most of the staff is here already, and we'll have to deal with that. It'll be one of the challenges of staffing those places, but it'll be a way to get people out of the hallways. Got it, got it, thank you. Okay, and then I, let's see. I think I am done. Thank you. Thank you, Robin. Next we'll go to Board Member Pelham. Tom. Well, thank you for being here. And I'm wishing for all of you the day that you can look back on this period and say that you were there and that you did a lot of good because I think that's what's happening, but sometimes when you're in the middle of a crisis like this, you don't have the time to even reflect on your own contributions to the Puff of Good. So thank you very much. My first question is it's not so much a question. It's just a kind of an observation, but it has to do with the cost shift. And I kind of feel that no matter how you calculate the cost shift, it's a big number. And so it's not something that's gonna get resolved in a year or two years or three years. And so a longer term strategy might be necessary. So I applaud you for going and meeting with Diva and talking to Diva about the cost shift. But I think you might also want to consider talking to the emergency board. As some of you may know is comprised of the chairs of Ways and Means and Finance and the Appropriations Committee and the governor. So it's five people. And they actually vote on at the beginning of a session on the kind of guardrails around the Medicaid program, very specifically. And so if you're not in their wheelhouse come November, December, when they get together before the next session, then you could fall by the wayside. And so for example, in the 2021 presentation, they voted explicitly not to allow reimbursement increases for Medicaid unless they were federally mandated. And to give you a sense of the significance of it, I just want to read a couple of sentences from their July 30th, 2021 meeting, which is three weeks ago. And in their report on Medicaid, they say, right, expenditures overall Medicaid and Medicaid related expenditures total 1.8 billion in fiscal year 21. This total is 3.9% or 74 million below the gross funds budgeted for fiscal 21 through all of the budget adjustment actions. And it's 1.4% below the amount spent in fiscal year 20. However, the general fund impact is much lower. This under spending results in 8 million general fund carry forward available for one time use in the next budget cycle. And it goes on to kind of profile that in terms of state funds that each 3.42 million in state funds is equal to a 1% increase in Medicare reimbursement rates. And that's a statutory requirement that needs to be reported. So, you know, I'm on your team when it comes to the cost shift and I think a long view here is important. And, but I also make one more quick note here that the composition of the emergency board is representative Hooper from Montelier, representative Ansel from Pant, Calis, the governor's on it, Jane Kitchell is on it and Senator Cummings is on it. So Washington County has a lot of representation on the emergency boards. So, Anna, it's up to you. Okay. So my next question has to do with the value-based chair participation. And I think that we, you know, before the hospital budget season we went through rate review and both carriers, MVP and Blue Cross Blue Shield with Blue Cross Blue Shield being pretty direct basically say that when it comes to their commercial participation in these value-based care programs that they don't have willing partners out there and kind of point to the providers as kind of liking to have a big foot in the fee-for-service canoe and it's hard to move them along. And so I'm looking at your presentation here for where the University Medical Center projects 182.3 million in FPPs for the 2020 budget comprised of 130.6 million in Medicare funds and 52.2 million in Medicaid funds. But no, but I know not a dollar is in there for commercial. And so I'm just, I guess my question here is what, you know, that fixed perspective payments equal about both 30% of your Medicare and Medicaid revenues, but what, how can you prove Blue Cross Blue Shield wrong? How can you prove to them that you are not the problem, that you have some solutions in your kind of pending negotiations for 2022 rates? So I can certainly start just to clarify one aspect of how we're looking at the numbers and that we do participate in the Blue Cross Blue Shield for all three of our Vermont hospitals. We participate in the Blue Cross Blue Shield in MVP, ACO programs, but those programs are not FPP, meaning the program has a spend target, but we settle at the end of the year instead of having a fixed payment throughout the year. And we've, you know, the place that we've been at for a while is a fixed payment that reconciles to fee for service really doesn't have value. All it does really is create an administrative burden that and creates uncertainty in your financial statements that you need to stay on top of to ensure that you're accurately reflecting revenues. So we do participate in both of those programs. And when you include those, you know, those numbers, it does increase, you know, our total percentage of revenue that is at risk in those programs. So I'll just clarify that piece. I don't know if anybody wants to add anything else to. Well, I'll just say that we'd be first up if any commercial payer wants to come forward with actuarially derived total cost of care targets and are willing to allow us to have the portion of the premium that would flow through the ACO to support care management be first in line. Well, I raise this because on your payer mix table and on the reconciliation tables in the budget submission, there's still a zero there for commercial carriers. It's, but significant amounts, as I said, 30 to 32% range for the Medicaid payer and Medicare. And I just feel caught, where I actually was surprised, you know, that the carriers were kind of saying, well, it's not our problem. We're here and we need willing partners. And you can go back and read the transcript. You know, that term came up quite a bit. And I'm just, you know, I'm glad to hear Dr. Brumstead, you know, make the point that you're there to increase your numbers and hopefully you find the path to do that. My next question, I had a question on the COVID program liabilities, which you answered, I think Jess or Maureen asked a question about that. But I had another one where I noted that the grand total column, and this is on appendix seven, that the grand total column did not include 4.98 million in Vermont healthcare stabilization grant phase two funds, nor 9.6 million in FEMA funds. And I'm just, I don't even know if there's any significance to that, but on the other appendix seven tables, I've seen everything ties out. And I couldn't tie out UVMMC's. Unless Mark can answer that, we might have to get back to you, Tom. Mark, are you able to answer that question? I don't have the appendix in front of me. Okay, because the FEMA one was like 9 million bucks. So it was a big number. So the, my questions on FTEs have been asked by two of my fellow board members. I don't need to go there anymore. I did want to just kind of ask what your thinking is about your Medicaid projection for 2022. You have it moving by a 20% increase from 135.7 million in 2021 projection to 163.2 million in your 2022 budget. And this is without a rate increase. And the three moving parts that you reference are utilization up as a big positive, reimbursement and payer mix is a big positive and the FY rate as a big positive. And I just wonder if you can add a little color here that if Medicaid is not coming in for a rate increase, but they're projected revenue for 2022 over 2021 P is a 20% increase. How does one kind of reconcile that? Or maybe you all can reconcile it, it's just me, but the 20% just seems like a big number. And it's in line with your Medicare increase and with your commercial increase, which do have rate increases to some extent, but Medicare has Medicaid has no rate increase, but you're looking for a 20% increase in an NPR FFP in Medicaid. I think the important thing to think, to remember about the projection is it includes our cyber attack that occurred in November. It also includes volumes with the surge last fall of the pandemic that weren't quite where they normally are. So that the projection number starting from a low point to begin with because of those two events. So now we're essentially, we're past our cyber attack where volumes have come back to pre-pandemic levels and then some. We've assumed that they'll essentially maintain that level into the 22 budget, but the biggest reason for that large jump is the projection includes those periods of time that were much lower than what they normally are. I get that. I just thought that I think Medicaid is within a point or two of its peer payers and I thought that they would be, because if they don't, Medicaid doesn't have a rate increase that they would be farther behind, but I understand the logic that you're putting forth. And other than that, I'm through with my questions it's nice to go at the back of the line because you get other people to ask questions that you don't have to ask. And I get to get out of the way of my chair. Thank you so much, Tom. So Steve, I'm just gonna follow up on a few questions about access and I know that you've been asked some of this already, but I can tell you that throughout the years, even as a legislator, I would hear stories about access problems, but they were one-offs, they were anecdotal. But this year, the amount of concerns that we're hearing at the board and the amount of concerns that we're hearing not only from patients, but also from providers about their concerns about whether or not they're providing good care, really scare us. And I'm just curious, other developed countries in the world that are putting out better quality outcomes that sometimes half the cost have twice as many primary care doctors as specialists. And yet we have the exact reverse in the US and you referred to higher acuity. That's a recurring theme throughout all the hospitals we've heard from this year is that the patients that they're seeing are sicker than what they've seen in the past. And I'm just curious if you think that our lack of having adequate primary care providers is adding to the problem. And maybe if some of the specialists are doing some things that primary care docs could be doing, and if they weren't doing those there would be more time to concentrate on their area. So if you could just speak generally about that, Steve. Thank you, Kevin. So I think part of the issue in Vermont honestly is once again that being the Academic Medical Center also in the most populated part of Vermont, if you say the UVM Medical Center serves 170,000 people as its primary care hospital, that's how you need a certain number of neurologists for that and surgeons, certain endocrinologists and so on. When you add to it that because the rest of the state is so rural and our other hospital partners are small and it's very hard to have more than one of any specialty in some of our smaller places if you have any, all that's coming to Burlington as well. So I think we have a particularly difficult challenge here in that Chittenden County is growing, consuming. And so the people from Burlington and Chittenden County and Grand Isle that expect to be able to come here and get timely access, which they deserve, it's hard for them and it's hard for a referring doctor. So I think it's a double whammy. I also think that being a very, very low cost state and being very frugal for a long time might be catching up with us a little bit. I think that it's possible that some of the investments that we need to make now, we have to make them more quickly to get caught up. In terms of primary care, absolutely, there's no question that having good access to primary care is the foundation of keeping people healthy, no question. But in a state like Vermont, where we're aging faster than most other states and we know as you age, you have more medical problems, most of the referrals and transfers we get need two or three consults. You need a cardiology consult, you need a pulmonary consult, you're coming for a trauma, but they've also had a heart attack because of the trauma. They would be very, very difficult to manage in any of our community hospitals, which is appropriately why we're here. I think that one of the options I've already mentioned is once we have Epic up for all of our network, that will absolutely improve access to specialty care because more patients will get what they need from primary care through that e-consult. I think telehealth also is a huge opportunity, we're doing some, but we have to do more. Being able to keep maybe someone at Rutland or at St. Johnsbury, because we can do a telehealth consult, we have to be able to do that. Because they're staying there now because we don't have a bed for them. So I think we need to really, really thoughtful about what care we want Vermonters to be able to get in Vermont. Because without some changes right now, Vermonters are leaving Vermont to get care because they can get in other places where there's better access, just to be honest. And someone asked earlier, an accountable care, care for them within your system because you're the low-cost, high-quality provider. So I think we're feeling the pressures right now of population growth, population getting older and being very, very cost-conscious every time, which is, I'm a Vermonter, I'm frugal by nature. But I do think right now we're feeling some of that. And I do feel here in your voice, I think that you genuinely have heartfelt concerns to make sure that Vermonters do have quality of care. But I do want to push back on Rick's statement a little bit because the question was about the measurement. And of course, UVM has always made the argument that third next available is not a good measurement. So a couple of years ago, you made the argument that 10 days was the right measurement. And it almost feels like you just signed up a bunch of left-handed hitters and are moving in that home run fence from 420 feet to 350 because now you've gone from the 10 days to the 14 days. And I think one of the things that we have to do before we can even begin to really assess what the true access problem is, is have a measurement of what is an acceptable wait time. And I just don't know why it went from 10 to 14 days and this year's answers back. But I think that it's something that we all have to put a lot of thought into and come up with something that truly is a good benchmark if we're going to have something that we're measuring against. What I would say, Chair Mullen, is whatever measure we use, we have a problem. Yep. Whatever the number is, I mean, we know that. And so I personally am less concerned whether it's third next, next. I basically want people to get in, they need to get in. I want providers when they call us to be able to get ahold of a specialist and get people up here. I want our patients to get in beds and they'll get scans when they need them. Whatever measure you want to use is fine with us, but that's what we're about. That's what I'm about. Yeah, and the measure certainly didn't change to Steve's point to make us look better. You look at that number and you compare it to the benchmarks, which is why we change because we can compare ourselves to other practices. We certainly didn't do it to make ourselves look better. The numbers don't look good. There's no, there's no, there's no hiding from that. So Rick, if you're convinced that the 14 day benchmark that you use this year is the right one, maybe you could just put in writing a few paragraphs about why it's the right one. And we could change what we're asking for from all the hospitals in Vermont for the reporting because everybody else is reporting, you know, third next available. And I agreed with you two years ago that it probably wasn't the best measurement, but I don't have a better measurement. So that's what went out again. And it would just be helpful in that. Steve, I just want to clear something up for the record. You have never ever said, I'm not going to hire someone in a specialty because I'm worried about them bringing in additional revenues to our institution, have you? Never. Thank you. Because there seems to be some type of misconception out there where people are hearing. People say that the Green Mountain Care Board is preventing additional specialists from being hired because they're not approving a higher NPR. And I just want to say that a couple of years ago we rebased your NPR. I think that just speaking for myself, you've made a very compelling argument today about population growth and why you should deserve a higher NPR. So that's not a concern to me, but I just want to make sure that people don't have the false impression that the Green Mountain Care Board is choking access to care because we're not willing to give you a higher NPR when in fact we take very seriously access as being just as important as controlling costs. So I just want to say that we're willing partners and we want to see that Vermonters have appropriate care. So if that means a higher NPR, so be it. So very, very heartened to hear that by the end of the year the inpatient psychiatric CLN will be submitted. It was disturbing, Steve, 22 psych boarders is what I heard you say this morning. So John, I think Vermonters should take some solace in the fact that you're heading up that planning. And I know that with your involvement, this will get done. So thank you for taking the personal involvement there. One more, I guess I can limit my questions to one more. And that is that, and I don't have any knowledge if any of this is accurate or not, but John and Steve, you were around a few years ago so you can help me here. But providers are believing that the communications is somewhat troubled in the network and that it's too hierarchical. And they pointed to something I believe they refer to it as etch findings from a few years ago from an outside consultant. Is that something that rings any truth in your heads and where the findings from that consultant ever put into place? Let me start, Steve. No, go ahead. Yeah, so after our difficult summer of 18 where the nurses went on straight, Dr. Brumsted asked for a consultant who'd been here before to come in and do a survey of the culture of UVM Medical Center. And that survey was done by a company called Edge Consultants who had been here numerous times before. And there were a number of findings from that survey. When I took over as interim president, many of them with John did 34 presentations across the Medical Center campus all times of the day and night. I attended every one of them to outline the problems at the Medical Center at that time. One of the major ones was disconnection between the leadership distrust of leadership and disrespect broadly amongst staff. I spent every single day I've been here working on this with my leadership team. We have regular communications. I walk this hospital every week. I make appointments that anyone has to meet with me and I think we've made huge progress. We have more than 8,000 employees here. So it always can't be perfect communication but I think that we've done tremendous work to make it better. We have as we've said over and over again today in our presentation had a lot of challenges in the last year which have been very tough. I think if we didn't have the culture improvement that we've had since the summer of 18 we wouldn't have survived it as an organization. It wouldn't have been possible to do the things that we've done. The Medical Center has a lot of grit right now but people are exhausted, all of us. So I hate to hear that that gets to our regulator the Green Nile Care Board that people think they don't have good communication because I can tell you that pretty much every email I've gotten for the past two and a half years as president, I've answered. So people know my email and we've worked really hard to be here for everybody, all of our employees. So thank you for the question, Kevin and Steve. Thank you for the great answer. An organization that wasn't trying to meet the needs of our employees, it would have been real easy to not take some really tough actions after the summer of 18, we could have just cruised. It would have been devastating. And so we did go out and with great intention to know what the ground truth was, we went out and we asked the question. And Shannon Casey and Etch, I can't even count the number of face-to-face interviews she did to come back and she did and her company did know our organization well. And I didn't make it to every single one of the presentations, the staff presentations that Steve did. But I got to the majority and it was tough. It was tough to stand there as a leader of an organization that both Steve and I grew up in and that we cared so much about and to hear how far off track we were culturally, how the distance between leadership and our line folks. And we have all taken that to heart. I certainly have. Steve has, Steve's recruited a great leadership team and we've taken that tact network-wide. One of the greatest times of my week now is with Dr. Duchamp to have a virtual open meeting for our providers and staff from across the network. And we've had great attendance at those and it's not as good as getting in a room but it certainly beats shooting out a blast email to try and communicate with people. And those along with the DEI listening sessions that I talked about, we're really trying to really be visible in every way that we can right now. And I think Steve and his management team at the Medical Center really epitomized what it is to be visible leaders in an era where it ain't easy. The best you can do is down a mask and walk around and talk to people. Thank you. At this point, I'm gonna turn it over to Mike Fisher for the healthcare advocate questions. Mike? Thank you, Mr. Chair. And thank you, UVM. And with a little apology to the chair, I'm gonna have a statement that I really wanna direct it all three hospitals. And though I know we're asking questions only at UVM. As long as you don't direct it three times, you're okay. That's my goal. I would echo the thank you and appreciation from every board member to you and to the leadership team that we have before us. But I wanna just take it a step further and ask you to convey to the people who are making the rounds, the nurses that are making the rounds, the people who are cleaning the rooms, the people who were doing the care, a direct appreciation from the healthcare advocate's office and I'm sure from the board as well. I think I'm going a little bit to the morale point. Sometimes appreciation from outside is important. So this is an exceptionally tough year for providers for sure. And tough time and just need to make the obvious point that there's a corresponding need to say this is a particularly tough time for Vermonters as well. Behind the story of the increased utilization that you tell is a story of increased need. So I wanna thank you for your efforts to be responsive to the healthcare advocate's office, both in real time meetings to address our question about Medicare benchmarking charges against Medicare or question one and look forward to follow up on that and also appreciate that you took the time to write down answers to our written questions. That helps us have a little bit more of a more in-depth conversation today. So that's appreciated. I'm just gonna ask, I think I only have one area to ask a question about and that is the bad debt and free care trend over this time period. And with full recognition that looking at 1920 actuals and 21 projected, the utility of that is only to understand how this trend, how we manage these issues during a crisis. Unfortunately, we seem to continue to be in crisis. So my follow-up question, so we asked the question in writing and I appreciate the answer. Let me just review it for a second and ask you to flesh it out a bit for me. For UVM, between 19 and 20, we see a slight uptick in free care and a slight downtick in bad debt. But between 19 actual and 20 projected, we see a sort of significant down in both. We normalized it for gross patient care revenue. We see free care went from 63% of gross patient care revenue in 19 to, I'm sorry, 0.63% to 0.47% and bad debt went from 1.13% to 0.98%. So that's a fairly significant reduction. That is a reduction in uncompensated care. And I think the answer, and I'll just say that I appreciate your answer that you recognizing the increased subsidies, the changes in Medicare, I'm sorry, Medicaid policy as opening up the door for people to be able to get those monies to be able to flow to you. I just wonder if you could say a little bit more about what you think is going on in the ground. Yeah, hey, Mike, Rick here. So yeah, that definitely is a piece of what is driving that 21 projection to be lower than what it has been historically for both bad debt and charity. The other two components are there's no doubt there was a lower amount of volume in the highly elective, costly types of services during the pandemic that care was delayed and that gets reflected in what we see in 2021. The other pieces that we did essentially put a hold on all of our self-pay collection activities of both internally, so our internal teams in terms of sending out statements, making calls, we put a halt to all of that. Same thing with our collection agencies, we didn't turn claims over to collections. They didn't do their normal collection activities because we stopped that or we suspended that for a period of time during the pandemic. So that's really the impact that you're seeing in the rates for 2021. But in checking with our teams, that isn't reflective of patients not being able to access our financial assistance programs and when they need it to. If anything, we tried to be even more out there and make sure that they were aware of those programs. But from a rate perspective, that's really what drove that down. And we expect and we have seen towards the tail end of this year that has started to pick up. And certainly in our 22 budget, we're anticipating those rates to be back where they've historically been and we'll continue to do all we can to make sure that patients are aware of the help that we can provide them with their bills. Yeah, thank you. I forgot to give another thank you. I wanna recognize that you updated your free care policy during a particularly difficult time that you engaged to make some real improvements in it. I guess my question, I really wanna go to the sort of the interaction with Medicaid here given sort of the continued conversation that we hear that we've heard today about underpayment from Medicaid. I think part of the story about, tell me if I'm wrong. I think part of the story of why your uncompensated care has gone down is because it's easier at this moment during the public health emergency to get people on Medicaid and to keep people on Medicaid. That's correct, yeah. And when I look at the real dollars between 19 actual and 21 projected, I think it's about, you've seen your uncompensated care go down about $4 million and sort of this is neither here nor there for your budget, but just to say out loud, my understanding is Medicaid ran hot about $21 million in last fiscal year and it's running hot seven weeks into this fiscal year by about $8 million. So to this conversation about being able to increase, go to legislators and ask them to increase rates, legislators have a challenge on their hands dealing with Medicaid utilization. I think that's really the point I wanted to make and I think we have another question from a member of my team, Sam Pesh. Good afternoon, everyone. I just want to start by thanking UVM for your attention and commitment to diversity, equity and inclusion focused efforts. We really appreciate that you took time during today's hearing to discuss this work further while also providing written responses to our questions. Also want to commend you for recognizing that becoming anti-racist institution takes time, resources and commitment from all aspects and levels of an organization and that there still remains work to be done but they could take courage to say that. I would like to briefly highlight the distinction too between stated commitments to anti-racism and allocating real resources and empowering staff and leadership to work on DEI focused efforts. So we're happy to see that UVM hired several staff to support this work, allocated funding in this area and plan to hire a chief DEI officer. So in line, just following up on something that was mentioned hours ago, I wanted to first ask if UVM would be willing to share their DEI action plans with the board and the HCA as I think this could be an opportunity for all of us in the hospital network in Vermont to learn from and support efforts in this important area work. So that was my first thought. We're happy. Simple answer is yes at the network level and Steve. Absolutely, Sam, we're right in the midst right now of building a three year DEI strategic plan but our VP of HR and our soon to be VP of DEI would be happy to follow up with you. So I'm not sure I have your email but I'll figure out a way for them to connect with you. Sure, for sure. Thanks a lot. And just as far as resource allocation, I think what we included in our specific answers is small relative to the importance and the investments needed, but that's what we have in the budget and it's not all inclusive. There's a lot of time and effort of executives at all levels and managers that are going into these efforts. And across the board when I'm involved in recruiting leaders, whether they're clinical leaders or administrative leaders, I think it's not the appropriate approach to sort of put out a dowry in a war chest and dangle that in front of people and have them come in what the approach that I take and we have a long track record of doing this. So I think those were recruiting can trust it. And that's to you come in, you understand our organization, regardless of what it is, a new head of the cancer center or a new chief of cardiothoracic surgery or a chief nursing officer or a chief diversity and inclusion officer. You understand our organization. We've recruited you because we believe in you. We think that you can really help our organization learn about us. You come with a vision and what I do, what we do is we invest in that vision. If we believe that you're the person we wanna recruit, we believe totally that you will bring a vision and we will invest in it and we will do everything we can to help us together reach that vision. So just to your point, Sam, we did answer your questions, but I wanna make it very clear that we will make the investments in time, energy, people, focus to move the dial and to move us along this journey. Thanks so much. Appreciate the response. And the second question builds off of that. Just, it might be too early to answer this question, so please say so if that's true. Just curious how these DEI focused efforts have played out on the ground for patients in particular, whether this is at a patient check-in counter at a financial counselor's desk, back office, just so you could shed a little bit more light on what this DEI work has played out on the ground. Yeah, I'd love to hear from our presidents on that. And Steve, you obviously can start and Anna and Tom, if you have some comments on that. Sam, a lot of our work has been focused on our staff to make, and we have between eight and 9,000 staff here to really make sure that our staff feel connected, they feel valued and they feel heard. But some tangible things we did, we made the important decision to fly the Black Lives Matter flag, we flew the Pride flag. And I heard from a number of patients that that was hugely important to them, that they felt like they were being seen, they were being recognized for who they were. And that having those flags up really made us feel like a more inclusive organization. Once again, you've already said it, we have a lot more work to do. But I do think people appreciate we're on the journey and we are doing everything in our power to be inclusive for everyone who works here and everyone that we serve. And I think just that makes a difference. And I'm proud I'm gonna be marching in the Pride parade on September 5th with probably 100 people from the Medical Center. And when I did that last year, I heard from a lot of our patients that meant a lot to them that someone who's at the Medical Center leading it was there and was supportive of them for who they were. So I'll just add to Steve's comment, Sam. For us, some of our work has taken the form of a DEI commitment statement, which is sort of a foundational statement that we've socialized with all of our team members, but also with our patients and our residents at Woodridge. And that's just to set the playing field on what we expect from behavior for all of us and how we treat one another. So that's just a foundational shift. We've embraced the Juneteenth celebration. So we acknowledge that here and asked our colleagues of color to participate in that and inform that and educate some of us who are less familiar with the significance of Juneteenth and our staff, staff, the Juneteenth celebration and Montpelier on June 18th. And again, those are just ways that as one of the largest employers in our community, we can set the stage and set the expectations. And I think it's a very powerful way to begin to shift the tide around systemic racism. Those are just a few examples. Mr. Chair, I wonder whether we've gotten ourselves out of order, whether we should be looking for answers from CBMC and Porter when we're asking those hospitals questions, you're muted. I think we're two thirds of the way there. So we might as well finish and just don't repeat the question. We go to those hospitals. Okay, so I'll be the final third on the answer of that question and thank you for it, Sam. You know, I would echo exactly what Anna and Steve said relative to the expressions of gratitude both from employees and from the community and vocally in both, almost like this, almost like a sigh of relief from people that our leadership position on this, our sincerity of our leadership position on this was recognized. I'd also say that when we've done work with policy work and gone out to our departments to share results of our DEI survey, in some areas there were some, there were uncomfortable conversations that need to be, that were held, but they were held, you know, and there was dialogue that occurred. Otherwise it was this, there were these unspoken things that were just lying in the background. I think it's obviously just a start, but under Dr. Bromstead's leadership, it's been very evident to everyone in the organization that this is, we're in this for the long haul. Do you have other questions, Mike or Sam? Just have one more, Chair McMillan, if there's time. Go ahead. Last question is, how is UVM Health Network investing in both multilingual personnel and in high quality translation services? Specifically, what translation services are available to folks seeking patient financial assistance and or emergency Medicaid? Thanks. So somebody on the team that can take that. I can speak more to patient care, Sam. So for patient care, we both hire a broad range of interpreters and we also have an iPad app that has more than 60 languages on it 24 seven. And I can tell you as an ER provider, that is an amazing, amazing change in the ability to provide care. You can roll it in the room with you, you connect with an interpreter, tell them the language that you need, have an interaction back and forth with the patient, you can give good discharge instructions. I've actually had the interpreter on the screen hold up, I hold the patient's phone and record the instructions for the patient on their phone in their language. We need to do more for discharge languages in terms of the written form, but we are building out on that right now. I'm not sure if that happens in financial services or not, but we could find out for you. I'm not sure how we do that. Yeah, that'd be great when we can touch base offline too, but those are all my questions. Thanks so much. Back to you, Jim. Thank you. Thank you, Mike. So next we're gonna open it up to public comment on UVM Medical Center Burlington. Is there any member of the public who wished to offer comment on the budget hearing that has just ensued? I'm not hearing anyone and I'm not seeing any hands raised, so we'll shift gears and move to Central Vermont Medical Center. And Jessica, you will be asking the first round of questions, so whenever you're ready. Sure, thank you. I actually really just have one question that I'm hoping I'm gonna shed some light on. So when I look at the NPR growth for CVMC, if we looked at 2019 actual of 208 million and if we grew it at 3.5% for 2021-22, we would arrive at about 231 million in NPR and CVMC is budgeting 251 million for 22, so about 20 million more than we would have expected if NPR grew at 3.5% per year since 2019. So I recognize that that's actually true at UVM as well, but there's a lot of population growth and a lot of other factors going on up there, pent up demand and other hospitals sending their patients to UVM that would explain some of that. I'm wondering if you can talk a little about it with respect to CVMC. It's not in one of the counties that we're seeing major population growth. I did see the chart that Ali, that you shared the 12 month actual volume trend to budget monthly average. That's helpful I think in understanding some of where this growth might be coming from where you're projecting it, but I wonder if you could talk a little bit more in detail that was driving that growth more than what would have 3.5% annualized growth would have been and also whether you factored in productivity losses that may occur with Epic Implementation at CVMC. We've seen with Epic Implementation elsewhere, EMR Implementation elsewhere, productivity's declined. So if you could talk a little bit about that and obviously my worry is that if your expenses are budgeted to grow in line with those projections and when you don't meet those NPR estimates then it might be another year of operating losses. So that's my concern. If somebody might be able to help me with that. I can maybe just answer a piece of that, Jessica. So while there isn't the same level of population growth in Washington County that there is and chitin' in the surrounding counties, there certainly is population growth. And so that certainly is a piece of why the NPR is growing more than the 3.5% So I'll just put that out there. I don't know if Anna and there's any other thoughts but there's definitely a growth population here as well. Yeah, Jessica I'll add to what Rick's just mentioned around the population growth. There is a slight increase in Washington County and we obviously have an age of demographic. So multiple comorbidities, what we're seeing is an increase in that. We certainly are seeing, particularly in the last couple of months, an incredible increase in acute care volume as well as what we've already talked around on psychiatric border volume but we also have med surge borders as well. And for us it's really not med surge, it's really medicine. So complex patients, age of demographic. And then to answer your last question around, did we build in some reduced productivity with Epic Go Live? Yes, we did. Because we know we're gonna see a voltage drop. This is all in on the acute care side unlike managing a Go Live in a practice setting where we can reduce our volumes and of patients we see in the practices which we did in October of 2019, we can't do that on the acute care side. We have to be ready to care for any patient that comes through. And at this point, because our volumes are increased, we will do our best to manage to that higher census but yes, we did build for slight reduction in productivity and we also know we'll see a slight voltage drop as we were bringing our revenue cycle online on the hospital side as well. So there'll be some delays in those work processes as well. Jesse, if I could just say one point. So this is just from recollection. I'm not looking at the spreadsheet that I would normally look at to talk about this. So I'm happy to connect with you and Patrick offline. But pharmaceutical expense was driving a large part of CVMC's budget over that three year period. Not so much this year, but over the three year period. And so that's been a factor there that we could talk about the drivers of and what is unique to CVMC versus the other hospitals that we have. Okay, that'd be great. Thank you for that. And that's it for me, Kevin. That was my question. Thank you, Jess. Next we're gonna go to Robin. Thanks. First of all, I wanted to say, Anna, that being in the community, I've heard lots of anecdotal praise for CVMC's COVID response and standing up the vaccination and testing abilities in our area. And also from at least some of your staff, I've heard a lot of positive feedback in terms of how the staffing was handled and how folks who otherwise perhaps weren't able to see patients at certain periods could repurpose into other roles. And it sounded like that was very well done. So I just wanted to share those anecdotes with you before I jumped into questions. My question, since we're on the topic of pharmacy, I did have some questions around 340B and how that is budgeted in your 22 budget. We have heard from a number of other hospitals about the issues around 340B with drug manufacturers, the recent or relatively recent letter that came out from the feds, that people are hopeful might reverse some of that. But could you speak to that and how that's reflected in the budget? So we have a slight increase in 340B revenue for our CVMC. We focused particularly in those programs in two areas. One is specialty pharmacy, which is a new product line for us. That was something we had hoped to launch earlier, but because of the pandemic response and the cyber attack, it was put off. So we've just launched specialty pharmacy here. And obviously that's being done in collaboration with the UVM Health Network in that pharmacy as a shared service. So that's a new product line for us. The other one for us is our health assistance program, which we also are borrowing heavily from the work already done at UVM MC. We had, that's not a service that we had provided in exactly the same way. And I think what it'll do for us is really give us the opportunity to provide those medications at a lower cost for patients. So those are two areas of the pharmacy service line that we've addressed this year. Thank you. And again, my apologies while I wrestle my binder to find my other questions. And Robin, while I have you, thanks for the positive feedback. Yeah, no problem. I did, the other thing I wanted to mention in terms of your staffing, Anna, is that I've always been impressed with your career pathways programs and it sounds like those are going well and that you've been able to expand those. And I was interested to hear about the EB3 visa program as well. Are you thinking that once you've sort of implemented those that that's kind of where you're gonna land in terms of your, what I would call innovative workforce issues or do you have other ideas in the pipeline? Yeah, we're gonna keep those innovations coming to the degree possible. If you had said to me in 2017 when I started that I'd be launching an LPN program at CVMC, I probably would have said no, but all the statistics out there with the labor market, particularly the nursing labor market in the state of Vermont as well as nationally really pushed us in that direction. And the other thing that it's done for us is it's really given people that had never considered a professional side of healthcare as an option for them from an occupation perspective. It's given them a whole new opportunity. So I think it's work we will absolutely continue to do. We've learned a lot through the first cohort who I mentioned, we've graduated 13 LPNs. That's a game changer for those individuals. 60% of that class, they are the first ones in their family to complete a post-secondary degree. So it is a huge game changer for not only them but their family and our community. And so we're gonna keep those programs going. The RN program we just launched, we just actually started this week. And again, that's in collaboration with VTC taking those LPNs that qualified and moving them into the RN program. So we're gonna keep those pipeline, talent pipeline programs going. We're working on the MA program because our practices still need that level of support. And that's another way to bring support or access is to make sure that we have other individuals and our practices that are supporting the care flow. So our providers can really focus on the clinical care. To do that, we really need to bring that talent into the organization. And we have to grow it, that's very clear. And the other lesson, primary lesson learned in all of these programs is people need support more than just the time. So we're paying them to go to school but we're also helping them in time management skills. We pay for them to have a 12 hour shift where they can study and also manage some work-life balance issues. And we've brought in other supports with our community partners as an example, the Thrive Group United Way in particular has provided scaffolding around financial management, those sorts of things. So it's really a way to bring a number of resources around those employees and really elevate their ability to function in a different role. So we're gonna keep those programs going. We're encouraged by the work so far with our EB3 explorations. We've looked at four companies. There's one that we're likely gonna go with and that there are a few other organizations in the state that have utilized them. And again, that's just, we know we have a limited end of people in the state of Vermont for sure. So bringing people from other countries is a way we can I think enrich not only our workforce but also give people an opportunity to live in the US and long-term potentially as they gain their visas. So I think it's likely a game changer. And I would also say that the likelihood of us getting out of a traveler business, it's not gonna happen. It travelers now will be part of our cost. And I think we need to acknowledge that and recognize that and budget for it. While we continue these other pipelines from evolving, so we're trying to do it in a sort of multifactorial way but it absolutely the growing the locally talent pipeline programs are core for us. Thank you. And then I was wondering about the OR used by UVM docs and whether that's something you think will continue into the future or is that really more time limited in response to some of the access challenges? I think it's something that's gonna continue in the future. There are again, if we're being patient and family centered offering the care local to where people live is one of our goals. And that's a goal for the network as a whole. So having some of those providers come down and offer care that we can provide in our surgical services area here at center of Vermont versus driving to UVM MC, I think is a win. The surgeons that have come down have had a very positive experience working here. You know, it's easy to park here and it's easy to walk in and we have high service quality. So those are all positives. So I don't see that going away. In fact, as we're recruiting new surgeons we're working with our colleagues at UVM MC to see which surgeons would prefer to work here for some of their patient volumes. So I think it's something we're gonna continue to utilize and the other pieces we have the space. So we do have ORs and as an old surgical nurse you never wanna see your ORs closed up. You wanna have patients in them because that's all cost that's in the system that's not being utilized. So we wanna maximize what we've got here. We have a great periops surgical team and the surgeons have been amazing coming down. So and what we're hearing from our patients that are experiencing that care, they love it. So I think it's a win on a number of levels. Great. And can you just connect that maybe a little bit back to some of your volumes and your NPR? Is that something that you think is a contributor to your request? Yeah. For 22? Yeah. Absolutely. Yeah. And I think it will also, it certainly will help us in that regard without the service lines that we would like to continue to optimize here and it should help with our margin overall. Okay. That's what I had. Thank you. Thank you, Robin. Next we'll go to board member Tom Pellum. Tom. Hello, Anna. How are you? I'm well. How are you? Good. I wanna follow Robin and say as a central Vermont resident the process of getting a test and the process of being vaccinated worked incredibly smoothly. And one little funny story is that I told my daughter asked me if I got vaccinated and I said, yes, I did. And the old JC Penny facility. And she said, well, which side was it on? Was it on the right side or the left side as you come in? And I said, well, it was on the right side. I said, dad, that's where I brought my sixth grade prom dress, you know? So it's just kind of funny to see life move along and how things change. And I just have two or three quick questions here. One of them had to do with the provider tax. I noticed that you in your 22 budget have that in at 6.4% and the rate I think is 6%. So you're in a 6.4% against not 20, 21 budget, but 20, 21 projected. And I'm just wondering if there's anything sacred about that, 24% above 6%. I would have to get back to you on that, Tom unless Rick or Mark could answer that question. Or Cam. Anna, I know one component of it, but we can validate that is that includes the skilled nursing facility for CVMC and there's a different calculation for the provider tax on that piece of it. Okay, because it's a million dollar difference. Yeah, that's one component of it, Tom. I'm not sure if it speaks to the whole thing, but that is one component of it. We can follow up on that. Okay. And then under other operating expenses, there's a 22 budget over 21 projection. There's a 23.9% increase from 33.5 million to 41.5. And I'm just wondering what the moving parts are there. You're the big ones. Are you pulling that up? Looking. So I think that the biggest piece, I'm not on that page yet, Tom, but I think the biggest piece is the epic implementation that comes with additional costs. I'm trying to find what else is in that number. But I think that's the biggest component of that increase. Okay, thank you. And finally, I'm just some alignment here. I'm looking at the value of value-based amounts on the income statement. And they're in at 47 point for 20, 22 budget. They're in at 47.4 million. And in appendix six, the value if you calculated out is at 45.4 million with 5 million held in reserve. So I guess I'm just trying to tie the 5 million to what. It's not, you know, and which number is the income statement number of 47.4 million in FFPs and reserves the right number or is it the one on appendix six at 45.4? And what then is the amount of risk being covered for 5 million bucks? I think that I'm gonna have to get back to you as well, Tom, I apologize. Which appendix was that that you were looking at? Pardon me? Which appendix was that that you were looking at? Appendix six, the value-based appendix. So Tom, he said he's gonna get back to you with that answer. So yeah. Okay, that would be fine. And that's it. Thank you very much. Thank you, Tom. Next we're gonna turn to board member Maureen Yusuf or Maureen? Hi, thanks. I only have a couple of questions. Just touching on the NPR and looking at it from your projection. So your projection of 227 million for the, for 2021 growing to 251 million is about an 11% increase. And if we back out the six million request for rate that 18 million left is an 8% increase. So kind of tagging along to where, you know, Jess was going on the growth, but, you know, can you bridge that increase year over year from the projection to the, to what your current forecast is to your 22 budgets there? Yeah, so I think some of that Maureen will be the same as what we're seeing across all our hospitals. So the 21 projection does include some lower volume is at the beginning of the year that in the fall when we had the COVID surge and even the cyber attack had an impact on CDMC as well, not to the extent that it did at the medical center that the volumes in that period of time which was in the projection is a lower number than it typically would be, which is why that's a pretty big increase from the projected to the. Okay, it's just the same concern is if you don't get the number and your expenses are at that level, it would be a hit to the bottom line. So kind of where Jess was going to. And that's why, I think Al might have covered it is section is that we do try to be inservative in our volume estimates because of that very reason, because once you build your budgets and our budgets, our expense budgets are, they're in line with what we're projecting for revenue. Once that number gets in somebody's head in terms of, I can hire this staff person or I can go up to this number. It's hard to kind of pull back from that. So we are in general, barely conservative in our volume estimates. Again, as our expense numbers essentially fluctuate up and down with what we were projecting. So if anything, we're probably as an organization, we're more on the conservative side. We budget what we see in front of us today and we look ahead, but we don't, certainly don't go out on a limb in terms of projecting volume to revenues. And Maureen, if I could just jump in and really my comment would be the same on all three budgets. The reason I showed the green, yellow and red volume charts is because that's what we are using to try to figure out if our estimates are right because we've been very clear with our team and with our board that we have to match expenses to volume. And so if those volumes in any of our affiliate hospitals are overstated, then we will have to take action to reduce expenses in a meaningful way. And so we're trying to use them to see if on September 30th, there's nothing magic about the next day, but it happens to be the next fiscal year. Like, are they gonna run into that and work right? So if you looked at UVMMC right now, you'd say, wow, they're running hot. They may be over your budget forecast, but that's just through June, we now have July. So as we get closer, we'll know better where we think we are if they're over. With CVMC, they're slightly under in the aggregate. Are they gonna keep going up and are they gonna hook up or are we gonna have to take actions with expenses? And so these are, this is literally the management tool that we use to do exactly what you're trying to get at because I completely agree with you. If we miss low, we've got to adjust expenses. If we miss high, we're gonna have a lot of expenses to go with that volume. And the question is, what is the volume? Who is the payer and is there any margin? And are you just frequently updating your forecast with that like on a rolling basis or for the year to adjust for those? Yeah, yes. And so what we've been doing is having monthly meetings with each affiliate to review these volume projections, expense, what is realized of expenses in the prior month and what we project for the next fiscal year. And so that's how we're trying to get everyone on firm financial footing across the network. The other place that this comes in in a very concrete way, Maureen is the position management groups that we have at each affiliate and the network. That is, that's a key variable that we're looking at when we're approving those positions is are we at our budgeted number and somebody's coming before us and looking to replace a position if we're not at those volume numbers even though it was a budgeted position, we're not gonna be filling that. So the volume and expenses again throughout the year we're constantly measuring and keeping those in sync to try to achieve our budgeted margin. And as late as April, we were still in the red because we're looking back to really February. So we were thinking, was this ever gonna come back? And then, wow, did it come back? Then we wrote aftershock in the narrative, bad choice of word because an aftershock while severe is short lived. This has been continuing. So now we're not sure if it will slow down at all as we enter the new fiscal year. Okay. And then just one last question on the ACO risk reserve that you have. Do you know what your maximum risk level is? It looks like you're gonna be carrying a $5 million reserve in 22 against a $45 million FPP. So that should be larger than what you would have in any given year for requirements based on the quarter. So I'm just trying to reconcile that $5 million number. Yeah, so I'm just pulling up the hard narrative where we included that number. So the maximum downside risk for all of the, all three of the, actually all four of the ACO programs is eight and a half million for CBMC. So eight and a half million and you're carrying $5 million for 2022. I mean, I guess, what is your process to go through to determine what you put on the books for a risk reserve? Because we've seen many hospitals take different approaches to this. Yeah, I mean, we look at historical performance and making that determination. And each hospital has a little bit different performance over the years in those ACO programs. That's really the only solid piece of data that we can go on is seeing how we've done in the past and make a projection for where we think we'll land in next year's budget. And then on top of this number, you potentially will be getting money back. Is that right for the 2020 settlements or? We will, but that's gonna be, that's already been accrued for in 21. So it's reflected in the FY21 financial statements. And so it won't be recruited so that when it does come in, it's not gonna impact the profit and loss state in FY22. I'm sorry, it's not gonna impact the what? The profit and loss statement in FY22. Thank you. Okay, that's all I have. Thank you. Thank you, Maureen. It seems strange being at a UVM budget hearing and not having Todd Keating here to say or do something that puts a smile on everybody's face. And I think back a couple of years ago where Todd was intimating that he had some strong ideas on what could change the financial picture at CVMC. And if you look back the last quarter of a century, most people looking from the outside have said, you know, CVMC should be doing better on its financial sustainability. And Anna, you've now been there for a few years. Are you confident that, you know, anything that Todd may have figured out or things that you have implemented in your time there or are about to implement, do you think that past history is behind you? Well, that's the goal. And we're working hard to achieve, you know, the margin that we're targeted for. I think the challenges are, you know, this is, these are, it's a razor thin operation here. With, if you look at our payer mix and you look at the type of patients we have, we don't have a large surgical pace, our basins we've put in place here and the support of the network that will turn that around. It's not a single thing, it's multiple things that we've had to shift over time in my tenure alone. And some of it is just operational improvements, trying to find the efficiencies in the systems, making sure that the staff, the amount of staff we have matches our volumes. That's a struggle. I think the struggle that's ahead of all of us in the network is, without doubt, we've said it repeatedly is workforce. We're paying three to four times the amount for staff. And it doesn't matter if they're LNAs or RNs or techs and that's nothing that we had anticipated. So again, we're gonna rely on these other talent pipeline development programs to help us out and being really creative in that space. But, you know, it is a challenge. There's no question. Well, everyone's rooting for the downtown Berry girl. Thank you. Kevin, if I could just give you three things that I'd wanna leave you with to your question, to your very good question. First is CVMC has an old age of physical plant, but has not borrowed a lot of money. And so, you know, that's a strategic mistake over a really long time that we're gonna have to deal with. And we'll do that, some of that through the pick, but we have other work that we'll need to do and we'll need your partnership on that. The second point I'd make is that I joke that we're a pharmaceutical company that enjoys running hospitals, but it's not really that funny in that we really rely on our pharmaceutical revenue to make up for payers that don't pay cost and for volumes that don't always produce the payer mix we need to cover costs. CVMC has not grown their pharmacy program. And that's why I wanna meet with Patrick and Member Holmes to talk about the history of where they've been, why it's grown rapidly recently and where they need to get to to be at a better place in terms of specialty pharmacy and contract pharmacy. The third point I'd make is we really need to work on productivity within CVMC as an affiliate. And that doesn't mean that somebody isn't working a full day. It means that because we haven't invested in the physical plant and we don't have clinics basically built the way we need to for the modern world, we just don't have the productivity we need. So that's sort of the strategic thinking but happy to talk about it at any time, Kevin. Great, thanks, Al. And I was kind of looking at that 1,700 employees for the revenue that's generated there and wondering the same thing. So I'm glad you've highlighted that as something you're looking into. Absolutely. So with that, I'm gonna turn it over to the healthcare advocates office, Mike or Sam. Thank you, Mr. Chair. Just one question from us for CVMC. I just, I appreciate your written answer on the bad debt and free care that you don't, aren't aware of any access to care, access to free care challenges. I just wanna note that the numbers are just a little bit different for CVMC than they are for UVM and that your free care really took a pretty tremendous dip. Those are my words. From 2019 actual to 2020 actual 1.08% of your gross patient care revenue to 0.66. And while it ticks up some for your projected 21, I just wanted to highlight that. And if you have no insights as to exactly whether something different is happening at CVMC, that's fine. I just wanna note it that it was a bit glaring as I looked at your numbers. Yeah, I think for the causes of that CVMC, Mike, I think are actually I know are very similar to what they were at UVM. It's definitely a combination of lower elective surgeries during that period of time. And just like UVM, both CVMC and Porter suspended their self-pay collection activities for a period of time during the peak of the pandemic. And I'm not aware of any other things that might have driven that drop in rate. Yeah, thanks Rick. And I'm not asking for the same answer again. I was asking sort of what might be different. And if you don't have any clarity on that, that's just fine. I just noted a difference between what happened to CVMC and what happened at UVMC. Thanks, Mr. Chair. Thank you, Mike. I'm assuming no questions from Sam. Yeah, that's correct. Okay, that's it for us. So on the CVMC budget, is there anyone from the public who wishes to offer comment at this time? If so, either raise your hand in the team's function or just begin speaking. Is there any member of the public who wishes to comment? Seeing none, we're gonna move to Porter. Last, but certainly not least. And we'll start that questioning off. I believe we're with Robin, correct? That's right. Thank you. Thank you. Thank you for your presentation earlier. I just had a couple of questions. I noticed in the narrative on page 27 that you indicated at Porter that you had started an LNA program in 2021. It sounds like you're sharing lessons learned across the network. And I wondered if you could speak to that in a little more detail. Sure, I would be glad to. And thank you, Robin, for the question. So we partnered with the Hannaford Career Center here in Middlebury to start with a pilot program to train LNAs in an almost identical model as what Anna has at CVMC, where folks would work for us half-time and go to school half-time and we would underwrite that cost. And so those folks proceeded through that program. We were successful only in retaining a few of those folks. We've been going through some changes in management there and some folks found some opportunities that they thought were gonna be more beneficial for their career. We actually did retain some of them in the hospital. I think we'll be going back to that program here in the fall and doing another cohort. Our new chief nursing officer, Tiffany Love, also has connected with Vermont Technical College about similar LNA to LPN to RN training. We still need to keep the Hannaford program for folks who just wanna stop at the LNA level. So I think, you know, we clearly are shifting to the grow your own approach to our workforce here in the future. Great, thank you. Could you also speak to 340B assumptions in your budget? Sure, Rick would love to, or is that? Yeah, I think like CVMC, actually all three of our organizations, we've been very conservative in terms of our, in those programs because of the activities with the pharmaceutical companies, obviously putting a lot of pressure to try to limit the ability for us to generate revenue in those areas. So we have been conservative. We're hoping that the tide will start to turn there and that we'll be able to begin to grow those programs, even with the pharmaceutical companies pushing back on this. There still is opportunities to grow even with that major hurdle that we have in front of us. But we've been fairly conservative in what we've built into all three of the budgets. It certainly seems to be a volatile area and this year's drawbacks on that program have been very substantial for us. Thank you. I just wanted to go back to one of your slides where you're talking about challenges for Porter, including capital needs and funding. And I did notice in comparison to the other critical access hospitals in Vermont, you actually have the third lowest age of plant. So could you speak a little bit more to what you're thinking about in terms of capital or capital needs? Are these routine sort of things, big ticket items? At 15 years average age of plant, that would suggest we're in a challenging place in Vermont with our facilities, if the others are worse. Yes, we in 2018 crafted a really well done master facilities plan that looked at how the whole campus regenerates over time, working at the outside group and really a strong plan in that it took us through incremental changes that allowed you to go different paths, depending on what happened within the operating environment. Our biggest priority out of that plan was our emergency department, which is not built for modern care. Lack of completely mixes public and patient spaces, has no safe rooms, has no sheltered for emergency vehicles. So it is our top priority. We all, for the hospital at this time. And the other piece in that, and so that was a multi-million dollar project in that plan. We are intent right now, and Scott is working with this on our end, is to re-engage that consultant who is doing some work with the medical center also at that time, which makes it convenient to refresh that plan, refresh the data, refresh the assumptions, ensure that the intent that was concluded in 2018 still holds today, and then set forth the implementation plan. Thanks. And then I had a question about the volume, the volume chart that Al provided for Middlebury and whether it actually looks like your volumes were fairly steady in a lot of areas in Middlebury. And I was just curious if there were any impacts from Middlebury College moving to remote learning or how the college kind of interacts with your volumes. All right, great question. So the college was highly conservative and highly successful through the entire pandemic. I mean, better than maybe anybody in the country or among the best in the country. And so when they essentially vacated the place and I know Jessica can probably speak, they're much, much better than I can. Together between us, Middlebury College and the town of Middlebury, we met weekly on managing through the pandemic. That, so I think relative to the college, we probably didn't see any impact during the COVID from college, from the college presence. I will say that we were fairly stable through the midst of the pandemic on the inpatient side. Obviously on the procedural side, on the cases that could be elective or would be considered elective, that was obviously a significant impact. But we stayed fairly stable on the medical and inpatient side and emerged earlier out of that process. And still even with that, we used a variety of methods to project the volumes that are in this budget because we were still far from stable or predictive. Thank you. And I think maybe all of my questions, thank you. Thank you, Robin. Thank you, Robin. Next we're gonna go to Board Member Pelham. Tom. Hi there, just a couple of housekeeping questions. The first is just to make sure that I understand the math associated with the hospital's operating margin. You're looking at a net operating income of 5.16 million and then there's 2.1 million associated with a loss associated with the Helen Porter facility. So that leaves you with 3.16 million, which is about a operating margin of 3.2% aligned with the hospital. Correct. Confirming. Correct, yes. Okay, thank you. And then the other is, I'm sure it's just a, not an issue, but in your on the income statement page is that stats, which profiles staffing and there for 2022B you, there's 6.3 travelers on that for 2022B. But then on your income statement for the line item that says services travelers is zero. So I'm just, I'm assuming the right hand and the left hand got a little stray here, but that those travelers then must be in the salaries line item. Tom, I can speak about that if you'd like. Please, that's exactly what it is, Tom. It is a nuance between the reporting and adaptive. They're being reported under purchase services and all of our travelers are under salary. So if you put the dollars there, but the FTEs are in salaries, there's going to be a mixed batch. And we're working with Patrick and his team on what we can do about that. But that's exactly what it is. Yep. Okay. So there is 6.3 worth of travelers in the 22 budget for them. And the same thing is happening for all three of the health network hospitals, by the way. And that's all for me. Thank you very much. Yes. Thank you, sir. Thank you, Tom. Next we're going to go to board member Yusuf or Maureen. Thanks. I just have a couple of questions as well. For the ACR reserves, can you tell me what your risk reserve plan is for 22 budgets? I mean, one of the backups I'm seeing zero, but it was 2.5 and 21, I think. So where will your reserve be for the ACL projection in 22 budget? I'm trying to look to one of my experts on that one, Maureen. Sure. I mean, if it's zero on that, let's get Maureen, and that's what we buy for the reserve in 22. Okay. I think you've always been adequately reserved. I'm sorry. Can you repeat that? I just said, I think we've always had a history of being adequately reserved. Thank you. Okay. And then order for the past, out of the past five years and including the budget projection, four out of the five years, you're the highest or the second highest operating margin. And I think a lot of that's come with the consolidation with UVM, which has certainly improved the financials, but just trying to really reconcile the 5.1% operating margin and I'm sure some of it's gonna be related to Helen Porter, but how do we reconcile that and the high rate requests versus having a lower commercial rate and lower margin, which still would put you above your targets but you put out there for operating margins and most of the other margins for this hospital, most of the other metrics. So I can just touch on a couple of those. So the rate request for Porter that we went through is, as we've talked about, is purely based on inflation and it's only based on the inflation of Porter hospital. So it doesn't include Helen Porter in terms of the targets that we have as a network and how we, that chart that we reviewed on age 25, that targets that we have there is the combined entity. And so the number there, for example, at Porter hospital that we've got of that 5.9 is the, that's the target just for the hospital. I think on the target on page 23 of 2.2 to 2.6 for operating margins and you're at 5.1, 5.2, 4.1, 4.5, 2.6, 5.1 for the past five years. Yeah, so that target there that we have the 2.2 to 2.6 is the target that we have for the combined entity. Yeah, Marine, I think the only thing I'd add to that comment is I think it's incumbent upon us and you've seen it in my comments about Porter. We have organized around and are implementing plans to operate as an integrated model. And I appreciate that we're presenting as a hospital to the, to the Green Modern Care Board. I just think about what the cost of care would be like without having the skilled nursing facility as particularly the post acute setting as a disposition site for our hospital for Porter and for the, and for the medical center particularly. I think it's going to be important for us to be able to demonstrate what that savings is as a result of that. Because I mean, we make this argument, we need to be able to show that. All I know operationally is that we are organizing and are deploying plans to be able to do that. Okay, okay, that's all I have, thanks. Thank you, Maureen. I have no questions at this time. So I'll turn it over to the healthcare advocate's office. Thank you, Mr. Chair. We just have one question and I'll ask it in a bit of a different way about Porter's bad debt and free care. Indeed, Porter has a similar trend about reductions in both categories, but I just want to note that Porter's free care is particularly small percent of your gross patient care revenue and your bad debt is a particularly large, compared to the hospitals across the hospital system, particularly large percent of gross patient care revenue. And if Porter sees that as something that you would like to work on, I would offer to engage with you in thinking through things that can be done to find a right balance between those two categories of uncompensated care. Thank you, sir. I think that would be great. I think that there's an opportunity to educate the community on what's available. So I think that partnership would be certainly welcomed because I noticed that as well, that I think there's an opportunity to provide the care and also not have it be a negative factor for those who need that extra assistance. Thank you very much. Mike, I would like to go back to, if I could, to volunteer something from Sam's original question earlier that I didn't chip in on just to let you know that we are awaiting feedback on a very substantial grant to support enhancement to our interpreter services. And so I think that's, we've done a lot here with signage and multilingual signage and pursuing press gamie to see if they would do something on being multilingual in our surveys, but we're awaiting some feedback on substantial grant requests for translation services for our non-English speaking patients to build upon the program we already have today. Very good, thank you. Okay, at this point in time, I'll turn it over to the public for any public comment on the Porter Medicals budget. Is there any member of the public who wishes to offer public comment, either raise your hand through Teams or just begin speaking? Hearing none, many of you probably think that we're through, but as you recall, before lunch, I mentioned that at the end, if people had some general questions, they could ask them. And I've already heard from member lunch that she has a couple. So we'll start with Robin. And if anybody else has any follow that, feel free, Robin. Thank you. So I was struck by the population estimates and the comments on slides 40 and 64 around the long-term projections, both in terms of the aging population and Medicare, as well as on slide 64, you reference predicting the population growth of Medicare to more than double, Medicaid by 12% and privately insured population by 16%. And I wanted to contrast that with the approach that you took in your commercial rate ask, which I appreciate highlighting the impacts of the cost shift, but I think it does raise a significant issue in terms of the future of healthcare in Vermont. Specifically, I don't believe that we can continue to rely on the commercial population to pay for the public payers, even just the incremental inflation expense. And I know that you have a plan to talk to legislators and AHS about this, but I would really, this is really more a comment than a question, although I welcome your thoughts, I just don't see how we can continue. And I hearken back to Algo Bays, one of his favorite slides of the Vermont family at the median income and how it just, the median income families in Vermont can't bear the burden of supporting our entire healthcare system. So that's really more a comment than a question, but if anyone would like to comment, I'd love your thoughts. I'd love to. John, is it all right if I go first? Sure. You wanna go? I would just make the comment now, you and I have talked about this, that the aging of the population has not been a surprise at all. We've talked about that over and over again. And I'm not gonna go past over it, but the negative compounding effect of sub-inflationary increases really put us behind the eight ball and make what otherwise would be smaller jumps required. What really is an eye-opener that I certainly didn't see that the discourse in Vermont has been, oh my God, we're shrinking, we're shrinking, we're shrinking. And all of a sudden, at least in our catchment area, we're not. And so the aging of the population is more of us aging, which is really a problem. I'll pitch it to Al, because he really has been working hard on figuring all this out. Thanks, John. So the chart you're talking about, the family of four chart, the whole theory behind that was that because it was done in 2014 and started in 2015 through 2025 was something's gonna break, something's gotta happen. And in fact, it did when the Biden administration came in, there's been huge changes. And Mike Fisher, it's good to see you. And none of us would have predicted when I produced that chart that we would split the small group market and from the individual market and that we would all be for it. I mean, things change and people adjust. And so when I think of this chart, I think this is as important of a moment, Robin, to your good point, because if we're going to rely on government payers, they've got to be able to fund the quality and access that we need as communities. And they haven't always done a good job of that, reference skilled nursing facilities today, for example. And so I've put this out there just in the spirit of partnership with the Green Mountain Care Board and with the healthcare advocate that we have got to get ready for what's coming because it's coming. And we just need to know that. So thank you for your comment, Robin. I'm sorry, Robin, you're muted. Thank you. My next general question was about the partnership that you've taken with MVP to create a Medicare Advantage plan. And I wonder if you could give us an update on that. And also I have to admit, I don't actually see it being entirely consistent with the goals of the all-pair model. So if you could clarify that for me, that would be very helpful. Sure. The update is that what we've put out in our press releases and what you started to see this Monday in some initial information sharing, CMS is very, very, very prescriptive on what you can share about those plans. It's foreboding to talk about benefits or anything related to that until open enrollment, which begins October 15th. And of course, we'll be actively in the marketplace talking about those aspects of the partnership as soon as we can. In our view, in my view, the all-pair model is an example of providers moving to a value-based business model, which incentivizes and is supported by a population health approach, keep people healthier. And so from our perspective, finding a partnership to launch a Medicare Advantage plan where over time, the UVM Health Network and other participating providers will be absolutely held accountable for the per-beneficiary cost and the quality of those services because that's how Medicare judges the providers in those plans. That's totally in lockstep with the core strategy that UVM Health Network has had since before we were called the UVM Health Network that we would move towards value-based reimbursements and have our delivery of healthcare fit into that model and that we as provider organization will be accountable for the quality of care, access to services and the cost of care. So that's why we think it's in alignment with any other effort to move in that direction and that's why to Tom Pelham's excellent question, I said we're all in. If any commercial payer wants to come to us with an opportunity that's in that construct, I would hope it would come through the ACO but if it comes directly to the UVM Health Network, we'll take that. Obviously, it depends on the details but if it's actually derived total cost of care target and we on the provider side can be held accountable for how the care is delivered, that's what we're all about and that's our core strategy. You're muted again, Robin. Sorry, I'm trying to keep my noise at a minimum. I can certainly see how at the high level that makes sense but certainly folks who then join the MA plan aren't able to be attributed to the ACO. So it potentially is pulling away attribution from the ACO program. So I think that's perhaps where I was not seeing a total alignment. Well, I could be corrected but I believe they're attributed to the ACO but in the commercial pocket but again, I might have that wrong but again, the goals of the healthcare reform in my mind aren't to meet scale targets of CMS or anybody else. The goal of the all-payer model is to move away from fee-for-service and to have the provider community take accountability for cost and quality. And so again, it's your perspective, I get it but I'm too simple, I guess. Yeah, that's helpful. I appreciate the discussion. It's helpful to see your perspective. And then I just had one clarifying question which was in the narrative on page 17, there's an indication that you're expecting approximately a 7.5 increase in value-based payment over a year-to-date actual experience. Could you speak a little bit to that? Is that increased attribution? What do you see as driving that? Piece of that is a little bit of increased attribution but very little Robin. We also have assumed that based on historical performance that we will have and this is different for each hospital based on historical performance but we did budget assuming that we would generate some shared savings in 22 as well. So the combination of those two things are what is driving that budget assumption. Great, thank you, that's all I had, appreciate it. Does any other board member have any general questions as follow-up? I just have one. Go ahead, Jess. Okay, thanks. Some of you may have heard, I've talked about it in a couple of the other budget hearings but it's about Mathematica doing some analysis of potentially avoidable utilization. They did it for rural hospitals across the country and then they shared some of their results with the board a few weeks ago. So I've been asking some questions about it and I wanted to actually just recognize that both Porter and CVMC on most, if not all of the measures actually for preventable or potentially avoidable utilization just looking at Medicare fee for service, both those hospitals were below the state median on most of those measures. They didn't do it for UVM so we don't know there. So I know there's still more work to be done but being obviously on the low side of the state deserves some recognition, particularly building on Robin's point as we move towards more value-based payments. So I guess I'm wondering, my question simply is do you think part of your relative success relative in the state has anything to do with your early and full participation in all the ACO programs, particularly the Medicare program which really this is looking at Medicare experience? It's a great question. Being able to draw cause and effect to that I think is really, really tough as you know as a economist, your science tries to do that all the time and we need to get more distance through the all-payer model to figure that out. I would say, and this goes back to my experience as a provider and the multiple hats I've worn and Anna Noonan can certainly weigh in on this and Steve Leffler as a former Chief Quality Officer and CMO is that our Vermont-wide but particularly in our organizations, our standards of care are as conservative as anywhere in the country and you see that when you look at our utilization statistics relative to others and Steve mentioned our use of advanced imaging on a population denominator is incredibly low and that's been a real focus throughout my career to make sure that utilization is appropriate and it's been made more approachable because of the early integration of all of the faculty practice with the teaching hospital and the employment of providers and now the UBM Medical Group. So Jessica, I think that that more is a long-term trend and I'm incredibly interested just professionally on what we're going to see when we get 18, 24 months out from the end of the all-pair model where we will have the run-out and CMS has that timeframe for really evaluating the five-year demonstration project and I'm gonna be really interested to see if there's any kind of inflection in the utilization and the cost of care as that plays out. Just as a brief follow-up, do you think that using potentially avoidable utilization asking hospitals to track that would be a good measure of understanding population health improvements? Is that a good metric to use and is that something that we should be asking all hospitals to track and measure and report on over time? I believe that it is and I think more and more there are databases that allow you to do things like find sentinel utilization measures and track those on a population basis. It gets really difficult when you start getting the small ends that we have in the hospital service areas in Vermont but at a state level, we certainly can track that and then we have things like the Commonwealth Fund and the Dartmouth Atlas, we have the all-payer claims database. So we have some tools and I think it's all of us to keep our eye on that but we're really conservative as state and it plays out in all sorts of ways like being the lowest cost state per beneficiary for Medicare but I think that is a very useful measure and certainly we can work with the Green Mountain Care Board for our organizations and continue to track that. Thanks, that's it, that's all I have, Kevin. Does anyone else have any follow-up questions? General in nature? Mike, does the healthcare advocate have any general follow-up questions? Yes, I have just one. As a follow-up to Robin's question about the MVP partnership for a Medicare Advantage plan, I wonder whether you have any prediction or whether you're able to say, whether you have any prediction about how this partnership will impact your budget in the next year, positive or negative? I don't believe it's gonna impact our budget significantly because it's the first year of what will be out of the starting blocks, a relatively small program so I don't think it's gonna have any impacts. Rick's nodding his head back and forth so I think I'm actually on firm footing for a change with my finance guide. Let me poke just a bit further because you said for the first year over time, do you expect it to have an impact on your budget? Over time, I would expect that like many Medicare Advantage plans and other value-based reimbursements that we would be able to, through good care management, working with the population, come in under the total cost of care targets and that we would be financially beneficial to us. That's my only question, thank you. Thank you so much. With that, I'm gonna call this hearing to an end. Thank everyone who participated today. Thank you to the court reporters. You guys tag-teamed and did a great job and we appreciate that. Is there a motion to adjourn? I don't think I can make that motion. Don't move. I'm back in. I was beginning to think the board members wanted to stay around for dinner. All those in favor of the motion, signify by saying aye. Aye. Aye. Those opposed, signify by saying nay. Thank you. And Al, I'm really proud of my members for not taking that softball that you threw about SNFs because I could just see the follow-up question being as the former secretary of AHS, why isn't there better funding? Because I failed, but we can't. Yeah. Thank you, everybody, for your time. It's been a marathon. We appreciate it. Thank you, everyone. Thank you.