 Call to order the Green Mountain Care Board's hearing of September 6, 2023. We have a number of agenda items. First, we're going to review the standard budget order conditions and there's a potential vote noticed. After that, we're going to have deliberations and potential votes on a number of hospitals. I'm not sure if we'll get to all of them today. I think we'll go in the order that's presented on the agenda. So Southwestern, Northwestern, Brattleboro, Mattiskutney, North Country, Grace, Cottage, and Springfield. I'm not overly confident we'll get to the last few or that we'll get all the votes done, but we'll at least start the process today. And they'll be led by Director Lindberg and Mr. McCracken. So I'll turn it over to Ms. Director Lindberg and Mr. McCracken for the budget order conditions. Thank you. So just a quick overview. We will review the standard hospital budget conditions, review some of the statutory factors that are part of the hospital budget review. That third item we're actually going to postpone till next week, but we'll talk about some of the inflationary indicators that we're looking at. And then we will see how many of these hospitals will have a chance to deliberate on today. So with that, I will turn it over to Mr. McCracken. Great. Thank you, Sarah, and board members. So we're coming back to what we're calling the standard budget conditions that we reviewed at our last meeting, and we had some input on and have made some changes. I wanted to start with just to note again what I said when I presented these last week, that these are effectively default conditions that would form the baseline of the conditions that the board would attach to hospital budgets. So for each budget approval, the board would include, in its motion, to include the standard budget conditions or any additions or changes to it. So the board could certainly add or modify any of these conditions for a particular hospital if the board decides that it would be appropriate based on the specifics of that hospital situation and budget submission to do so. So with that note up front, the changes from what were reviewed last week, and I'm only going to highlight the changes here since I walked through all the conditions last week at our last meeting. So changes are highlighted. The first one is in condition D, which is that the hospital's expected commercial NPR based on its budget submission as adjusted by its order is a dollar amount that GMCB can determine based on the budget submission. The hospital would then report its actual expected commercial NPR not later than we had previously said February 15th. But there were some comments that that didn't provide sufficient time to see like a full month or enough time for the hospital to actually calculate its NPR commercial NPR. So we moved that back to March 15th, recognizing that not all hospitals are the same. I also suggested some flexibility here that the chair could specify a later date if that were necessary given a hospital's contracting cycle with their commercial insurers or any other factors. So that was the first recommended, that was the first change from what was covered last week. Next slide, Sarah. I had no suggested changes on this set of conditions. These are generally reporting conditions for the hospitals and fairly consistent with prior years. Next slide, Sarah. This is an additional condition that was raised by board member Holmes and hopefully I've captured it here in a kind of appropriate way. So it's to say the hospital shall develop a system to be able to measure and report to the board the referral lag and the visit lag for each hospital-owned primary and specialty care practices as well as the top five most frequent imaging procedures. And then referral lag and visit lag are defined here in the same way that they're defined in the board's FY 24 guidance. The reporting for primary care and specialty care practices and top five most frequent imaging procedures is also the metric that was used or the practices that were identified in the FY 24 guidance. So really we're capturing that same wait times reporting requirement. And so the condition is for hospitals to have a system to be able to report those metrics. And then in the bullet down below you'll see the hospitals would be required to report referral lag and visit lag for those practices and procedures once mid-year on April 30th, 2024, covering the periods of February and March 2024. And then as the board might require in the FY 25 hospital budget guidance. So in other words what would be required to be submitted with the hospital budget submission next July for FY 25. So next slide Sarah. And I didn't have any proposed changes in these final set of conditions. They're again they're consistent with what we've had in prior years. And I didn't have any changes to those coming out of the last meeting. So with that free free cap and summary of the changes I will turn it back to you Mr. Chair for Board. Discussion suggestions changes and there is some potential motion language here if the board decides it's ready to vote. Thank you very much. I had one late addition that I wanted to make to the standard conditions which relates to the population health management dollars earned by hospital-owned primary care. And the goal is to ensure that those dollars are being utilized for primary care. And I think the language and we can discuss it if board members would like. That's something along the lines of hospitals must account for and report back to the Green Mountain Care Board in their annual budgets. The amount of population health management dollars earned by hospital-owned primary care. Specify how those funds were used to support primary care and describe the impact those funds had on improving primary care. Could you just reread that one more time. Yeah I think the the proposal I had in Tritie Millie to Russ just a moment ago but it would be hospitals must in their annual budget account for and report back to the Green Mountain Care Board the amount of population health management dollars earned by hospital-owned primary care. Specify how those funds were used to support primary care and describe the impact those funds had on improving primary care. Can I ask you a couple questions please. Are you do you mean to include the ACO so there what I'm trying to sort out is what we mean by pop or what you mean by population health management funds. So that could be inclusive of the blueprint for health PMPMs that go to primary care the ACO dollars that go to primary care and if Blue Cross creates a primary care program their dollars are you inclusive of all of those dollars were you looking to be more specific to just the ACO dollars. Yeah good question I meant to be specific to the ACO dollars given some of the concerns and lack of clarity that came out in our prior hearing about whether or not those dollars had been focused to primary care. I don't have the same concern as to the blueprint or any future insured dollars because they haven't happened yet but I would be open minded to doing that in the future if we needed to. Okay so my suggestion would be it should be clear that we are specifically talking about population health management dollars received from one care Vermont unless you also want to include the Medicare only ACOs in this as well. Do you have thoughts either way on that? I guess I would err on the side of including those ACOs since they are fairly new to Vermont and you know they don't have a big footprint but it's my understanding we're going to have several of them coming in with budgets this fall so I think just so that we're keeping all the ACOs in the state on a level playing field it would make sense to understand that broadly. A hospital wouldn't necessarily you know they won't be receiving it from more than one ACO potentially unless they're participating in a Medicare only and then one care for the other programs. Or not one care in one of the others as a possibility. Right right right. No I think that makes good sense. I think that makes good sense we could change it to population health management dollars received from an ACO earned by hospital-owned primary care would that address it? Yes I think so yeah. Robin did you have more questions I don't I don't mean to interrupt but thank you along the same lines of inclusivity would it be possible for a hospital to receive population health management funds and use them in an appropriate way but not to primary care? So I understand the concern that the specific concern oh and that you raise with primary care funds that came out in a prior hearing but do we want to be keeping track of how the population health management dollars are distributed? Overall perhaps somebody's distributing them in some other way and that works great or it fails miserably and we'd like it to be more focused on primary care. Should we allow people to describe allow hospitals to describe what they're doing even if it's outside of primary care? I guess that's my question. I I think I'd want to speak with the ACO team and the policy team a little bit more to understand if that's best in the ACO process or if it's something to be done in the hospital process and how that relates and if we're getting sufficient information on the ACO side. I I tailored this proposal I apologize for doing it so late but I tailored it to the specific issue that had arisen when we were doing the ACO review earlier this spring so I don't know that I wouldn't be open-minded to that kind of suggestion but I wanted to keep this pretty pretty tailored. Just a logistical note is the way that some of these funds as I understand it are transferred may not make it easy to isolate some of what I think you're trying to get at part of that is by design for an all-payer program so I think yeah I think this could use some more workshopping and just figuring out if it makes sense as a standard budget condition or if there may be as a other avenues to make sure that we're getting the information in a way that is meaningful. Yeah so I want to take away the opacity and ensure the money's going there so if it's not easy to isolate I want to see if there's a way that we can just to be clear yeah I don't want to be misunderstood I'm sorry to interrupt but like the population health payments from the what we think of as blueprint are lumped in with other things and so yeah so like the exact payment that you are I think trying to isolate may not currently be flowing so we just have to be mindful of what that would mean in terms of lead time and burden and you know the juice squeeze ratio. I think to Tom's point there could be dollars that are earned by the primary care that flow to for example a nutritionist who supports the primary care but is not necessarily in the primary care budget so I which I think oh and to your point would still support the primary care but may not be quite as one to one as the language suggests and I think you would want to capture that right so you'd want to make sure that we were capturing uses that support primary care even if that is not located in the primary care office. Yeah I think that's right and the intent of the latter clauses about specifying and then describing the impact is to get at that and if the money is being intentionally allocated to support a nutritionist because it's beneficial to the primary care goals and effort good let's understand that and then second let's think about whether or not that is having the impact that we want so I just want it to be intentional if the money is going to support additional supplies at the hospital you know that might be more loosely connected to primary care and so that's the intent of the latter clauses is to be intentional about where those primary care dollars are going and if they're supporting the reform policy effort that we have behind this. I think the other sort of wrinkle we need to think through is not all hospitals own primary care so it really should not be a standard condition it should be only for those hospitals who own primary care or I guess we could you know make some additional edits to make it clear that if you know if it's appropriate meaning they don't have primary care affiliated with their hospital like for example Rutland does not. Right the language that it would be to describe population health management all earned by hospital and primary care so if you didn't have it this condition wouldn't be triggered. Got it got it got it yeah sorry it's I'd like to see things in writing it's hard for me to process it verbally. Yeah no same. And how would that apply to like Gifford which the hospital is owned by the FKHC right so it's not hospital on primary care but it's hospital affiliated primary care. I don't know the dynamics of that specific situation and how the money would be earned and flow within a hospital owned by an FQHC. I guess I go this a general question hospital could a hospital earn population health management dollars without having primary care affiliated there and if they could wouldn't we want to understand also how they're using those dollars because we may learn something interesting about how they're using that money that could inform other places so I understand the desire to have a a for this to be tight based on our history but I'm just thinking what do we really want to understand and from my point of view it's our population health dollars being used in a way that improves population health and that may or may not be primary care we had an instance in a prior meeting where we're not sure that primary care funds got to primary care but if population health funds can be earned and spent and improvement results I'd like to I'd like to know about that so a description of how the money how they earned it how much it is where it gets distributed I'm interested in removing and making that clear yeah I think to me this just feels like you know as was on the docket is as we reevaluate the data model for our kind of collecting information from hospitals and tracking this funds flow it is complicated it's will take some time to unpack but I think yeah I just have some concerns about you know just adding it without some more diligence so I would maybe recommend we put a pin in this for now and offer a chance for the hospital finance team to consult with the ACO team and figure out what makes sense and come up with a proposal that we can provide in writing to take up next week I think that makes good sense but before I do that if there are there any other so I hear like trying to make sure that the dollar understanding the funds flow making sure that the return on that investment is operating the way we would expect or in a way that we can measure more directly any other board member thoughts about what we're trying to measure or get at with such a condition okay so we'll I think that means probably not worth a vote today and likely that we'll be ready to vote on this on Friday but hopefully Monday we can take this back up all right you that could work for you Russ yeah I think that's fine I think that's fine before we move on though I would just open it up to any other board number comments questions concerns or additions that we should work to incorporate as well I didn't have any others although you know just for a preview I would support all of the conditions we have in here and as written I would support it and if there's a way to incorporate the suggested change that I made today I'd be supportive of looking at it and seeing if we can do it but otherwise I would approve all of these yep yeah I haven't said very much but I would approve all of these as well as written and I support the spirit of what chair Foster is trying to achieve with the accountability on the funds flow so look forward to kind of seeing what that language shakes out like but support the spirit of it to be sure I do as well I just would comment quickly with regards to the amendment that chair Foster suggested I think that we talked about maybe maybe two subtle differences and I and I support both initiatives I don't know if they're both appropriate for the hospital budget conditions but one is an accounting of the dollars that were intended to go to primary care and another one is I think getting to what member wall suggested which is thinking about how population health dollars are being used coming up with a broader understanding of this and trying to reflect on what's working and and how we can help use our position to help share the successes that people are having and maybe areas where they're not successful in use of this money so that I almost feel like there's kind of almost two aims of that have been brought up here and I just think we need to think through if both of those are appropriate or maybe I misunderstood what member Walsh was suggesting but I think it's actually a really potentially significantly beneficial understanding that we could have and share. You didn't misunderstand and you said it better so thanks. All right I think with that we can probably pivot to the next agenda item. We can we can move on I when this comes back before I'll also make clear in the motion language here that this applies to as the standard budget conditions apply to any hospital budgets that were approved with the standard budget conditions before we made this vote so just so that it all holds together correctly but I just wanted to note that before we look at hospitals later. Yep okay you're ready for the next slide. I am thank you sir. So I'm going to take a couple of minutes here and look at the board's criteria and principles for hospital budget review as set out in statute and I know that you're all have seen these before and you're familiar with them so I'm just this is a review but you guys we know the board has a statute has some statutory duties to review and establish hospital budgets consistent with the board's overriding obligations and healthcare reform principles. There's a hospital budget rule that gives us a more specific process and then there's of course the FY24 guidance adopted under that rule and all three of these are relevant and applicable for the board's hospital budget review and deliberation. This today is a look specifically at the hospital budget statutory factors and starting here just as a kind of a refresh these are what the board said in FY24 guidance around the statutory factors. I'm not going to reread it because it was in our guidance and it's a long thing and I'm going to go through the statutes in the next slides so we can go ahead to the next slide Sarah. Under the board's hospital budget review statute in 94-56 it instructs the the board on what to review and what to consider in establishing the hospital budgets that includes things like public comment where it says that the board shall solicit public comment on all aspects of hospital cost and use and on individual hospital uh individual budgets submitted by the hospitals. There are a number of other factors set out in the statute that the board goes through process-wise. Then the statute says that hospital budgets established under the section meet these six criteria which are be consistent with HRAP taken to account national regional or in-state peer group norms according to indicators ratios and statistics established by the board which we have set out in our guidance promote efficient and economic operation of the hospital reflect the budget performance of prior years include a finding that the analysis provided in a prior section which is related to how this statute reflects a shift from shift between commercial and public payers and demonstrate that they support equal access to appropriate mental health care needs that meet standards of quality access and affordability equivalent to other components as part of an integrated holistic system of care. Then we move from next slide Sarah. Moving from the hospital budget statute we have the board's the broad authority statute that says the board shall execute its duties consistent with the principles expressed in section 93-71. Those duties include reviewing and establishing hospital budgets. Next slide Sarah. These are the health care the principles for health care in Vermont set out at 93-71. I'll highlight a couple but not to the exclusion of any others so you see the first three here that the state must ensure universal access and coverage for high quality medically necessary health services in Vermont. Systemic barriers such as costs must not prevent people from accessing necessary health care and Vermonters must receive affordable and appropriate care at the appropriate time in the appropriate setting. Overall health care costs must be contained and growth in health care spending in Vermont must balance the health needs of the population with the ability to pay for such care and the health care system must be transparent and design efficient in operation accountable to the people it serves and the state must ensure that public participation of the design implementation evaluation and accountability mechanisms of the health care system. We can go to the next slide. We have here the importance of primary care and the importance of appropriate mental health care. I actually just included all the factors in these slides but like I said I'm going to highlight just a couple. So Sarah we can go on to the next one. So among the factors we have that Vermont's health care system must include mechanisms for containing all system costs and eliminating unnecessary expenditures including by reducing administrative costs and by reducing costs that do not contribute to efficient high quality health services or improve health outcomes efforts to reduce overall health care costs to identify sources of excess cost growth. We can go to the next slide Sarah and then we have an important principle that Vermont's health care system must operate as a partnership between consumers employers health care professionals hospitals and the state federal government and the state government must ensure that the health care system satisfies the principles expressed in this section. In addition and we'd go on to the next slide in addition to the principles of health care in 9371 we have here the principles of the Green Mountain Care Board set out in section 9372 improving the health of the population reducing the per capita rate of growth and expenditures for health services in Vermont across all payers while ensuring that access to care and quality of care are not compromised enhancing the patient and health care professional experience of care recruiting and retaining high quality health care professionals and achieving administrative simplification in health care financing and delivery um so I wanted to provide this as the kind of statutory bedrock on which the board's hospital budgets review and decisions are based and I'm happy to take questions although I would say if you're good if there are questions that um solicit legal advice council the board may consider whether those questions are appropriate for an executive session I don't have any questions but I really appreciate you providing that framework to remind us of the factors we should be considering and um I found that really valuable so thank you I too don't have questions at this time but I could see having questions at some point through this process on a specific hospital with a specific factor in here that I could see wanting uh advice on so would that be an opportunity as time goes on absolutely if as you know this is a general non hospital specific run through the statute if there are specific questions that come up we can address them if they are questions that call for advice of council that can be appropriate in an executive session to and that's a determination the board could make at the time the question arises anything else or any good to move on okay all right wonderful thank you very much for that background um so just a quick I wouldn't say quick uh just as we think about um inflation which I don't know if you've heard it's been uh uncharacteristically high in recent years um we're trying to you know there's different ways to think about inflation how it affects the consumer how it affects the prices uh that our hospitals and other providers are forced to pay and so um just wanted to provide some grounding in some of the um metrics that are available um to project so those that we have on a go forward basis versus those that we kind of have a historical perspective on so um one uh indicator that is used by our partners in Maryland to kind of think about um their global budgeting process and the prices that uh that providers face um and is factored in to local conditions is what we call the Medicare Market Basket um it has several different iterations but here we're looking at just the inpatient hospital portion so the projected growth from fiscal year 22 to 24 for that measure is seven percent um so again that is really the the cost basis as Medicare tries to look at it and if you just look at how much of that they're projecting from 23 to 24 it's 3.1 percent so um a little bit more heavily loaded from 22 to 23 than from 23 to 24 but these values are still um a bit higher than historical values and if we look at median income we were able to um leverage some projections there so the projected growth in Vermont's median household income is 8.6 percent um from fiscal year 22 to 24 um with that growth looking like at 3.9 percent from fiscal year 23 to 24 um the indicator we used in the guidance this year was related to um the producer um producer provider producer provider index the PPI um which had to do with general medical and surgical hospitals and when you look at kind of the longitudinal trend of two-year growth rates the median um in the that series was 5.8 percent growth over a two-year period but quite a wide confidence interval of 1.1 to 10.5 percent so a lot of um kind of noise in that data when you think of consumer inflation the CPI consumer price index uh if you recall or have a chance to review the work done by the um Cavett and Carr last year um the medical inflation tends to lag CPI and that has to do with um how sticky prices can be so you negotiate the prices one time for the year and then come back to it and so if you kind of shift the distribution you'll see uh the the trends are more aligned so just some things to think about as we think about inflationary growth and and how to grapple with that really difficult question um in our proceedings. So next I'd like to just turn to um uh the hospital budget decision tree so in consultation uh with the board there have been a few modifications to this um but in principle the left side um of the decision tree remains unchanged um those are the hospitals we made decisions on last week and that those were the uh those were Gifford and Rutland who were able to submit a budget below the benchmark of 8.6 percent net patient revenue growth from fiscal year 22 actuals to the fiscal year 24 budgets uh we've determined that those assumptions were reasonable and approved them as submitted um and now we're moving our attention to the other side of this decision tree and so if if and when these hospitals have come in above benchmark um you know submitting budgets in good faith from that they uh determine they need we will consider modifying them by evaluating and weighing the reasonableness of the budget assumptions um how each of the expense factors and the guidance compares with reference ranges how expense growth compares with peers um how the the um requests particularly for rates compares with the Medicare market basket and wage growth um might want to consider some other inflationary indicators there uh the factors and criterias out in the guidance and the factors criterion principles set out in statute which we just reviewed so again we're moving to this side of the decision tree um we have some kind of generic language if and hope we get to any votes today that I can pull back up uh but any questions about the modifications to the decision tree or the way we're gonna um kind of start tackling these deliberations okay all right so first up I'm going to pull up a template okay um so are you able to see my screen okay great um so what we have put together are some templates that essentially uh are designed to summarize the record uh to date and so uh this is for southwestern Vermont Medical Center um the top box uh looks at budgetary growth over time so you can see for each fiscal year what the guidance was uh for NPR what was submitted and then this delta from the approved so how much did the board's decision change what was submitted so in the case of southwest you can see that longitudinally there haven't been modifications to the NPR in this time period and you can see the submitted and approved commercial NPR um and finally operating expenses so how those have changed over time um and the last little bit is the change in charge um so as a reminder the board historically has only approved changes in charge which is the charge master um and so that's kind of the guiding star we have in looking at things uh longitudinally um and you can see what was submitted um if there was any changes from what was submitted and then this last piece is the commercial weight of the improved uh increase so um that's looking at of what was approved in rate looking at the prior year's share of gross patient revenue among commercial so of that 2.9 percent we looked at the fiscal year 17 uh gross payer revenue share of commercial to kind of weight that growth and so you can see over time uh pretty low uh weight of that improved increase among commercial for southwest um with some jumps uh in the recent year um looking at 3.1 percent growth was approved last year and if approved as submitted an additional um the overall growth would be 2.0 um from 22 to 24 um so a little bit of a reduction in the reliance on that rate the next part of the template is looking at the actuals so budgets are you know a good guess but never perfect and so you can see that um what the NPR has done uh over time for both in total and just the commercial portion of that NPR as well as the change in operating expenses over time um and then we have here uh in the corner the gross patient revenue mix so that's uh remember if everyone comes in and is charged the same amount uh this is the share of that gross revenue that each payer would have um in southwest case uh the traditional Medicare and Medicare advantage are grouped so back to the data model improvements we have in store um and see that um that that commercial payer mix for southwest uh in 22 was 32 percent of their gross patient revenue uh in looking through their expense factors um we can see that for labor the growth from fiscal year 22 to 24 in per FTE compensation was 6.8 percent which was uh the fourth lowest among Vermont hospitals uh the median among Vermont hospitals was 4 percent and we see the benchmark of 5.2 percent uh over time with a range of 0.8 percent to 9.7 percent utilization growth um at 1.6 percent which was the 12th uh near the bottom of Vermont hospitals the median at 7 percent with a range of negative 5.5 to 4.2 percent so within benchmark for both of those indicators uh the pharmaceutical expenses are not broken out in the data reported to us today um but in the testimony given as part of the budget hearings um we found that uh that uh southwest's uh information came right from their group purchasing organization and was within the range of 2.3 to 21.6 percent and cost inflation uh 5 percent was uh toward the top uh or i'm sorry low lower is better so among the lowest in the state at three um with the benchmark being 5.8 percent so right around that kind of historical growth indicator um just uh summarizing the financial position so um i think a lot of these results um in recent years are are pretty difficult it's uh the financial challenges have been uh really uh i toughest i think in fiscal year 22 we're seeing definite recovery in 23 um but when we look at uh the values submitted in the fiscal year 24 budget uh we see values that are very close to median um in almost all cases a reminder that when it comes to days cash on hand a lot of that is held at the parent level for southwest so not the most meaningful indicator so not going to lose any sleep over that um 61 days um and seeing kind of the long-term debt capitalization ratio dropping um and uh fairly stable age of plant over time which is close to the vermont median um and then when we look at the ratio of administrative and general salaries to the clinical salaries from the cost report um southwest had a result of 36 percent which was 13th so right near the bottom of vermont hospitals um the percentile rank among its comparator groups was in the 38th percentile so uh below the median uh with that intercortile range being 37 percent to 53 percent so um right near that 25th percentile among the comparators um when we look at the average cost per medicare discharge uh they uh really stand out here uh at 8 8451 that's uh you know the the least uh the lowest value that we have for that indicator um and among their peer group they also were in the first percentile so among the least costly uh based on that indicator and then finally uh probably the the hardest thing to wrap our minds around is the relative cost and price um so we have uh inpatient and outpatient indicators here so the commercial cost per discharge comes from the burns data so you can see that they um are below the 25th percentile in uh fiscal year 18 for that commercial cost per discharge right at it again in 19 per below it in 20 below it in 21 and far below it in 22 seeing um cost that stable over time is notable um that indicates uh to me um because it is consistent for both inpatient and outpatient and over time that that is uh evidence that there's probably a lot of attention being paid cost uh management uh and when we look at the cost coverage um again that's saying so that's what medicare says the allowable cost per discharge was how much did they actually get paid um so they're at 105 percent uh in fiscal year uh 18 so the 75th percentile and pretty consistently staying right near there through fiscal year 20 um staying relatively in the same place in fiscal year 21 and uh showing a little bit more cost coverage in fiscal year 22 um again because they are low cost some of the cost coverage is a testament to uh their management of those costs um and then for the standardized price um that comes from the RAND information that we saw and so that's saying here's all the money they got from commercial payers according to the all payer claims database let's divide that by a standard unit of cost and we see that um they are within that interquartile range um for the inpatient uh turning our attention to outpatient we see very similar trends in the commercial cost per discharge so right at that 25th percentile among the hospitals in vermont um and then the commercial cost coverage being on the other end of the um box plot at 75th percentile um and again right within the interquartile range on standardized price um so uh you know the main reason that this hospital was over benchmark had to do with five million dollars worth of investments to increase access um to care that they wanted to provide in their community so you know the the um easiest way to get this hospital to be within benchmark would be to be to eliminate those enhancements but uh I think they uh in the evidence I saw demonstrated some real thoughtfulness about what they were expanding and did it in a way that they knew that the cost um that they would be providing to patients would be an improvement from where they're getting care today um so uh that is kind of what I wanted to present for you for this hospital so interested in what other information would be helpful um in deliberating on this hospital thank you um director linberg I will um one procedural question I think I got this right but we'll do board member questions and comments we'll have a potential vote I'll read that then we'll take public comment and then if there needs to be a vote there'll be a vote that sounds correct sorry Russ I can't hear you Russ okay sorry is that better okay yeah I think what I just what I heard was board member questions comments discussion um any I guess going back to Dr. Merman's prior point if there's a need for confidential executive session um and then a motion public comment on the motion and then a vote I think that works yet great okay thanks for confirming um okay I'll open up to board members for any comment or question they may have sir this is Tom could you um bring back up the actual table yes eventually bear with me not such a boomer all right um there you go so could you help me understand the um in operating expenses where it's uh in fiscal year 18 it's 4.7 percent and uh 7.2 million dollars is that the change from prior year the percentages are changes from the prior year the dollars are amount certain so those were the operating expenses yep thank you was having trouble thinking of 7.2 million dollars added yeah yeah okay thank you for clarifying um no problem that's it thanks okay can I just pull one more clarification on that so that's confusing to me because if it goes from say 19 which is 7.2 million dollars and then 20 yeah it goes up by 1.5 percent yeah they're the amount change I'm sorry I'm in spoke yeah yeah yeah okay yeah so that it is the amount of change sorry um sir could could you remind me I think I remember but the um investment in access improvement can you describe that a little bit more for me again yeah sure um so investing in primary care finally staffed up uh since uh the pandemic uh so really trying to enhance the productivity among primary care providers and then they're also looking to provide more cardiology and oncology services locally and really coming up with some neat ways of implementing some particularly oncology plans from uh from uh you know out of uh out of state providers that able to administrate those uh or administer those locally right okay thanks um I have nothing else the only comment I would make is that you know a hospital is containing costs and has high quality and is doing well we want to see them making investments to do more of it so I I don't have any um concerns with the budget as proposed maybe others do but I'm okay with this one yeah I'll just jump in and say you know Southwest has always been a very well managed hospital and really good stewards of Vermont's resources evidenced I would say by their complete avoidance of traveler's costs they figured out a way to avoid traveler's costs and an error when most other hospitals couldn't do that um their costs per adjusted discharge really low their employee costs have kept pace with the ECI growth um five-star hospital leap prog A rating you know quality is really high and they're managed to do that with low costs so for me um this is a hospital that I think you know the budget was reasonable the assumptions seemed reasonable to me and um we should applaud them for their cost containment efforts and the culture they've built there that allows them to retain employees and not rely on travelers so I would support approving this budget I agree with everything you just said Jess and I just want to throw out a few things that I want to highlight that I do think we just sort of need to keep an eye on um on the Medicare cost report they do have high admin costs as Sarah mentioned but they have this amazing ability to balance that with a low adjusted cost per discharge so I think that you know it's something for us just to keep an eye on over time and and make sure that relationship is maintained the other thing I would like to point out is that the recent partnership with Dartmouth Hitchcock um may have increased costs over time and I think as a care board we should keep an eye on on what the cost of consolidation is to to the providers to to Vermont and to that region but I also am hopeful that the way they're doing it is actually going to lead to increased access and increased services for the community in southwestern Vermont um and so just things to think about things I'd like to keep an eye on in the future but overall you know this budget is just over you know the recommended benchmark the cost can uh operating expenses um managed to be contained it's not asking first a large rate increase especially given the climate we're in so I I support it similarly um I think it's a an organization to be applauded for the effort um but as with Dave's comment that the admin to clinical ratio um is not where we'd like to see it but I wonder if they could help us unpack that number a bit further if we could ask in our order to clarify that measure how they calculate it what goes into that measure every organization has some discretion in what they put in line five in the cost report so helping us understand that um I think it's a type of organization to learn from so I support it um otherwise without one request I support the budget as well and don't have anything further to add great I'm happy to make the motion if that would be helpful I if yeah if you'd like to I think it sounds like there's consensus and um I will just point out I recall the testimony being pretty specific as to the cost savings efforts that the affiliation was intended to drive and um you know that is something to make sure and follow through on and and to hold accountable but I think the intent was there and they actually sound like they had a pretty good plan they're speaking about some of the redundancy they're going to make more efficient through the affiliation so I'm looking forward to seeing that come to fruition and sounded like they had a good plan on that um so yeah member lunch you want to make the motion that that'd be great great so um before I do that Sarah I just want to make sure I have my numbers that I have in front of me correct I think the mpr over the two-year period is 8.96 percent would you prefer I round that up or are we good with 8.96 8.96 is fine okay and the problem before you get into the specifics this I just want to address Tom had mentioned wanting to have as part of the budget order um sort of an accountability of the admin to clinical ratio I guess I just want to confirm Tom would you be okay if I was outside of the budget order do you feel that that should be part of the budget order and part of this motion um I defer to uh our council and chair I'm not I don't have a specific um request for where it is I think it would help us so whatever is most appropriate I'll give my quick reaction if you go ahead well I was gonna say I did the board could take either approach I um um hospitals are generally pretty responsive to our requests to help understand and unpack um data and cost reports so I don't think um you know it um let me give you two responses um one is that you know we we can and do ask for information from hospitals without having it as a specific um called out as a specific condition but we do have in the standard conditions that the board is considering a requirement that the hospital shall file all requested data and other information in a timely and accurate manner and then separate from that the board does have authority under statute to collect information from hospitals so I think I'm inclined to say that we could accomplish that goal and get that information from the hospital without specifying that particular piece of it in the budget order uh conditions but having said that um I could defer to the board if um you thought it was important and wanted to call it out specifically as a particular condition I'll just give my view as one board member which is the hospital has done really well at containment so even if those admin numbers are not where we want I know I you know there's some judgment here and I feel the culture is very collaborative with southwest and that they'll give us what we need and they're going to shoot us straight like I just have that feeling that we don't need it here would be my reaction I guess I just trust that we'll get what we need yeah and they've already kind of helped us understand it from their perspective and I think the work is kind of trying to um integrate that learning across the different facilities that all sounds good to me okay so um and Sarah the change in charge that I had noted was 9.5 is that am I correct so the charge will be from 23 to 24 so that is 6.6 oh thank you okay here we go I move that we approve southwestern medical center's budget is submitted with a 8.96 percent increase from fiscal year 22 actuals to fiscal year 24 budgeted NPR FPP a 6.6 percent change excuse me charge increase from fiscal year 23 to 24 and that the budget be subject to the standard budget conditions that we will approve next week I'll second all those in favor please say hi hi hi thanks did you want to take public comment yes sorry I'm sorry I wrote it down to I apologize um all right well thank you for the motion in the second and I'll first turn to the healthcare advocate and then to public comment thanks chair foster nothing from us on this and just to remember Walsh's comment the admin to clinical ratio I think it could be something we think about with the guidance maybe formalizing that more in FY 25 but yeah we support as we said in our recommendations we support it thank you okay in a public comment via the raise your hand function uh mr d and just for the record I believe you're the ceo of southwest please go ahead that's right thank you um chair and I just wanted a thank the board for their support and please know we will respond quickly to any requests on any further to break down information necessary on the administrative cost and for Dave your comments on the on the integration with Dartmouth Hitchcock certainly well taken but are clearly our strategy and vision is the help to make ourselves our operations more cost-effective under that's integration strategy so we welcome further review um next year thank you great thank you for your comment any other public comment okay um and we had a second so all those in favor please say I hi hi hi and motion carries unanimously thank you very much um and I think we can move on all right um moment while we shift gears um so next we'll be discussing northwestern okay so same template um sorry just had the clash in my head for a second um so here we have northwestern medical centers so uh you can see that over time the board has made adjustments to northwest uh submitted budget um so there was a minus 1.3 percent uh adjustment in fiscal year 18 and a minus 4 percent in uh adjustment downward in fiscal year 21 uh of note that budget already came in as a negative and the board further uh further uh adjusted that downward um also of note uh they were one of the only hospitals that submitted a budget within benchmark last year but if we looked at the two-year growth rate at 10.3 percent they are a smidge above the guidance of 8.6 um looking at their commercial NPR over time um the board actually uh made an upward adjustment in 18 that had to do with some uh late breaking information in the budget process that year um but there was a downward adjustment again in fiscal year 21 of negative 7.7 percent in the approved budget so that's where some of that adjustment came from um and then some adjustment after the board's decision uh related to um they took it upon themselves when the final Medicare rule was higher than they had proposed to give themselves a bit of a haircut to account for that um so operating expenses were adjusted a little bit upward um in fiscal year 20 um if memory serves that was uh mostly COVID related um and giving kind of more room for some of the unexpected uh expenses that hospitals were facing that year um and then looking at the rate increases um that were submitted over time you can see again in the years where the NPR was adjusted uh those rates were adjusted downward uh to the tune of negative two and a half percent in fiscal year 18 and a negative 8.1 percent adjustment in fiscal year 21 um you can see that the commercial weight um of the increases um was a little bit higher in fiscal year 21 but generally was um you know within the range of about two to four percent um if approved is submitted um that change in charge would be um 6.0 for the two years um so a little bit back loaded um for the two years um but only about half of that is kind of uh being reliant on the commercial uh pair mix um looking at their actuals over time again uh so these are got that clear changes in rates and amount of money so seeing that their operating expense growth um had been a north of five percent up until 2020 but has been below um you know close three or almost or near that or under um since so pretty impressive uh management of the operating expenses um also you know seeing a lot of volatility um in the pandemic um and seeing that recovery starting to kick in in fiscal year 23 um have a relatively higher proportion of commercial payers and their gross uh pair mix and again uh the one that's tricky here is that Medicare advantage actually is in this bucket for them so that number is a bit deceptive and it likely is inflating some of these estimates a bit so just uh note that um so the labor expenses uh they were among the uh you know most impressive in terms of uh you know decrease in the perft compensation some of that has to do with the restructuring they're doing um but certainly within uh benchmark and below the median among Vermont hospitals um some modest changes to utilization related to places that they're trying to address access issues um and uh again don't break out the pharmacy pharmaceutical expenditures and the adaptive information but testimony showed that they were comfortably within that range um and that was based upon the group purchasing uh values that they have um in cost inflation again very close to southwest so seeing that five percent which is uh very in line with historical values uh if a bit above the Vermont median for this year um so yeah looking for some recovery um but seeing that uh most of these values again are very close to the Vermont medians uh D's cash on hand are a bit higher um than the median uh I think that that's uh as hospitals contend with the volatility in their revenue um nationally we're seeing um kind of a more interest in trying to routine that cash and uh kind of protect the ability to borrow when needed especially for deferred improvements um debt service coverage ratio um below the median but um not necessarily um a lot more volatility in this just due to kind of market conditions um in long term to debt capitalization ratio very close to the state median and the age of plant looking pretty consistent over this time period uh they were near the bottom of the at 27 percent of that ratio um of uh admin in general to clinical um among their comparators they were the 33 33 percentile which is below the 25th percentile so um you know relatively lower uh you know more investment in clinical information uh clinical salaries uh and then the CMI per adjusted discharge this is one that um Stephanie Bro and I have been kind of noodling about um what might be going on here but uh just trying to learn more about that indicator as it is manifesting at northwest but uh near the bottom number nine so i'm getting towards a little bit above the midpoint um among vermont hospitals and among their comparators at the 96 percentile so pretty close to that 75th percentile or i'm sorry a little bit north a little bit higher than the 75th percentile among their comparators um and then when we look at uh the um commercial cost per discharge we see that they over time um are kind of relatively uh stable near the 75th percentile and cost but also see this cost coverage so um they are not getting the costs covered the medicare allowable cost covered by the commercial rate some of that um in recent years has um you know improved a little bit but um seeing that at 76 percent is um not necessarily common for commercial cost coverage and looking at their standardized price they were below the 25th percentile on inpatient on the outpatient side we see a stable trend but here they're um towards the 25th percentile over time um with the cost coverage being uh more favorable um but declining uh in uh you know getting back to around that 200 percent of the cost so the medicare allowable cost being at the 25th percentile they're able to cover about 200 percent of that cost um and seeing here they're right it within the interquartile range on the standardized price so to me that's showing kind of um relatively low uh commercial reimbursement uh compared to peers um which you know uh put putting their uh commercial request into context which was uh I want to make sure I say this correctly oh where are you um there you are at six percent so of that six percent rate increase expecting uh 4.5 percent uh from the commercial payers so uh so that um again is kind of the summary um you know this one uh seems really clear uh they've uh demonstrated a lot of work to improve the quality and uh seem to be tackling that head on uh just we've uh received some late breaking news that they will in fact participate in all three ACO programs which um I think is a a really big deal to the communities operating up in that area so um just a shout out for uh for that from staff or from how I see it anyway so that was uh what I wanted to present today um uh related to this submission any questions comments concerns that would help the board in this uh decision sir could you keep that document up and actually uh pan back up again I just have one question for you let's see so uh on commercial NPR submitted and changed and approved I just want to understand to get this field quickly so say at FY 21 where this submitted was 11.4 percent and the change to prove is negative 7.7 percent so the board adjusted that 11.4 down by 7.7 percentage points okay so it's still a positive it wasn't they were given a negative rate but the board adjusted the 11.4 down by 7.7 so it's still okay yeah this is my one question on this I I guess I'll just start otherwise um so I think northwest is coming in very slightly above the NPR FPP target and I think largely driven by um some increases in utilization that I think is probably appropriate for the region I'm very supportive of their budget I mean I think the admin to clinical ratio that gets flagged out on the cost report is something to think about and again I think similar to what Tom suggested for southwestern that we could speak with um northwest to discuss it but I also think that that's balanced by low inpatient prices and prior low increases so in spite of having this one this one data point just seems aberrant from the rest of the trend so um I'm supportive of this this approving this budget in full same I have the same response as to as I did with southwest I'd like to understand that ratio better at this facility um and if you could scroll down a little bit uh please to the uh cost per discharge table yeah I'd like to understand this uh a little better to at this facility there's um it it doesn't make sense with the rest of the information and data points that we have um I think it's a strong uh strong submission good trends but I'd like more information from them to help understand that number yeah I I don't want to speak for um Stephanie but uh she's also very eager to get to the bottom of it so yep yeah I'm happy to work with them to try to figure that out because it's um yeah my my suspicion is there's just something um yeah it'll be good to learn more with them I don't have anything to add um I did have one question to make sure that I caught it correctly Sarah if you go up a little bit on this I think you were saying that for northwest that the Medicare Advantage is reported in the commercial right so even though the chart on the right says there's zero Medicare Advantage that's because it's reported in commercial am I getting that correctly that's correct yeah and they're uh in the process of starting to break that out in their own systems I think everyone knows that that's an important uh revenue stream to isolate so great yeah understood okay thank you I don't have anything to add I support the budget um with member wash I'm very interested in understanding more about the cost per adjusted discharge and why it's so high but I suspect we'll we'll learn more as this goes on and hopefully we'll either figure out if there's an anomaly in the data or uh I suspect given the you know the efforts underway at northwestern around productivity and around cost containment already happening that that number will come down so I support the budget as it was submitted I also support the budget I'm happy to make a motion if we're ready for them uh I think we are okay and before I do that I was remiss in in saying I did want to come in to northwestern on their equity efforts they've been a real leader in that area and we have uh some of their folks from quality and equity participating in the global budget tag and they've been very helpful in thinking about that those aspects um so I'll move that we approve northwestern medical centers budget and Sarah if you could move to the motion language please that's why I get it right try to do it try to do it I'm seeing standard budget conditions great I got it thank you uh move to approve northwestern's budget as submitted with a 10.32 percent uh increase from fiscal year 22 actual to fiscal year 24 budgeted NPR FPP taking into account the provider transfer included in their budget with an increase of six percent in charges from fiscal year 23 to 24 and subject to the standard budget conditions please correct me if I messed that up but I believe that's correct just you know for the record um that is accounting for the provider transfer so um that is kind of the yeah we typically do need to approve the right or have approved the provider transfer impact on the NPR which is why I included that in there thank you yeah yeah all right that's my motion all right I will second it and then I will turn to the healthcare advocate sorry I'll take my second nothing from us we support it thank you and uh is there any public comment uh Miss Realt? Hi I just want to thank you guys um for supporting northwestern and I want to turn it over to Peter Ray as well because I know he wanted to say a few words but really appreciate the collaboration with Sarah and her team and very very happy um to continue working with you on the admin ratio and the cost per discharge ratio because I agree there's something going on there and I really really really want to know what it is so we will absolutely get to the bottom of that great thank you um and just for the record I believe you're both associated with the hospital um but uh Mr. Wright please go ahead thank you chair Foster yes Stephanie's our chief financial officer um I definitely want to thank the spirit cooperation um we we're very very willing to come to the table to better understand those numbers as you recognize and we appreciate very diligent about keeping our costs under control while moving forward hospital quality and safety and making sure we do that in a an environment that supports equity and equality so really appreciate you taking the time to mention those things we're working really hard on and appreciate our partnership with the board and you tell us when you can meet and we'll be there so thank you great thanks um I don't see any other public comment um I think Mr. Wright's point is right I mean when you can do what they're doing in an economic and efficient way it's a benefit for our system and so I think that's why it looks like we have unanimous support and we'll take our vote um all board members and say it for the motion please say aye aye aye hi hi hi um motion carries unanimously thank you um director Lindberg I I want to take just um a three minute break if we can um and then we'll just come back and proceed so we'll come back we'll make it five we'll come back at 11 a.m. okay it looks like everyone's here so we can uh resume I'll turn it back to director Lindberg okay um so the next hospital that we will look at is Brattleboro Memorial Hospital all right hopefully that's coming through for you um so uh a few important uh differences about Brattleboro Memorial Hospital is um they have some medicare designations as a medicare dependent in low volume hospital that um uh affects the reimbursements they get through medicare so that that is kind of uh the main driver of the npr uh that we we've seen in the submitted budget so we do see that um over time uh and uh I apologize I didn't uh flag these but um over time we have seen some downward adjustments uh to the submitted npr for Brattleboro so took uh 1.7 uh off of the five percent that was submitted in fiscal year 18 took a percent and a half off in 19 2.2 percent off in 20 um and in 22 there was a downward adjustment of 2.7 percent so quite a quite a few adjustments um but were approved at the 13.3 percent last year for the two year total of 19.9 so a lot of the two-year growth is uh front loaded in the the current fiscal year seeing a lot of change uh in the commercial npr over time so again uh some of those adjustments trickled down to the commercial npr over time um seeing you know substantial growth in 23 um I'd like to point out that that is um largely driven by utilization um so they were hit pretty hard uh with the Omicron variant in fiscal year 22 and had um especially low utilization rates so I just don't want anyone to see that as a pure price because it's largely driven by utilization um operating expense growth so again some downward adjustments over time um but aside from fiscal year 20 and 23 below five percent um in the submissions um and then looking at that change in charge uh there were some downward adjustments um but again given the uh mix of the commercial payer uh in the gross revenue we see that uh by and large the contribution uh that that's making to their bottom line is is pretty minimal uh with 23 being an exception at the 5.2 percent but uh the ask for the current fiscal year would be a 1.5 percent uh change in charge which is about half a percent when you weight that by the commercial payer mix so just a lot of that uh approval was happened last year um you can see over time that uh we uh the operating results here um you know are pretty spotty a lot of volatility that's mostly because of the small numbers um but seeing that the operating expense growth has been pretty well managed fiscal year 20 being the exception due to some COVID related stuff and obviously the inflation nary growth that we've seen in recent years working on getting kind of the most up-to-date information for them so I don't have that populated for you today and the commercial case mix so again not seeing that breakout for MA so that's appearing in the Medicare a traditional Medicare bucket for now um in that commercial gross contribution to the revenue is at 36 percent for expense growth factors the labor uh per comp per FTE compensation growth was at 10 percent so the third uh ranked hospital in Vermont uh well you know just above the benchmark so seeing that uh they're kind of trying to invest in more resources locally we heard in their testimony and move away from travelers and bring some of that cost in in-house utilization again so this is a testament to uh how low the utilization was relatively in 22 so just a huge increase in utilization uh just again mostly uh due to the amicron variant and some other disruptions in fiscal year 22 um another crazy outcome for the pharmaceutical expense so that's uh you know usually you have a patient that had a very high cost pharmaceutical that moved on so um just a very volatile number in this case and the cost inflation at 6 percent is right near that benchmark um in number two uh ranked among Vermont hospitals the operating margin submitted is very modest at 0.7 percent so definitely not trying to grow too fast um from or to too high a margin uh still trying to recover in terms of their cash position um total margin also quite far below what we're seeing in the Vermont median and that age of plant uh is is pretty high compared to other Vermont hospitals at 25 years so know that there's probably some additional capital improvements uh that are going to be happening um and so for the admin uh ratio of administrative and general salaries to clinical salaries uh they were the third lowest at 16.8 percent uh right at the median uh compared to their comparator groups um or the 54th percentile um which uh the way that the the data's very skewed so that is also the 75 percentile um and then the cost per discharge is also quite low at 9,928 so um seeing they happen to be right at that same relative position and near the 25th percentile in that distribution um and then finally uh so when we look at the cost per commercial cost per discharge from the burns data we see that they were right within the intercortile range uh in uh fiscal year 18 but only had 97 percent of those costs covered their cost was relatively lower in fiscal year 19 below the 25th percentile so that drove better cost coverage um that trend has kind of continued since and seeing an improvement on the cost coverage but not seeing an improvement in cost so um one reason you would see that trend is um cost management improving um and then uh see a very almost identical pattern um on the out patient side though in recent years um seeing that creep up a little bit I think that's more as care shifts from the inpatient to outpatient setting and um seeing that their cost coverage is relatively high for commercial payers um uh for outpatient procedures but and their standardized prices within the intercortile range so um yeah I think um you know this one's a little bit funky in that the npr growth is is the highest that we saw but the commercial rate increases the lowest so kind of an odd uh mix to see I don't think we see that pattern every day so I think there's a maybe a lot of questions here so want to understand what will help you make your decision on this uh this particular submission um I have one quick one um Sarah before we turn to the other board members but you go to the age of plant one there's just a number that jumped out at May so in 22 actual it's 15.7 but then it jumped up to 16 and then 23 year to date 26 and then 24 submitted 25. I just didn't quite understand how those ages can fluctuate so drastically. Yeah let's uh look into that because uh yeah that jumped out at me too and I didn't get a chance to go back to the record on that one so uh I cannot take that as homework. Okay I'll turn to the other board members. So Sarah on the utilization and the npr growth so when I look at the profit and loss statement that was in the submission it looks to me like from at least at that time um 23 budget was 105 484 860 the projection at that point was 106 227 721 and then the submission was for 111 164 182 and that the fiscal year 23 to 24 budget to budget was 5.4 percent so it seems like the the growth from 23 to 24 it would be a little bit less than that from projected to budget exactly yeah um just that just helped I just thought I'd say that out loud because that helped me kind of follow the 22 actuals which are skewed because of the COVID issues that they had with their staffing early in 22 um so that's all I just wanted to make sure I was I wanted to say that out loud and just make sure that would still seem to accurate yeah no that that's a really good way to kind of frame it like yeah this one really is a little bit um not like the others always hey hey Russ um I have some questions uh for you regarding this budget that I think um relate to uh matters that are confidential and I'm trying to figure out if there's a way we we could speak about them um in an executive session so um I was interested in at some point in here making a motion to to enter executive session to to discuss this if that should be now o n uh or if it should be after further deliberation I'm not sure um let's take finish board member questions and comment um actually let's finish public comment as well I think then maybe do executive session if that's okay with you okay um do you have anything else aside from the legal advice Dave uh I'm gonna hold off for now yeah any other homework for the team here um so I think uh the board looks set unless chair foster you have anything for us no um why don't we put up the motion I don't think we're gonna vote on this one today but we might as well put up the motion and just see the language and then we could take public comment um actually you know what I'm sorry I should wait until we actually have what the motion is before I take public comment so why don't we turn to um the potential executive session and I think we need two motions to do that so I'll I'll move first um and move we find that premature general public knowledge regarding legal advice of counsel at the board regarding the board's consideration of rattle borough's budget would clearly place the board at a substantial disadvantage and any appeal or other challenge may arise out of the board's decisions second um all those in favor of the motion hi hi hi um the first motion carries the second motion uh is that I move that we enter into executive session to consider confidential attorney client communications regarding the board's consideration of rattle borough's budget under the provisions of title one section 313 a1 f of the Vermont statutes attendance at the executive session will be the board members and the board's legal team executive director and staff working on hospital budgets second all those in favor hi hi hi um the vote carries unanimously um Ms. Lusher do we have an executive session set up already just keep it to you great great thank you okay um we'll adjourn this and the board will go into executive session and I don't know how long it'll take but 15 minutes perhaps okay thanks we'll adjourn and go to the second session okay we'll reconvene our hearing but it will be brief because we are going to I'm going to move to seek to adjourn because of a meeting I have to get to and I think Robin has to get to so we'll take up rattle borough and the other hospitals um on Friday and so is there a motion to adjourn so moved second all those in favor please say aye aye aye hi we're adjourned and um we'll see you on Friday thank you