 Our November schedule is also posted on our website. Scheduling update for next Wednesday, it is Veterans Day. So that is a state holiday. We will not be having a board meeting on that day. We also on the next, just to highlight on the next Wednesday, November 18th, that's when we're going to be hearing the 2020 update to the 2018 to 2022 health information exchange strategic plan on Wednesday, November 18th. That same day we'll have a primary care advisory group from five to seven. We have a meeting TBD for Wednesday, November 25th. I believe that's the day before Thanksgiving. But since probably most people won't be going anywhere this year, we'll probably, we're going to keep that on the books and we'll see how the schedule goes this month and see whether we need that or not. And that is all I have to report out today. Thank you. Thank you very much, Susan. The next item on the agenda are the minutes of October 28th. Is there a motion? Some of them. Second. It's been moved and seconded to approve the minutes of October 28th. Without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show that they passed unanimously. So it seems like today would never come. We tried to set up this meeting about a month ago and get feedback from the hospital budget process. But first we were interrupted by a nationwide problem with teams and then it was one thing after another. But we're here today and hopefully in our foggy memories we can have a good debrief of this year's process and come up with some, you know, maybe some interesting proposals on how it can be made better. So really today's about a discussion of what went wrong, what went right, how can it be better in the future? And to tee it off, I'm gonna turn it over to Patrick Rooney. Thank you, Mr. Chair. It's good to see everyone again. And yes, hopefully we can make it through this time. How would you like me to proceed? Would you like me to run through our list and then board members can kind of pick out some of those items to discuss or would you like me to go through it one by one and we can discuss one by one? Why don't you try going through the whole list but if it becomes apparent that that's not gonna work, any board member can just pop in with a question. There enough, that sounds good. And I apologize for any awkward sounds that come through. I am living and working in an active construction zone right now. So if there's any awkward noises that come over the speakers, that is me and I apologize in advance. So, okay, let's kick this thing off here. So our list is a bit of a brain dump. We made this following on the heels of the decisions by the board. We were still actively involved in drafting the orders at the time. But as we went through, we did try to find areas where we thought value had been added this year and potentially where value could continue to be added throughout the process. So that was really our focus while we were kind of dumping this all out on paper. So I'll start from the top here. We thought the board did an excellent job in adhering to the request this year to keep any follow-up questions of a technical or clarifying nature. That seemed to help keep the process moving forward. It really allowed us, the staff, to just continue to pound away at the work that was ahead of us without having to go back too many times to the well of knowledge that our hospitals in answering some follow-up questions. And we did that in a year in which we were actually requesting less information. So that gave us some hope that if we can return to the more normal process in the years ahead that we can still adhere to that because we'll have more information which should bring about even less questioning just by the nature of that. So we thought the board did a great job of getting all of their questions asked and answered when they had the hospital representatives in front of them. So we really would like to continue that in the future that if there are technical or clarifying matters to be answered that we adhere to that. Next would be the value added by the collaboration by the hospital finance team in legal on motion language. This seemed to be beneficial to the board members and kind of remove the burden from Robin's shoulders on the spot motion language. One area of improvement, we did have a couple of places where we probably need to ensure the completeness of the motion language. So still a work in progress. We felt that that really helped you all kind of frame your thoughts in a way that expedited the motioning process. So we would continue to improve that and keep that going in the future on all matters whether it be acknowledging private transfers and accounting adjustments and the overall motioning for rate and NPR growth. The budget review process as part of deliberations, we kind of changed it up this year while we were waiting for some more clarity from AHS around some of the state funds that were to be handed out. And if you recall what we did was we kind of went through all of these hospitals after the hospital presentations and we reviewed them. And then you all made decisions kind of in rapid succession after that. And that was beneficial to, that was beneficial to it seemed everyone and that you got reminders, you can take a lot of information in the very short time with all of these hospitals and we were able to compile that and review it one after the other with you all. And then when it came time to making decisions you move very rapidly through it. So that might be a benefit for the future just having to do that out of necessity this year. So we would encourage that maybe we do that again. It seemed to work. We just had a request on whether or not we're supposed to be seeing a list or if it's available somewhere. Oh, I can, here, let me share. That would probably work best. And I think we could email it out Patrick to anyone who is interested in it as you share it. I don't, so. Certainly. Okay, let me know when you can see it. We can. Okay, good. All right, let's see. Budget review process. Okay, so I'm on bullet point number four. Another one that we thought maybe deserves a little exploration in the future guide and to be breaking down the components of a requested increase in change in charge. And I've been kind of thinking about this over the last month or so, which is the benefit to this meeting being canceled the first time, is that what does the board want to begin to look at what components of a rate they are willing to accept? We had some discussions, specifically with the UVM Health Network hospitals this year. They broke out their rate request. And do we want to accept a portion of that to be a contribution to their bottom line or their margin? And do we want to agree upon an inflationary factor, et cetera, et cetera? So if that would be something the board would be interested in, we as staff would be happy to begin to have those conversations with hospitals and obviously some board members to kind of break out what the hospital is building into their rate. And then kind of a sub-bullet to that would be better definition around commercial rates and these charge requests. We continue to have health network hospitals putting forth a commercial effective rate. And the other side historically has been requests to increase charges. And they're two different measurements and maybe it's time to decide which one for keeping track of these types of things and better defining overall what the board is expecting. We have the UVM hospitals who use that commercial effective rate, which from what we understand is they go back to their commercial payers and negotiate a better margin on that book of business. And then we had other hospitals who used it but in the sense that, well, we're gonna increase our, we wanna increase our charges by this but effectively what we will end up with is something else. So those are two different approaches and we probably need to define that and decide how we wanna move forward. So that we felt would be a value add to the process as well if we can hammer that out. Another one was the impact of public payers on the change in charge. And could this be built into the point we just made about breaking down the components? Do we wanna have an other payers offset? If someone's requesting a 5% rate increase but for not the increase in either Medicaid or Medicare rates, it might be 5.5 or six. How do we wanna see that moving forward? It seems that some of the critical access hospitals will tell us that due to cost report settlements, there's an impact on their request for the coming year and so on. So just kind of building that out a little bit more as part of our process. Another one that kind of came to the surface this year would be the, and maybe looking at it in the future be having hospitals disclose, materially supported dollar transfers to and from entities not within the hospital, including the dollar amount anticipated. The fact is we live in a post Springfield world and there were transfers going back and forth between the hospital and the FQHC, et cetera. It would probably be prudent of the Green Mountain Care Board to at least inquire as to what those are anticipated on being. So moving forward, working with the hospitals and stakeholders about what that looks like. It does not mean that the board does not support that. It just means let's put a new set of eyes on some of the activity that's going on there to ensure that these organizations are stable and sustainable and that these transfers are not injuring one entity to support another and so on. So maybe opening that up a little bit or unpacking of this, we often say. More guidance on change and charge and how we want to approach that maybe that's something that we can build out in the future and that kind of goes back to the components of the great request becoming a little more explicit around what the board expects for change and charge that way both hospitals and the board know what to expect. Another one we've been thinking about lately is taking a better look at fixed versus variable costs. Cost is always a big topic in the budget meetings and maybe we need to start looking at where do these hospitals draw the line on fixed versus variable? Where do they have potentially room to reduce their expenses? But in all reality, it would probably help the board to see what their level of flexibility is. So if they have high fixed cost, is that determined by their designation, et cetera? And the services they have to carry just again, educating and getting more knowledge around some of the operating costs that these hospitals incur. And kind of a sub bullet to that too is maybe trying to get a better understanding and unpack some of the, we'll call them hidden or stealth costs that are being incurred by these hospitals. We heard from Mount of Scutney. They discussed the border situation there and in the last month, as most people know, we've been engaging hospitals in sustainability plan meetings and this topic has come up over and over and over again. And hospitals are not, and nor will they, nor should they turn these people away. But they're getting care, but are they getting the appropriate level of care? We'll use an example of a psychiatric patient that comes in, but there's no beds available for the long-term care that they need and they end up in the hospital. So can we begin to show some metrics around what that looks like for the hospitals, whether it's costs or whether it's average length of stay and how many do you have and really show that perhaps there's an opportunity there throughout the state and maybe even dovetailing that into the all-perry model to begin to help hospitals solve some of these issues that they're having and getting people the appropriate level of care that they may not offer at their facility. So potentially we could begin to uncover some of those hidden costs. Also, this seems to come up almost every year we've received budgets and then Medicare or Medicaid will release their rate decisions or reimbursement decisions. And how do we want to approach that moving forward around those public payers? Because it seems like every year CMS comes out and says, well, we're gonna give 2% this year and it's gonna have X billion dollar impact on the hospital industry. So is this something that we want to figure out how to use in rate decisions or do we just need to accept the fact that with the timing that's probably not gonna ever become part of our work during budgets. So trying to reach a decision on something like that just so we either address it or we move on type of scenario. And the next bullet point would be strengthening guidance around NPR growth and the application of the guidance around that. And if NPR is the route that we wanna go continue to build out our expectations around that. The next one kind of goes against that with some of what we've talked about around inflation components of a rate, the matters of cost at these hospitals. Do we wanna continue to use NPR or do we wanna begin discussions on moving away and maybe looking at expense growth and trying to build in inflationary factors around that? Because obviously these hospitals want to cover their costs in total and they also wanna make a margin. So maybe we can arrive at some new measure in the time period before we get to the payment reform goals that we have in the state and moving away from fee for service. So something to put on the table there. If expense growth is the driving factor then maybe that's what we want to measure and build in inflationary factors to see what that growth looks like and then hospitals will need to get the appropriate level of NPR to cover that. And maybe we can have benchmarks around margins that they have to manage to. That's probably a bigger item for long term, maybe not next year, but we began to see some of that kind of trickle up this year during our discussions. Another one would be a matter of procedure and that is starting the deliberations with the UVM Health Network Hospitals, specifically the Medical Center. Because of economies of scale, it bends the metrics as we all know. It's also probably the most, and this is not to be derogatory towards any other hospitals, but it's probably the most important decision that you make. And if we address it up front, you're mentally more fresh to tackle a bigger, more complex budget. And there's also the fact that it does bend those metrics, the NPR growth, et cetera. So do we want to consider kind of flip-flopping what we do now and taking on the biggest hospital in the state first and then move our way down the line for the remainder of the hospitals? And the next bullet point kind of dovetails into that as well, which may be pooling hospitals into critical access, PPS, academic medical centers. Their reporting requirements are different at certain levels, their reimbursement models are different. Do we want to begin to kind of cater the process to those designations and look at them that way instead of kind of the more broad brushed approach that we do now? Again, that may be a more long-term big picture, but that's just an idea to put it out there for discussion. Another one was understanding the fixed perspective payment impact on payer mix and reimbursement ratios. We really don't have a whole lot of clarity around that yet and that's something that we need to build out. Again, that's just one of those value add items that certainly would need a lot more discussion moving forward as the all payer model continues to grow. Another one that we heard last year in the budget guidance discussions from a few hospitals where a certain portion of their rate request is going to pass down into bad debt and free care and do we want to get a better understanding of that? That can probably go into that components of a rate request piece if we choose to go that route because inevitably some of that money is going to go to bad debt and free care. So if they're getting a 5% rate charge increase, what is that actually after the factors of bad debt and free care? So that's probably something we'd wanna have more discussions with the hospitals on. The next one was some of the relative pricing models. I believe we had a hospital this year that pointed that out. Do we wanna try to build that out a little bit for the board to inform you better as you work through this and finally, and this is not irony. I had this written down when the system crash was that we really liked the virtual board meetings. It saves a lot of time. It was very effective, very smooth. And we think that that could be something in the future that the board adopts as opposed to some of the traveling board meetings. So that concludes our list. We put a lot out there but some of it is obviously a little less explicit than others. And some of it can be short-term fixes and some can be long-term items that we tackle down the road. But with that, I will turn it back over to you, Mr. Chair. Thank you, Patrick. Board members, do you have questions or comments for Patrick? Can you guys hear me? We can now, yes. I think on my internet working now, my speakers aren't working. I feel like Jeff, she always has to call in. So I have to call in and I'm on my computer. Yeah, is this where we're gonna be doing our comments, Kevin? You can actually choose if you wanna do them now or if you wanna wait till after you hear from Mike Fisher and Jeff Thiemann. Okay, I can wait then until after. Okay. Does any board member have any questions or comments at this point in time or does everybody wish to wait to hear from the other two? I'd rather wait. I'll wait here. Okay. So next we'll go to Mike Fisher. Mike? Let me try and unmute myself. Well, thank you and yes, thanks for finally, good that we were finally getting to this meeting and I do, I guess I do wanna just appreciate the moment we're in and just recognize it. Not only the election that has many of us distracted today, but also the COVID crisis we're still in and I also, I really do also wanna recognize the tremendous challenge that UVM Health Network is in with their network incident. Some of you may know from our legal aid had a similar network incident not terribly long ago and it is incredibly difficult and I appreciate that it is leading to a tremendous amount of work and a tremendous amount of lost nights of sleep and so on. So and that sort of does lead me to the, I think it's worth saying that in these moments we really all do need to recognize that people are doing the best they can and take a deep breath and give each other a break, really. And I don't say that just because now I wanna be extra hard on everyone. I really do mean it. So I appreciate the list that Patrick just went through and there is one aspect of what I wanted to say that is in some way similar. I think that over the last couple of years the board and board staff, well, I do wanna say that I really do appreciate the board staff effort in hospital budget process. There's a tremendous amount of work in aligning data from different hospitals and attempting to put them in such a way that we can compare them. That, so real effort's been done, real improvement has taken place and it continues to be a challenge from our perspective that we ask a question or the board members ask a question and we're not sure that the answer is being given from hospital to hospital in a way that's comparable. So commercial costs as a percent of Medicare are hospitals answering this question using the same benchmark. Various approaches to ACO reserves is bad, how is bad debt counted against commercial costs or spread across all categories? When is hospital data provisional and when is it final? These are just a few examples and so we appreciate that every hospital thinks of itself as not comparable to anyone else that they are individuals and they are yet if we can't compare the data to each other it makes it very hard to measure how hospitals are doing. I do have to go to a high level for a minute and ask the tough question with the hospital budget process and along with the other tremendous efforts that the board undertakes to regulate this healthcare system, are we having an impact on the cost to Vermonters who need care and coverage? And so I know that's a challenging maybe an existential question but it's an important one. For me it's a lot of effort on your part and on everyone's part and I appreciate that the board can and will and should present the amounts that you've trimmed budgets and rates over the years and I appreciate how much of a burden that the process has on the hospitals and others but at the end of the day I think from my perspective we don't experience enough of a downward pressure on the cost of Vermonters when they need coverage or care it's a little bit of a higher message than higher level than I know you were looking for here but I felt the need to say it and I fully recognize the arguments. I fully, I heard UVM of just a few weeks ago say how much the costs were out of their control with pharmacy and personnel and I also heard Marilyn Bartlett from Nashville speak to you the other day we had a follow-up meeting with her just yesterday and even if I take a giant step back from the details of her presentation it presents a picture that there's more room that there's more room for us to be putting downward pressure on the costs. And then I won't go down the same track that the old executive pay track. I understand how small executive pay is compared to the cost of care but I do think that it tells us something about these organizations. When I look I'm not just talking about C-suite employees I'm talking about even significantly further down the hierarchy when we compare what people in the healthcare sector are being paid compared to people in the human service sector it's twice or three times as much. And maybe that's a statement that the human service sector needs to be paid better but I think it tells us a little bit about the culture of these organizations and I think it tells us a little bit at least from my perspective that there's room to put more downward pressure. I really appreciate the board and the board staff's efforts to create more transparency and more cooperation and we think that the hospital budget process adds to that effort and it improves that and we think it could more. So lastly just a few very specific things I think it's really important that we keep asking out loud the racial disparities in healthcare and how implicit bias is built into our systems and how it impacts people's care here in Vermont. I appreciate that the board and I'm sorry the hospitals and other entities predicted my question me raising that and I would ask the board to join in some continued focus in that. I'm fearful that we see, I'm fearful of a pattern that we maybe are starting to see that hospitals who are below average commercial rates were given increases but don't see that pressure put on ones that have averages that were significantly higher that have above average rates and we don't concern that we don't see downward pressure. I'm absolutely fearful that what was originally contemplated as a one-time commercial one-time rate increase this year due to this very difficult time we are all in will become part of the base. I know and I heard board members articulate clearly how important it was to not do that and I appreciate it and I also apologize it's hard for me to believe it. And so please prove me wrong on that. So you've heard me say it plenty of times and I'll just say it again that this is an extraordinarily difficult time for many Vermonters and we don't think they can afford it and we don't think they are affording it. We think that the impacts of commercial rate increases leads to people not getting care. People call on our office and tell me that they're going without coverage and we see the direct impacts of higher premium costs leading to higher deductible plan choices which lead to healthcare bills that can't be paid. And I continue to believe that consumer affordability presents one of the biggest challenges to the reform effort that is underway. So I appreciate the time and I appreciate this conversation and I appreciate the work that the board is under with this tremendous task and I really do mean what I said up front. And we also all do need to recognize how hard everybody's working on these efforts and give each other a little break. Thank you. Thank you, Mike. I'll give you a follow-up question before we go to Jeff. Maybe other board members have a few as well but you brought up the topic of compensation and healthcare and this isn't a new topic. Just a couple of years ago, a number of people both from outside observers and I would say from inside the ledges raised the issue similarly. And the board has never micromanaged a hospital's line items of a budget. And basically at that time, I told legislators who were inquiring that if that's what your intent is, pass a bill and say that. And again, this year, we saw at the most recent joint fiscal committee, a leader in the legislature asking Adam Greshan to make sure that the Green Mountain Care Board made sure that the healthcare profession did not see raises in the year when others in Vermont were not receiving that. And a number of legislators have contacted me again. And again, I've kind of tossed it back at them if they truly believe that, put it into a bill. And I'm not sure that it was ever the intent for the Green Mountain Care Board to micromanage each line item in a budget. But I do share your concern. I think that we are in an arms race and it's an arms race that nobody can win. So what we see is one hospital gives a 21% increase in nurses pay and then another hospital decides that their pay is out of line with that. And we certainly have heard over and over again the executive compensation questions. But it would be your intent, Mike, are you advocating for the Green Mountain Care Board to go through each line item in a hospital budget? Well, to be completely honest, Mr. Chair, I think that you would experience a tremendous amount of pushback. In fact, I think we saw something of that pushback. I saw something of that pushback from the hospital community in the context of the legislative discussion about your sustainability work. And so I don't know, I wasn't exactly saying that I think you should go to that level of evaluation of a hospital budget line by line. I was saying, hey, we can see something here. This is an input for us to be able to see so that hospitals often say, everybody who comes before you says, hey, we are as efficient as can be, you can't put downward pressure on us. If you put downward pressure on us, we will give less care. And I was merely trying to push back on that concept some to say, no, there's no way everybody is as efficient as can be. There are decisions that every organization makes and this is not easy. I don't mean to imply it's easy, but just to speak directly to it, I think we have some evidence that there's room to put downward pressure on the costs of these big organizations that are very good at, that are not evil, that are not trying to harm anybody, but their systems support themselves pretty darn well. Okay, board members, does anyone have a question for Mike? Hearing none, we'll go next to Jeff, but I'm hopeful that everybody stays on the line so that in case questions come up in the discussion following everyone that we can have some back and forth if that's what really should happen at that point. So, Jeff. Great, thank you, Mr. Chairman. As Mike Fisher pointed out, clearly we chose a day with just a few things going on. And so I'll start with that actually, because I think clearly a lot of uncertainty in our national political landscape at the moment and also here at home with what's happening at the University of Vermont Medical Center. So I just wanna say a few words about that before I move on. As you know, the hospital and the broader network are managing an attack on their information systems and cybersecurity. They're doing everything they can to address the situation, working with authorities. And I think doing a great job providing updates and information to patients and families while also making sure their clinical operations stay up and running. So I'm proud of that quick and effective response, which we should always remember starts with a singular question, which is how do we put patients first? And that was exactly what happened here. You know, at a VOS board meeting about a year and a half ago, we had the director of cybersecurity for the American Hospital Association come talk to our group. And he discussed in great detail the constant threat posed by domestic and foreign actors who seek to compromise information technology for a lot of different reasons, sometimes to disrupt operations, to obtain data, to steal academic research or to attempt to extract funds or some kind of ransom. John Riggie, that's his name, this cybersecurity expert who was also previously the director of counterintelligence and counterterrorism at the FBI, said that it's not a matter of whether hospitals will be attacked, but when they will be. And so right here in Vermont in the crazy year of 2020, we have yet another example of how hospitals have to be prepared at all times for the emergencies and situations that can clearly come their way and affect not just them, but hospitals throughout the state. I do wanna say that this morning, we had our weekly hospital CEO leadership meeting and there were immediate offers of support and collaboration to the medical center and the network as there always are in these kinds of situations. So with that as our backdrop, why we're actually here, I really do appreciate the opportunity delayed and I know it may be for us to offer some observations about the hospital budget process and what we might do to improve it. I wanna thank the GMCB, particularly board members and staff that I know it's a lot of hard work that you do an obvious preparation that goes into being ready for these proceedings and our members really appreciate that. I also wanna thank Mike Fisher and his team at the healthcare advocate. Mike does important work to be sure that the consumer's voice is heard and I appreciate his contribution to making sure that everyone in Vermont gets the healthcare they need and deserve. That's a critical role and we're grateful that he plays it. In that very spirit, I'm deeply concerned about the future of the now 10 year old Affordable Care Act, the threat to which grows literally by the moment, I fear and represents another major area of vulnerability for patients and employees as well as healthcare providers that are already managing through a pandemic that itself has actually cut coverage levels. So I think as you heard throughout the budget presentations from hospitals, they're managing the old challenges and the new ones and not just passively, but really as a key part of carrying out their missions. It's why they're engaged in health reform despite the costs and the risks and despite $209 million never coming. It's why we provide uncompensated and discounted care. It's why we advocate for policies that put patients and consumers first and to Mike Fisher's other point, it's why we're working really hard these days on diversity, equity and inclusion efforts to make sure that we're prominently in that important space. So I think it's important to ground observations in the fact that the regulatory processes of the Green Mountain Care Board are complex and hugely detailed and it can make it kind of easy to lose sight of what we're trying to do here. Which is together, improve the system and make sure that it's as good and affordable as possible. So the few observations I'm gonna make are in the form of a kind of SWAT analysis, a fairly traditional way of looking at a process, strengths, weaknesses, opportunities and threats. So let's start with the strengths. The first as I've alluded to is that Vermonters have a robust regulatory system that looks out for them. That's working all the time and keep their healthcare costs reasonable and to make sure that it's of a high quality. Similarly, the Green Mountain Care Board and my association along with all of our hospital leaders share the goals of the triple aim, which now includes a fourth dimension, the health of our workforce, which as you know has been strained across the country and certainly here in Vermont over the past several months. A second strength of our process and of the budget evaluations this year is how transparent and public they are. Nowhere else in the nation are citizens of a state able to learn so much and really participate so personally and directly in the healthcare that their local hospitals deliver. Nowhere do people get this up close of view of how the system works, where it thrives and where it struggles. So the flip side of that is our first weakness. This year, I think like in other years, the board's deliberations on each hospital's budget and including the reconsideration hearing that took place can be hard to follow. I take incredibly close and careful notes. In fact, I usually have 10 to 15 pages of notes following each of these hearings and I often cannot discern having listened to the hearing and the proceeding myself and then reviewing my careful notes just how the board arrived at a given decision. Now, as I said, I understand very well this work is loaded with arcane details and that's part of what has to be gone through to make these decisions. But a public process like this should be understandable to the public. And I would say this one is just simply not. If the experts like my team and others who routinely follow this have trouble understanding the deliberations and how they landed in a certain place, I think average citizens don't stand much of a chance. The next weakness I would mention is around administrative burden. In the four years that I've been here at VOS and part of this process, I've only seen that burden grow. I think we make changes around the edges with guidance and other procedural changes, but hospitals are required to provide more information and answer more questions. I do want to comment on Patrick's observation because it's true this year there was an exception to that in the sense that fewer questions were asked and there wasn't as much followup and that was greatly appreciated given what hospitals were going through. I think maybe the reason it's on my mind so much is that because it is particularly evident to me in the sustainability planning process, which I know we're not here to talk about today, but that represents significant new reporting and analysis and work with no new resources to match and nothing taken away from the broader process to sort of ensure that hospitals are not overwhelmed. So now on to opportunities. I think it's an opportunity for the board and hospitals play a role in this too, which I'll get to in a second to better understand and acknowledge expense structures that they're not easy to change, that they're real and that these expenses are generally what is needed to run our organizations. The notion that expense cutting can occur kind of ad infinitum is simply not reasonable. There's a floor and going beneath that floor eventually threatens patient care. It sometimes seems in these discussions that hospitals are not believed about their expenses or that somehow they're not doing everything to manage them and then political pressure enters the equation. And I think the board then sometimes feels the need to do something, even if that something might be more symbolic and more harmful to an individual hospital than it is to any kind of systemic improvement. Now our hospitals readily I acknowledge have a role to play here too and that's to make sure that they are careful and deliberate in explaining these factors. So I think both the board and the hospitals have an opportunity here to explain to one another their perspectives on that issue. I think finally we look at the threats and the first one is the most obvious to me which is the pandemic. The vast majority of the nation is red hot with COVID right now. This includes our neighbors in New England and the Northeast. And while still low in absolute terms we have three people in the ICU today with growing case numbers and pockets around the state. We all know that winter with people going inside is likely to exacerbate this situation and could even lead to some of the measures we saw earlier this year like suspending surgeries. Hospitals right now as we talked about on the call this morning are tightening visitation policies for that very reason. Another threat consists of a dramatic or unplanned change in the direction of health reform. We have to be patient with what we're already doing. Transformation takes time and persistence and cultural change does not happen overnight. The other threat is a combination of broader factors including Medicare and Medicaid payment policies, growing numbers of uninsured which is made even worse by the ACA being in peril and the constant need for us to make sure we make infrastructure improvements and can afford the growing cost of drugs. I also think that over regulation itself is a threat. I would say that not just to the regulator but anywhere. This includes burdening hospitals too much detracting from the work they really need to do every day and continually pushing down margins. It does seem that sometimes margins are viewed negatively and really without a margin a hospital is at risk of closing. We need to remember that margins in Vermont are not returned to shareholders as they are elsewhere but invested in our facilities and community health and preparedness. So just a couple of final thoughts. I think we're always working to take steps to reduce cost growth. That's our responsibility. Hospitals are involved in the work and they are also involved I think in being part of this careful and thoughtful regulatory process which is not just to regulate hospitals but to make sure that we're doing right by the people of Vermont. And I hope that we will continue to do that in a way that's collaborative. My closing comment is that hospitals simply cannot afford to do anymore in the regulatory space. We were at the max before sustainability plans with COVID our leaders and clinicians are stressed and tired and burned out. We are on COVID issues every single day, every single week. This week's meeting with CMOs was all about COVID issues even when it's not prominently in the news it is prominently in hospital space. And so with all of that going on there is literally just not room for additional inquiries that require hospitals to spend more resources and more time especially if we don't have a clear understanding of the goals achieved by asking those additional questions. So on a positive note, I have seen a lot of exchanges in the past week from my counterparts around the country who are fighting with their governors and fighting with their legislators about mask mandates, about public health initiatives and steps that need to be taken that are common sense here in Vermont that are being hotly contested around the country. We do not politicize those issues in Vermont. Hospital leaders sit around the same table once a week and try to work through all these things together and we do so with you and with the governor and with Dr. Levine. And we need to keep in mind that that's a strength and it's one we need to build on even as we work to improve this process. Thank you. Thank you, Jeff. Board members. Sure. Thank you for all the comments from everybody and I'm gonna go through a few comments and then also some areas that potentially may be an opportunity as well. First just wanna say that budgets are a puzzle and there are many pieces that need to come together to produce an acceptable budget. And certain things are required to be sustainable, certainly revenue and operating margin. We do have to have operating margin, I agree with that. And there are certain levers that can drive those budgets and I think that's where some of the regulation comes into play. Some of those drivers are utilization, rate increases and cost savings and efficiencies. So kind of with that in context and then looking at the list that Patrick put together, I will give a few comments, particularly when we talk about rate increases. And it is very clear that the commercial rate increases are pricing consumers out of the market at times. And it's also clear that hospitals' reliance on that, those rate increases vary. I think some of the hospitals really did balance both the community need and their margin, sometimes sacrificing their margin rather than putting in huge, large rate increases where other hospitals may look at that rate increase as one of their main levers that they can use to drive their operating margin and thus creating a significant rate number, commercial rate increase. We have kind of shied away from giving guidance on rate increases in the past, not one of five board members and this is where some of that process that Jeff pointed out, we all can't talk about this separately. That may be something that we need to put in next year. When we only put one variable, the NPR in there and the hospital doesn't hit their NPR and comes in with a significant rate increase, double digits in instances, and just say, hey, I'm hitting the NPR, I'm hitting what you said I needed to do and therefore I can get this rate increase. That to me isn't always working together throughout the system. So there may need to be a ceiling of putting a rate increase in. We tried this year to be flexible and put in that temporary rate increase because of the concerns of COVID and trying to make the hospitals fall. And I guess for the most part it backbired, it didn't really, most hospitals didn't request a bifurcated rate and maybe it was convoluted but the intent was to help and to make up gaps that may have occurred in hospitals. And I will go out on record, Mike Fisher to say, I do think that those should be temporary or we're gonna need to factor that in next year when we look at what rate approvals would be because the intent was that they would not be permanent. Of course we'll have the benefit of hindsight in a year, so we'll either know, did some of the hospitals that projected very low utilization, is that what happened or not? So we'll also, we'll certainly work together. You know, one of the points that Patrick brought up about what happens with the other payers because when I talk about that puzzle, I do think hospitals need to have a margin to succeed. I don't think you can operate with a negative margin and be sustainable. But should the rates come in higher for Medicare or Medicaid, I think that should be something to look back on what the commercial rate is, whether that's a delay and a year later, but again, we're all trying to get a healthy population and allow patients to come to the hospitals. And we do not know how many people just don't come because they can't afford it. And that's a big factor. And I disagree a little bit with Jeff on, I know you can't cut your way to success, but there are always efficiencies that can happen and it can never give up and let up on efficiencies. And one thing we did see, COVID has been a terrible thing that has happened, but hospitals were able to react and cut savings and programs and do things and efficiencies in order to protect their bottom line. And maybe we can learn from some of those. Maybe some of those are things that could carry for the future, but cost savings and efficiencies don't go away. When we hear from the outside consultants, we hear elsewhere people are doing things for less. So how do we do that? Just looking at a couple other things on this list that aren't on there, that maybe are things we should think about. Hospitals have brought up in the past, should we look at PMPM? Is that a metric we should look at so when we're talking to that NPR or expenses, should we be looking at that PMPM? Because if more people are coming to a hospital, that is gonna drive more revenue and if we have revenue caps, that would be an influence. So that's something that potentially we should be looking at. A couple of things I think in this process that we did well as a group is, I think we managed well with less information and we should look maybe to understand what we're gonna need in the future. Obviously we skinning down the requirements that we needed from the hospitals. And I think that's also on the board to really look at, what do we need to know in order to make our decisions versus what would we, what's maybe as nice to know or is it really influencing the decision? So I do think it's for all of us to work on, looking at the old requests we used to have to where we came out now and potentially reducing some of that. I also think we need to have a way to marry a little bit more utilization and rate information to the insurance assumptions. When we work with the commercial insurance pieces, there's a lot, a huge amount of, what did we approve from a rate request? And what went into the QHP is less than what we ended up approving for the hospitals. However, the utilization assumptions that the insurance companies had, I would say are higher than what the hospitals have. And at the end of the day, it's gonna be, the premium is gonna be a combination of the utilization as well as rate. So I think we need to make sure in the process, we're not just saying, when insurance companies say, if you gave hospital X 10% and we only allowed them 8% in their rate increase for the insurance company, the other piece of that is utilization. So again, that all catches up on the insurance pieces. It's what gets paid out and premiums come in. So we will catch up on that. Price transparency, we need to do a better job here. We talk about, this being a transparent open process, and it is, I don't see that we have price transparencies though from the hospitals. And so we need transparency on both sides of the equation here. And we don't know, I don't know, I don't have a good understanding in all cases of what the prices are in each of the hospitals, across all the payers for what they actually receive for services. So, I think we need to get a better understanding of that and what's paid for services by payer type. I do think we still need a better understanding of contribution to margins by payer type, by services and things like that. That's how businesses are run, hospitals are businesses and we need to understand that. And maybe all the hospitals do, but boy, when we ask questions about it, we don't get an answer. And then there are times when we'll hear that there's profitability where they can get the cost per service. So I think that's an area where we, yes, maybe it is more administrative burden, but that's transparency. And I think that's most of my, that's about it. I guess a couple of other things, just beyond some of these other metrics. Again, we really look at NPR. I talked about rate, maybe operating margin needs to be a factor in their cash flow, days cash on hand, as well as, again, the cost savings and efficiencies. But look forward to continuing to work through the process. And that's my comments. Thanks, Kevin. Thank you, Maureen. Other board members? So I'll jump in here and wanna thank you all for this conversation. I'm trying to kind of find the big thought to kind of organize all the factors that kind of go into this process. And for me, it's, where do we wanna be at the end of 2021 going into 2022? And we have a kind of a well-established North Star that the legislature has agreed to and the governors agreed to and for better and worse, it is the all-payer model. And so, in terms of the total cost care of the population, that's kind of an established target. And we get to that target through population health and through converting from a fee-for-service system to a fixed perspective payment system. And so, are we in a position to do that over the next remaining two years of the all-payer model? And I would say the infrastructure that we have in place, I think can work. It's not a well-willed machine, but I think it is something that can get us where we wanna go. We have a hospital budget process that we just went through and we held the NPR growth rate to 2.7%, which is highly respectable, I think. But within that, if you look at the FTP growth, it's quite slow. And FTP is the kind of a capitation system that at least the all-payer model hopes will encourage hospitals and providers to be more efficient. We have our insurance review process and we've been through the QHP process in recent months. And on a combined basis, we held those premium increases to less than 3.5%, which is consistent with the all-payer model. And now we have the machinery for this. The ACO machinery is established and it's up and operating. It's not just a concept anymore. It is the MixMaster that is trying to integrate all the variables that need to be integrated to secure population health investments and the benefits of those in the context of the fixed prospective payment infrastructure. But for me, there's a whole bunch of macro imbalances that I think we also need to address. One of them is the Medicaid cost shift. It is just very difficult for me to understand how the state can say that there will be no increases in reimbursement rates for Medicaid folks other than those that are federally mandated. And at the same time, say that that is consistent with affordability. And so maybe we need to look to kind of link our efforts a little bit to the emergency board, which every year meets and kind of creates this framework for Medicaid benefits on a total basis, a gross basis as well as per member per month. And so that we can influence that process to be complementary and not just totally independent. I learned about that directive to of no reimbursement increase just by reading the state budget. No one ever talked to me about it or maybe talked to some people about it, but it just kind of popped up. So I think that the cost shift is something that really has to be addressed. The payer mix issue where we have at one end a commercial share for one hospital is at 62% and for at the other end of the spectrum is 34%. And so, I mean, that is to me a real issue in terms of the budget, the hospital review process is who has access to the resources in the system to do the things they wanna do and who doesn't. And as Patrick's data shows that from the 2015 period to the 2019 period, 90% of all the operating margin went to one hospital. And I'm not saying that's bad or good, but it just seems in an imbalance when you have negative operations in some places and fairly healthy operating margins in others. And this last budget process of the $72 million that we distributed in increased NPR, FPP 93.6 of it, you know, went to one hospital. And that just seems an imbalance that somehow we have to think about and try to correct. I think in this last budget process, it was about 16% of all of the NPR FPP was FPP. And so that to me is, as I said, the capitation mechanism to encourage efficiencies and to, in savings driven by population health investments in terms of the commercial insurance growth in the last budget process. On an overall basis, hospitals were asking for a 4.5% increase, but one hospital was asking for an 8.2% increase. And kind of looking at, this is, you know, I think one of the most difficult areas is that Dr. Brumstead, when he presented to the board, both during the budget process and during the appeal, was saying basically that the board needs to be driven in its decisions by the expense growth of the network. And so, you know, he handed out this chart that showed that the expense growth of the network from 2016 to 2020 on the expense side was 5.8%. And I have to step back and say, is that sustainable? Can we really do that? And I don't think we can. I don't think we can achieve affordability with the state only not contributing to increases for Medicaid reimbursements and the largest provider in the state, which occupies about 25% of the total hospital spend growing at 5% or 6%. So within this infrastructure that we have, we need to kind of like, I think get a general consensus or maybe a disagreement, it could be, but as to how we are going to achieve the goals that the legislature and the state is contractually signed on to and not kind of get lost in the weeds of the details of the budget process. I mean, maybe Patrick's point about separating out the network hospitals is a good idea, but that seems to be an important one to me given the impact that the medical center has on the overall budget process. So I don't disagree with a 3.5% growth rate. That is consistent with underlying economic growth. And I've gone back and actually calculated how that number was arrived at and it's based on growth state product growth. But I think sometimes, you know, that we're all kind of like, you know, moving forward at times kind of somewhat in the dark, like having to deal with a just a surprise fact that there wasn't gonna be any Medicare increases or Medicaid increases in 2020. And so I guess I would look to, you know, this process to try to help refine in a simple, clear, large thought kind of profile as to where we are and where we want to be and is it realistic, you know, given our recent track record that we can get to where we want to go. I do think that the affordability issue is one that just gets hung out there to dry. You know, Diva with their consultant Wakeley did do a study that showed that we could address the premium cliff from 400% of poverty to 500% of poverty for about a cost of $2 million. And to me, you know, those are the kinds of things that are worthwhile doing rather than just kind of wishful thinking about affordability, you know, where there are opportunities. And this one was done by an actuary where there are opportunities to make improvements. You know, we should seize those opportunities. I'm very glad that the board agreed this year to in the hospital decisions process to raise the cost shift as many of the hospital administrators and CFOs did that the cost shift is really a structural flaw in our system that we need to address. So that's my stream of consciousness. Thank you, Tom. Robin or Maureen? I mean, Robin or Jess, sorry. I'm happy to jump in unless you prefer to go, Jess. Go ahead. Agree with both Patrick and Maureen that having a clearer sense of both informational inputs and potentially guidance around change in charge and commercial rate increases would be a good next step. That obviously requires more conversation in terms of what exactly that means and what that looks like. But I think because my sense is that we do all share an urgent concern around affordability, particularly in the commercial sector, obviously. We have more levers, I would say, in the hospital budget process than in rate review to address that concern, since rate review only applies to about 90,000 people as opposed to the charge and commercial rating requests in the hospital budget process. So I think developing that so that there's both more clarity around expectations and to Jeff's point, taking out some of the mystery may be there. I didn't feel like it was particularly mysterious, but I suppose when you're the one communicating that you never do. So I think we could figure out a way to make that process a little clearer that it's an important consideration for us, assuming other people agree with me with that. But I think in the last two to three years, if you look back at our processes, we have really taken a much more in-depth look at the commercial charge increase side of things. So I do think that's an area we could explore and should explore. I'm completely open to thinking about how to maintain streamlined or reduced information. I'm not interested in getting information that is not usable to me, but I will say that I often feel like the information we are receiving is not as transparent as it could be. And so that I think then leads to many follow-up questions. I would hate to see some of the non-financial reporting be completely lost. Maybe we haven't been doing that in the right way, but I do think that community health needs assessments are an important job that the hospitals do. And I think we did make some improvements in terms of reducing the administrative burden on hospitals by having our staff maintain sort of those in the cycle so that people were only submitting them when they were newly done and we were managing the information on our side otherwise. And in terms of quality, I think that is a big black hole in this process for us. And maybe the way that we had been trying to build that in was not the right way. Although for the most part, it was asking hospitals to react to existing metrics, not produce more obviously, but maybe there's a better way to do that. I don't know. I also, in terms of, I'm intrigued by Patrick's point around pooling hospitals into categories that's not something, I don't know exactly what you were thinking there, Patrick. That's something that I feel like we kind of do in our discussions. And it certainly when I'm doing my own personal analysis I naturally kind of look to those categories when making comparisons because of course a critical access hospital and an academic medical center shouldn't look the same and they don't look the same. So that is intriguing to me, although I'm not sure exactly what you were thinking. So we need to think about how to do that. To Maureen's earlier point around transparency, I do think that we've tried in the last couple of years to get at least a little bit better sense of relative pricing across hospitals with the new federal information that's coming out early next year that may produce a lot more information that I do think we should try and figure out how to incorporate because it is helpful. I think that one of the challenges in this process is that we tend to set our metrics purposely in a statewide system level and then tailor an individual decision to an individual hospital circumstance and budget pressures, which do vary substantially across hospitals even within the same categories, quite frankly. And that I think is kind of the push pull in this process is maintaining that system wide perspective but also ensuring that you are really looking at an individual entity as well and being tailored to their specific situation. I just will, because Jeff brought up the sustainability planning and obviously I'm not involved in that until it comes back to the board again as a whole in our public process, but I'll just say that we've been talking about the concern around sustainability for a long time now. I think our panel around hospital sustainability will be two years ago and next spring, maybe, and I may be a year off there, I'm not even sure. And certainly from my perspective to the extent that hospitals are engaging in that, we would like to understand that process as opposed to create new requirements, at least that's how I feel, but that information is not transparent to us. And so I think on the flip side, I have not particularly, and when quite frankly hospitals are in financial trouble, I don't see a lot of creative thinking happening. Now, maybe that's just not being communicated to me and that's why I don't see it, but I think that's what at least I was hoping for with the sustainability planning is like, it's all trying to put our heads together to think about how we can maintain our hospitals and maintain affordability because that would be the gold standard. I think what we're seeing in other states is there might be more affordability, but there's also less access as a result. And to Mike's point, I think Maryland's tools are, and Nashville's tools are really helpful and interesting and we should think about how we can use those to provide more transparent information. On the other hand, the approach there in Montana was to require consumers to travel a really, really long distance in order to get care that was considered to be the greatest value, which is not necessarily good or bad, it's just culturally, I think that might be a stretch here. So that would be a huge cultural shift here. And also I think somewhat inconsistent with what, at least the HCA has talked about in the past in terms of ideal travel times and that. So those are my thoughts. Thank you, Robin. Jess. Kevin, do you mind if I quickly interrupt? I apologize, but I have to leave at 2.30 to get on another call. And I was wondering if I could just make a couple of responses and Mike Del Treco will stay on to continue representing us after I leave. Okay, go ahead, Jeff. Okay, thank you. Just to a couple of the points Maureen made, I think just to clarify, I was not saying that hospitals cannot find ways to continue to find efficiencies and reduce expenses. I just think we need to acknowledge, as I said, that that can't be sort of an ad infinitum exercise that doesn't end and will eventually cut into bone, which then makes a difference in what services are available. And then I liked what Maureen said around, there's a possibility of managing well with less information. And she said, you know, what do I need to know versus what's necessary? We used to do an exercise in associations called nice, but not necessary. Things that are interesting or provocative, but don't necessarily fuel the process. And I think that's a valid sort of way to look at this. And then with regard to Tom Pelham, a couple of his comments, I think sometimes what we do in Vermont is we tend to take federal or nationwide problems and express them in Vermont terms, which is not wrong, but then think that somehow they're unique to us and they're not. And we're not capable of single-handedly addressing all of them. We, I think we're doing amazing work on all of the areas and just to name a few, insufficient reimbursement is certainly one that affects all of us across the country, affordability and premium inflation. The difficulty of participating in advanced alternative payment models and the challenges of doing so, certainly I think we're miles ahead of what's happening elsewhere in the country. Workforce, the cost of drugs, commercial rate increases to manage expense growth, those things are happening everywhere. So I just think it's important to understand those are not Vermont specific. And then the last thing I'll say with regard to Robin on the sustainability planning, she said one of the objectives or to her the main objective is, how can we be sustainable and maintain affordability? I don't at all disagree with that. I just think it names yet another objective for this work, which has already been at least five or six or seven other points of the work have already been named. So we can't boil the ocean. Whatever we do with sustainability planning, let's be clear about what we can reasonably accomplish. Thanks. Thank you, Jeff, Jess. I'm gonna be off the hook with Jeff's comments because he has to go. So let me start a little bit with 40,000 feet up. I do think that we did a skinny down version this year and I think that we can learn a lot from that. So how do we manage with less information? If the information that we are receiving is enough for us to make decisions. So I think we should look back on what we actually received this year, what we did not receive and do we need to really make sure that we have all of that information to the point about the administrative burden. I get that. And then the other kind of 40,000 foot comment I'll make is that I think there's two approaches here. One is to continue to put numeric measures on guidelines like we have the 3.5 on NPR. We could, I think there's probably too much emphasis on that one number. And I think that we may wanna either add more guardrails around commercial rate, for example, so that hospitals have more information, more direction in the budget process since we do seem to be making decisions around commercial rate. We could potentially put more guardrails around that and I can talk about that in a second. There would be fewer surprises here, but there also be a little less latitude in instructing that budget. The other approach could be to basically think about, to some degree what Tom was saying around, we have an all-payer model, we have payment reform goals, we have quality goals, we have financial targets that we have to meet. We could potentially just say, hey, these are the state's goals under the all-payer model, submit a budget consistent with achieving those goals and give a little bit more latitude for the hospitals to submit those budgets, but the recognition will be then there's gonna be more surprises potentially because there's fewer guardrails. So I think that's a conversation that we could have. I think there probably is too much emphasis right now on NPR as the target and if you meet it, then your budget is approved. I don't think that's what the board intended with that particular guardrail. So I think we need to be clearer on that as we go forward. Others have talked about the commercial rate. I think a couple of things. I think the commercial rate requests have to be, first of all, better understood and more consistent across hospitals. We really need to truly understand what is the effective commercial rate ask here, not what is change in charge, what is the effective commercial rate? How is it gonna hit people's pockets? So we need to have an apples to apples comparison when we have our hospital budget process, we have two columns, one for the network and one for everybody else. And I think we just need to make sure that the information we're getting is consistent across all hospitals. And I think to others points, we absolutely need more information on the base rate. We are operating a little bit, we talk mostly about rate increases, but we don't know that rate increase upon what base are we talking about? So we've tried to get at some of this and in part, the healthcare advocate has been helping with asking about commercial to Medicare ratios as one mechanism to understand what is the base rate here? The sustainability plans have been asking about, we've gathering information from the cost reports on charge markups and private price ratios. These may be mechanisms to understand what the base rate is. If the federal government does that rule goes through in January, we will get a lot more information about the hospitals. I don't know if that's actually gonna go through, I know it's in the courts right now. So I think we need a mechanism, I would just argue strongly, we need to understand the base upon which these rates are being applied and we need to figure that out through either using the cost reports, using the commercial to Medicare ratios, getting that data somewhere, getting it from the insurers, I don't know. But I would really, I think we need to understand that better. So we can make better decisions. I would also say that I liked Patrick's idea, this was something I've been thinking about breaking down the commercial rate request into its component parts. We tried to do that a little bit this year. I think we need to understand, first of all, I think we should be asking the hospitals about their medical inflation. We need to ask them, break down for us, what is your wage and compensation growth gonna be? And what percentage of your expenses are wages and compensation, right? For most hospitals, wage and compensation growth is the vast majority of their expense growth, right? This is a service industry. That's where their large expense growth is coming from. So understanding what that is, is it a market adjustment? Is it COLA? What's happening in that line item? And then understanding pharmaceuticals, we understand pharmaceuticals are an expense that a price inflation that's beyond the hospital's control. So what are the anticipated pharmaceutical increases and what component of their expense budget is that? From the hospitals this year, that was a smaller component. It was about 10% or less for most hospitals. So while the rate increase or the inflationary pressures of pharmaceutical drugs is high, it's still a small component of their expenses overall. And then there's non-medical expenses, and there's also medical supplies and non-medical expenses. So we really need to understand what that is. Some of it is beyond the hospital's control. Some of it may be in the hospital's control. We need to understand that. And then, so that's one component of a commercial rate increase, for example, might be, hey, we gotta cover medical inflation. There could be other components to it and we need to understand that. One might be, hey, we gotta cover medical inflation for the public payers that are not increasing their rates in conjunction with medical inflation. So effectively the cost shift. What component of your commercial rate increase is effectively covering the cost shift? And then finally, what is the component of your commercial rate increase is trying to increase your margin? Those are the three components that I can see and we don't have a good sense of how that breaks down. And I think we can do a better job of asking hospitals to break that down for us in a way that's consistent in apples to apples across all hospitals. And I think it would help us if we really are gonna be thinking about what are reasonable commercial rate increases. So I would also say, and this is to a point I think Maureen made, if we're gonna continue to rely at all on NPR, which is price and utilization, we absolutely need to understand patient migration because there are hospitals that are seeing inflows of patients that's gonna drive up utilization and there are hospitals that are seeing outflows of patients that are gonna see a decline in utilization. So it doesn't make any sense to just have a fixed NPR amount without somehow accounting for patient inflows and outflows. So we need to do a better job on that. We've talked about it before, but somehow, and we're getting closer because I think our data team has been really looking at this a little bit. So how can we incorporate that in our analysis next year if we are gonna be looking at NPR again? I still think it'd be helpful to understand in state and out of state because border hospitals have different patient flows and to the degree that we're mostly concerned about cost to Vermonters, inflows from out of state, I think about as medical tourism, that's helping the bottom line and it's not costing Vermonters. So how do we think about that? We've never really gotten our handles or hands around that, but I will add that to the list of information that would be helpful. I think that benchmarking, which we're getting at with the sustainability plans will be helpful as we go forward with our hospital budget process. There's a lot of metrics that now we're looking at that we're trying to find appropriate benchmarks for that we can bring into an import into our hospital budget process that I think will be useful and it will allow us to break down academic medical centers compared to other academic medical centers, PPS hospitals compared to other PPS hospitals and critical access hospitals compared to other critical access hospitals. So I think that is gonna be something that will hopefully be a holdover or an infusion of information from the sustainability planning that I think we should bring into the hospital budget process. The quality work I think is interesting. I think one of the things that's come through with some of our sustainability meetings is NISQIP. NISQIP used to be a quality reporting service that hospitals participated in when there was funding for it and it gave a lot of information about hospital infections and surgical information around quality, around surgical recoveries and surgical infections and all of these sorts of things. Some hospitals participate now, others don't. I wonder whether we might explore further having all hospitals participate in that and allowing that cost to be in the budget. So allowing that, there is a cost to it, although if all hospitals are in, there could be a statewide discount for that, but I think it's worth exploring to have more information about quality because I do think we could benefit from more information on that. And I think it would be helpful. There's also lots of learnings that can happen. My understanding from the hospitals that participated in it is that it actually has impact on the delivery of care. That information is impactful for how hospitals deliver care, which ultimately is what we want. What else is on my list? My other, I think it would be helpful to have a reconciliation of what happens we approve commercial rates in the hospital budget process. How do we then learn about what happened after the fact with the negotiations with the insurance companies? How do we reconcile what happened in the hospital budget process with what was ultimately negotiated and then therefore how do we reset the base price? How do we understand what the base price is? Is there really truly negotiations happening or is what the board is setting as what we believe as a ceiling, is that ultimately what gets negotiated? That would be information that I think would be helpful for us to have. And then I just wanna say about impact, and this is a little bit to your point, Mike, about how do we figure out the impact of the budget process? And I think the impact of the budget process is always gonna be underestimated because we don't know what the hospital budgets would look like in the but for world without a hospital budget process, right? The hospitals are submitting a budget, understanding those hospitals that those budgets are gonna be scrutinized and be fully transparent. So whatever the impact of the board on the ultimate decision of those budgets is gonna be underestimated with what would have been without a board process and we'll never be able to calculate that. So I just wanna say that out loud because I don't think that's always considered when people talk about the impact of the board on hospital budgets. They're submitted knowing there's a board process. So I think that those are my comments, but I really also wanted to appreciate everybody's comments and everybody's thoughtfulness and we're always iterating, we're always trying to improve and hopefully this will be another iteration. So those are my thoughts. Thank you, Jess. So I'll just chime in here a little bit and let me start by saying that I'm proud to be a regulator in Vermont. And I say that without reservation because I think if you take a look at any indication of the quality of healthcare in states around the country, Vermont always ranks near the top. And I take very seriously our role in ensuring that Vermonters have access to quality care. At the same time, I do think that we have failed somewhat in our specificity and it really gets down to the guidance because I can't blame a hospital who plays by the rules of the game and comes in with a budget that meets everything that is in the guidance. And I think that the guidance is where we really need to focus and try to do a better job of getting better information. I don't agree with everyone that believes that this is an entirely transparent process. I feel sometimes like I'm making decisions in the murky underwater because we've all been in the situations where a hospital has made the arguments that they have received one of the lowest average increases in rates since the inception of the Green Mountain Care Board in that you then look at their total cost of care and it's way above the state average. And so I think that what we really need to be doing is taking a step back and looking at the bigger picture. And the bigger picture is that we want every Vermonter to have access to high quality care at the most affordable rate possible. And in order to do that, I think we have to really focus more on what that total cost of care is and what the quality is in a given area. And at the same time that we're doing that, I think that now more than ever, we have to go back to what we were doing a few years ago because during COVID, unfortunately, it's a natural reaction to preserve yourself and your organization. And I think that even though from the beginning of my time on this board, hospitals and politicians and everyone has agreed with the premise of moving away for free from service or volume to value-based care. But I do think that when you're forced with a situation like everybody is forced across the country right now with dealing with a pandemic, or if you take Springfield as an example, when you're forced with a situation where your doors may close, I sometimes think that the quality side gets forgotten. And I think that there's been a big push towards just trying to get back to volume and not value. And I think that that may have been necessary in a number of situations. And I understand that, I accept it. But I think that as we move forward, if we're truly gonna be successful with reforming healthcare in Vermont, we have to get back to the premise of what the underlying goals of the reform strategy that the state of Vermont has chosen, which is to move towards value. And so in the past, we had specific pieces of our guidance that gave a hospital a little bit more if they were doing certain things to push healthcare reform in their hospital service area. And I think we should get back to that. I think that we need to create carrots for people to do the right thing. And we shouldn't expect them to be able to do that at no cost. And so for me, it's all about specificity in the guidance. I think we need to be specific, not only about the revenue side, but I think the change in charges should be very, very specific. I think that we should be probably, and I don't want to micromanage a hospital, but I think we ought to consider at least, for example, what the healthcare advocate suggested today that wages in healthcare were growing faster than other sectors of the Vermont economy. We might want to consider tying budget orders to specific criteria such as a percentile of peers in the healthcare world in New England or in some other metric that might be more appropriate. I get a kick whenever I hear somebody say, well, we're well below our peers, but then they're comparing themselves to other markets such as Boston or Albany. Vermont is never going to be Boston or Albany. If you take a look at all the sectors in the Vermont economy, I would think that the vast majority are working at pay scales that are below that. And we've talked about workforce for ever since the first day I came into this position. And yeah, sometimes I feel like our message has not been heard because we tried to create a message that we needed to do more to grow our own. We need to do more to create additional supply of quality workforce in the state of Vermont. And yet, what I've seen recently from hospitals, it's the exact opposite side of the economic equation that they're addressing. They're saying, we have to pay more because we need to compete with our colleagues. And the problem with that is it's an arms race that nobody is ever going to win because once you raise your rates, somebody else is gonna have to raise their rates to be competitive with you. So I guess what I'm saying is we need to try to hammer home that message more that we need to increase the supply. And that's the only way that Vermont is going to be successful. I think that we have rare opportunities given these crazy times that we're in to create a message to healthcare workers that Vermont is a place where you can and should be working and you can make a darn good living in the state of Vermont working in healthcare and you can go home and plant in your garden, breathe fresh air and not have to go into an elevator with 25 of your neighbors and worry about if they have something or not. So I think that out of really a tragic situation, there are opportunities that we should be seizing upon. And so, but getting back more specifically to the hospital budget process, I really do think that we need to tie a lot more into guidance about what our expectations are. And it is not going to be welcomed, I understand that. But I think we need to have the conversation and it really gets back to we need better information and it may not even be in this process that we'll get that information. Maybe in order to make better decisions in the hospital budget process, we'll actually have to do something that the Green Mountain Care Board since its inception has been loath to do. And that's to use our subpoena powers. And I could envision us using those subpoena powers in rate review to try to get to the type of information that would better answer our questions. Deep in my heart, I'd like to believe that we are going to have better information in January because of the federal guidelines for transparency, but I also am a skeptic. I'm a skeptic that we're actually going to get the information that we want to get. Hospitals are a powerful lobby and I respect that because hospitals are us. It's our community. It's who takes care of us. It's who keeps us healthy. But at the same token, it's very hard to understand why hospitals fight back so much on everybody trying to do what's best for everyone in the future. Because if it's not sustainable, hospitals in the end are gonna pay the price and Vermonters are gonna pay the price. So those are my ramblings. Does any board member have any followup or should I open it up to public comment? I just had one thing, Kevin, like just in thinking about some of your comments and Jess's comments around the guidance, I think that it does make sense to try and figure out if we can be clearer in that process about what we're looking at. I do think one area that I forgot to touch on is Patrick, one of Patrick's question is, should we be trying to factor in public payer rate changes in the budget process? And I think that's particularly tough with Medicare. I think it's, if there were rate increases in Medicaid, it would be easier because while this year they were behind because of COVID, normally they try to get those out by July 1st. So while the hospitals may not have it in time to submit, we should be able to get hospital-specific information from Diva. And I do think that's an important consideration for us to think about. And I don't think that piece is necessarily that hard. It hasn't been particularly impactful the last couple of years that we've gotten it because it didn't really change the impact of the commercial requests. So that was one other thought. Thank you, Robin. Any other board member? If not, I'm gonna open it up for public comment. Does any member of the public wish to offer feedback on the hospital budget process? Well, very quiet group today. I think everybody's in a little bit of a post-election funk. I know I didn't get to sleep very early myself last night and just trying to keep up with some of the local races in my county was a difficult thing where, you know, it's just everybody wants to know immediately. And unfortunately, sometimes you don't know as fast as you want to know what has happened. And one thing is clear. We're all Americans. We need to hang in there together. And you will get through this. And yesterday demonstrated that democracy does work. Americans went out in incredible numbers to let their voices be heard and their votes did matter. And so if there's not anything else on hospital budget, I wish to thank Jeff who's no longer with us. But Mike, if you could pass that thank you on to him, Mike Deltrakow. And also a huge thank you to Mike Fisher. Mike, I think Jeff really hit it on the head. You are the voice for the Vermont consumer and you are every day protecting Vermonters and we respect what you do greatly. So thank you for your work. So I want to thank the board members for a really interesting insightful conversation today. Thank you, Mike. One thing I want to know is how did the boiling frog party do in the presidential race yesterday? You see that on the back? It was, the list of presidential candidates was amazing. But when I got down to the boiling frog party, I kind of lost it. So I don't know if it's accurate, Tom, but I did see in one of the national press stories that Kanye got 1200 votes in Vermont. Really? Whether or not that's true or not, I don't know. But I did read that. Is there any old business to come before the board? Hearing none, is there any new business to come before the board? Hearing none, is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Aye. Any opposed? Say nay. Thank you, everyone. Have a great rest of the day.