 All right. Well, I think it's 8 30 and we have been great at starting on schedule and ending on schedule. So I always appreciate that from everybody presenting. Good morning. My name is Jessica Holmes and I'm currently serving as the interim chair of the Green Mountain Care Board. Today is day three of the Green Mountain Care Boards Hospital budget review process. We're going to be hearing from the UVM Health Network, the UVM Medical Center, the Central Vermont Medical Center and Porter Hospital today. Just as a reminder to folks who are just tuning in now to conduct our analysis and ultimately make a decision for each hospital, the board looks to our statute and to our hospital budget rule for guiding principles. So our review requires us to balance several often, as you can imagine, competing factors. For example, the need to slow the growth in health care expenditures while also ensuring that our hospitals have the resources that they need to recruit and retain health care workers and provide the high quality care that we've come to expect in our communities. So as we look to balance cost containment access quality and health system sustainability, we must be really mindful of this year's unique circumstances and the significant headwinds that we're facing with high historically high inflation rates workforce shortages provider burnout. And the continuing impacts of the COVID-19 pandemic. So both nationally and in Vermont hospitals are facing unprecedented financial challenges as our businesses, families and individuals. As an aside, I wanted to note that there's some relief in sight for individuals and families who purchased their own insurance through Vermont Health Connect this week's signing of the Federal Inflation Reduction Act included an extension of subsidies for health insurance premiums for eligible Vermonters through 2025. So the board will be continuing making announcements about these subsidies as we get closer to open enrollment this fall. But anybody listening who's interested thinks they might be eligible and not sure if they're eligible should really get on that Vermont Health Connect website to learn more. This is an important extension of those subsidies. So over the next few weeks, the board's immediate and perhaps unenviable task is to set the fiscal year 23 hospital budgets for all 14 of our community hospitals. I wanted to remind everybody though that the board is working very closely with the Agency of Human Services to begin the work outlined in Act 167, which aims to move us closer to a sustainable hospital system that ensures for monitors that access to high quality, affordable care. And that work is going to involve extensive data analysis and hospital and community engagement and the end result should be a more sustainable path forward. As we turn back to the hearing today, the business at hand today, I want to extend a thank you to the UVM Health Network for the time and effort taken to submit all the documents for our review. There were tremendous amount of the budget is thick. It's it was comprehensive and it was also submitted on time and I really want to extend my thanks and appreciation for that. I know how much hard work goes into those submissions. A few housekeeping notes about the hearings today. The presentation is a public meeting. It's being recorded and transcribed so there will be a publicly available record. If the networks leadership believes that there is any confidential information that the Green Mountain care board should consider either as part of the presentation or in response to board or staff questions. Please let us know before responding because if needed, we can go into executive session and review confidential information. Executive sessions would be limited in scope as provided by the open meeting law and limited to information really involved in contracts and information that would be considered confidential under the Public Records Act. But if at all times or any time some issue of possible confidentiality arises. At that point I'll just call on the board's legal counsel to determine the scope of what could be considered and discussed in executive session. And if deemed appropriate and at the appropriate time I can then ask the board member for a motion to go into executive session. So I wanted to make sure that you are all aware of that. Prior to our starting. But at this point I think what we could do is we could commence and begin the UVM health networks presentation for each of the three hospitals. I'm going to hold all board and staff questions until the end of that full presentation so that you can walk us through everything you have. And with that I'm going to ask Russ McCracken to please swear in the UVM health network witnesses. Anybody from the UVM health network and associated hospitals planning to present or answer questions today if you could participate in the swearing in process that would be super helpful to Russ. Thank you chair homes this is Russ McCracken staff attorney with the board. I'm going to swear in and it tends to work best if we just swear everybody in right at the beginning. So, I guess, Mr go pay who from the network in the hospitals to expect will be speaking today. I'm going to take that out. I will. John Bromstead, Al go Bay, Rick Vincent, Jason Sanders on your radar wall like Jackie Hunter, Dr Steve Lefler, Anna noon and and Tom Thompson. Anybody else that answers a question will have to pick up. As the question comes up but I believe that will suffice. Thank you Dr Bromstead. If you could all raise your right hand. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth so help you God. Thanks so much. Everyone is sworn in and I will. If I could ask one other thing before you speak for the first time if you could identify yourself by name. It's very helpful for the court reporter in the transcription. And with that, I'll turn it back to chair homes. Great. Thank you so much Russ and team. Dr Bromstead, before I turn the floor completely over to you and to your team. I just wanted to recognize your upcoming retirement. So congratulations. And I acknowledge also the hard work that I know you have done to move us closer to a healthcare delivery system that's really focused on population health. You know, I think we can both agree that the reform road is long and steep and bumpy and all of that but you've been a passionate navigator and an advocate of systemic change and I just wanted to take some time to thank you for those efforts to move us in the right direction. We're getting there. The work we'll do hopefully with act 167 will take us closer to that destination but having a leader of an academic medical center and a network that believes in the same, you know, population health goals that we all do has been really much appreciated. So thank you to you and this is the last time you have to come before the board so I don't know what kind of margaritas are in celebration for that but I do want to acknowledge and appreciate your hard work. Thank you so much. And chair Holmes has kind of a nice ring to it, but we'll leave that lay. I appreciate the kind words and I appreciate the context and as you say this probably is the last time that I will be presenting to this board or to a Vermont regulatory agency. And I do want to recognize the board, the Green Mountain Care Board staff, our staff as you did. Chair Holmes, a lot of work has gone into these budgets, more than usual because of the circumstances that we collectively find ourselves in. I want to start by thanking several of our trustees, trustees are volunteers in our not for profit world. They dedicate huge amounts of time to helping to guide us and connect us with our communities and today we have Linda shipper, who is the chair of the boarder board back. Chair Holmes and in your hometown, Karen Stackpole, who's vice chair of the network board and has served on the medical center board in Burlington for years, Ali stick me, whose chair of the health network board and is also chair the academic medical centers board and Tom little. Everybody knows Tom, and Tom has contributed greatly to Vermont and Vermont successes and he's currently chair of the medical center board. I am kind of the old dog here. I've been doing these presentations in one form or another to regulatory constructs in Vermont since late 90s I believe 1997 was the first time, and I haven't gone back and check but probably just about every single year. And this is the 12th time I've had the honor to be accountable for as CEO for the UBM health networks budgets that we bring forward. And I certainly take very seriously the attestation that Ali stick me and I signed for bringing forward these budgets to you today. In that longevity. I think we can all agree the word unprecedented that gets used a lot and overused still is apropos to where we are the situation and the factors and circumstances that we find in not for profit health care right now and that that whole sector of our economy that's so critical to our people is teetering on a financial precipice. And I certainly never wanted to see this, but we are where we are. Two things that I would characterize that I've tried to bring forward in all of these interactions and to have our people bring forward to two things transparency and trust and transparency. We are an open book with folks in our communities on when our finances are good the investments we're making and when our finances are really really tough. And we're very transparent with regulators and we've increased our degree of transparency. In this recent round, I would cite starting with the with the mid year rate request where we brought you literally and figuratively an open book on where we stood and we will continue that transparency we've been meeting with business leaders with community leaders. We've certainly kept our trustees and all of our 15,000 employees up to date with great transparency on where we are with this budget and where we are financially. Second trust and trust is bidirectional and I will admit that that has been strained over the past few years between the Green Mountain Care Board and our organization. I would ask that we not have it be strained and that we realize that we all want the same thing. We want Vermonters to have access to high quality affordable health care as close to home as we possibly can have it when they need it and to have that be something that Vermonters are proud of our health care system. We trust that you will judge our budget and what we've brought forward on its merits and in the context of what's occurring nationally and that you will put in the correct context information that you receive both its accuracy and any other agendas that might come forward with that information. You I believe can trust us that what we are bringing forward is as accurate a reflection as we possibly can bring forward of what we need to provide the services that Vermonters need and depend upon us for not anymore and certainly not any less. So Jen could you bring the slides up please and go to slideshow if you're going to do that. Chair Holmes you can see those. We can see the slides Jen it's just not in slideshow mode but so we'll get going. So these are our presenters today. You heard me read the list when we when we were sworn in. I'm going to have a relatively small part. It's really important for a chief operating officer. I'll go Bay and our chief financial officer to carry the bulk of the presentation. This is a budget presentation. We also have Dr. Jason Sanders who's joined us from Oklahoma to lead our physician enterprise and more broadly our population health efforts. Dr. Anya Raider Wallach who you all know be speaking to some aspects of health care reform that we believe are important. Dr. Jackie Hutter was joined us as a chief diversity equity inclusion officer. We'll be talking about health equities and then our three presidents Steve Leffler in a noon and then Tom Thompson will have some specific comments about their their organizations. Next slide and the next slide. So there have been no changes in membership since we last met. There have been some changes for the UVM Health Network in April we completed implementation of the epic electronic health record based on a certificate of need that we received from the Green Mountain Care Board some years ago. So we have epic in all of our clinical practice sites. We still have home health and hospice to go. We've learned a lot facing the headwinds that we faced with the pandemic and with the stresses of the financial situation for not for profit health care. We've learned a lot about how to depend upon each other how to collaborate how to integrate and I think chair homes and member lunch for spending about two hours with us as we talk through a real example of sustainability in a rural environment as we integrated the Ticonderoga campus into Elizabeth Towne Community Hospital. And we have many lessons that we've learned. And if I do have some interaction going forward with health care in this region it will be around trying to continue to learn more and to spread that that learning. Next slide. So we current themes and things that you're going to hear from us today. You're going to hear about our financial position has continued to deteriorate and that puts the waters really at risk. And there are no hyperbole there are dire consequences to not having this budget approved. We're not alone. We know that you've gotten information. You do your your homework the staff and the members have seen from many credible external sources what's going on with not for profit health care in this country right now. And it is incredibly concerning. We are asking for significant increases and we understand the strain that this can place on some commercially insured folks in this region and Vermonters as you said chair homes in your opening. We're working really really hard to do everything we can and we'll come back to that towards the end to do what we can to offset those increases with other revenue sources. We've worked hard to reduce expenses. There is no way that we're going to be able to cut our way out of the current situation. We're already seeing the impacts of two little resources throughout the system with inhibited flow of patients and backlogs and difficulty with access. We're going to bring forward external sources that document our high quality and low cost. And again thank you for recognizing chair homes that we remain very committed to value based care. The recruitment of our senior most leaders. They are all as passionate as I am about this transformation. We're totally committed to improving health equity and Dr. Hunter will speak to you about some of our efforts in that regard. And this gets back to the bidirectional trust. We really need your support to be able to continue to serve our state in the region. This region deserves and needs to have a academic medical center from a workforce perspective from an economic engine perspective. And most of all from a care perspective so that we can take care of the needs of the promoters. With that I'm going to turn this over to Mr. Go Bay and obviously I will be riveted to the screen. I wish I was riveted to everybody's faces in a room and I will be available for questions at the end. But Mr. Go Bay over to you. John thank you. I appreciate that. Madam chair. Good morning. It's good to see you and thank you for your service in this role. Member Lunge. Member Walsh. Member Pelham. Good morning. Thank you for the time today to team Green Mountain Care Board. Sarah in your new role. Congratulations. Thank you for all of your hard work that you've done since you received our budget on July 1st. What I hope to do this morning is to continue the conversation that we started at the mid year about how we build a partnership between the Green Mountain Care Board and the UVM Health Network. So that we can continue to provide the high quality care that we do and remain financially sustainable. As we begin to emerge from the pandemic and I have to note that this is the third year in a row that we are doing this by teams. And that's because when you break the pandemic down into three buckets. The first was the crisis and we all know what we did through that. Things like PPE and ventilators were what we were talking about. We've now entered the stabilization phase which is the second bucket. The third phase is normalization and we are not there yet. And you're going to see that in our current condition. And you're also going to see that in our revenues and our expenses that we're projecting for FY 23. When you take a look at the national landscape of health care. You can see that what is going on in Vermont. What is happening at the UVM Health Network. What is happening at each of our affiliates. We are not alone. The workforce workforce crisis is driving the business results that we are seeing. It is affecting the delivery of care every single day. Every leader on this call is dealing with the workforce crisis. Every moment that they work. And I can't stress that enough. If you've read what Fitch had to say lately they have labeled the nonprofit health care system in the United States as deteriorating. That is something that should concern all of us greatly. And I think that when you look at our numbers and where we're at you'll agree with Fitch. Jen if you could go forward. So this is our UVM Health Network. This is not just the three hospitals in Vermont. This is our UVM Health Network operating margin. It has seen a steady decline since 2017. It was only buoyed by federal and state dollars in 2021. And the key thing here is that this is a trend and this trend has to be reversed. Because this margin is so far below financial sustainability. Let alone where we want to be for our actual for our financial sustainability threshold. Rick is going to get into how bond rating agencies look at these numbers. You know what is a what is a good margin or a bad margin. But there is no one involved in health care that can look at this slide and think that this is OK for the state's only academic medical center and health network. Next slide please. So with the margin chart. The result on this slide is sort of was sort of predetermined. If you take a look you'll see that you know our days cash increase in 20 and our days cash increase in 21. And that was a combination of a couple of factors. One we did a large borrowing in 20. And we also again saw state and federal money to offset the pandemic impacts. If we did not borrow our days cash on hand would be closer to 100. Then the one twenty seven point one that it was in June of this year. When we spoke at the mid year Rick and I forecast our margin and we forecast our days cash. And now we're seeing that our forecasts were accurate. You know. So when you look at this chart you know you see one twenty seven point one. And this is again for the whole UVM health network. So the thought may be that UVM MC must have the bulk of the money and the smaller hospitals must be relying on the big hospital. Unfortunately that's not the case in this picture. UVM MC's days cash on hand as of June 30th is one hundred and twenty one days below the one twenty seven point one we have as a network. And I call that out because the solvency the sustainability of our academic medical center should be at the forefront of the partnership that we need to build through this process. Next slide Jen there's a lot going on in this slide and there's a lot of health policy that you can think through the more the longer you look at this slide. And so if anybody ever wants to like hang out and talk about the slide you know over a cup of coffee I'm happy to do that. But I'll point out a few key things that I take away from this and and how I kind of see it. So first of all the lime green line the lower line is our net patient revenue. The red line is our is our expenses the dark green line is our total operating revenue. So whenever the red line is over the dark green line we don't have a margin. And so the purple dotted line is the revenue needed to achieve a three percent margin over time. If we were going to build to be a sustainable health care system. So a couple of points a couple of policy points here. First expense growth has outpaced our total operating revenue during this period by point one. Second point net patient revenue does not cover the expenses needed to deliver the care without pharmacy. We would not be able to cover those expenses. I'll get to a pharmacy chart in a little bit and talk about that a little bit more. But I want to point that out. Also net patient revenue only grew at six point six percent and did not keep up with our expense growth. Next slide Jen. So from here basically this is where we're at financially. From here we had to build our FY 23 budget and we started this process in March and it's really important to understand that we basically build it from March through May or the first week of June. And then it has to go through our board processes and then to you by July 1. And so we have to make a series of assumptions on different things that are going to affect our budget and we're not always right to be candid. Next slide Jen. One more. And so these are the assumptions that we've made in our net patient revenue. So this is only revenue not expenses. And this is just net patient revenue. So this slide actually totals to the bottom. So for the three hospitals in Vermont we have a one hundred and seventy eight point seven million dollar net patient revenue increase. And I'm breaking it down here into three buckets. I'll break it down more in the next slide. But basically the first bucket is changes to our FY 22 budget from actual experience so that when we begin the process of building our FY 23 budget our numbers are as accurate as they can be. The second bucket is payer rates. I'll break those down individually in a moment. The last bucket are assumptions that we've made about revenue. And I will tell you that this year's assumptions are greater than any year I can remember in dealing with it with hospital budgets. The only thing I can use as an example was back in 2014 when the Affordable Care Act basically was implemented. And I think many of you will remember the cat amount bump and the migration of people out of Medicaid and into the exchange etc. This was as difficult a year as that year plus some. So first we have fifty two million dollars in revenue in volume and access improvements spread across our service lines. Now these are things to improve access. Key point here. This is the revenue. There is there are expenses. And as I just said with net patient revenue they they typically are greater than the than the revenue that we receive. So if it's fifty two million in volume we have fifty two million in expenses you know plus or minus a little bit. The second and this is this is a risk in our budget. And I have to call this out. We created a model to basically forecast what would happen if the Biden administration's emergency order for the pandemic was to be allowed to sunset. And states were to begin to redetermine the Medicaid population. Currently states are not doing redeterminations on Medicaid. People can leave Medicaid if they gain employment and gain employee sponsored insurance voluntarily but they cannot be moved off of Medicaid involuntarily. We forecast that the emergency order will sunset and that there will be a migration from Medicaid to commercial that will occur during these redeterminations. The number that we came up with for our three affiliates is twenty four point one million in revenue. And obviously if that emergency order was extended for all of fiscal year twenty three this would be a big miss in our budget. But we felt that this was the right thing to do to make sure that our budget was tight and we want to be transparent about it with you. The next bucket is epic revenue optimization. This is basically the fruit of the implementation of Epic across the network and our ability to more consistently code across all of our affiliates that have Epic now. So in Vermont we see this as an eight point three million dollar revenue bump to our budget. Next. And this this is a revenue piece and it's also an expense piece that I'll talk about later. The system is currently frozen in many ways. We do not have the flow of patients into the E.D. into inpatient and out to skilled nursing facilities or long term care in the way that we need it to happen. We believe that we can that that that will improve and we have a plan to help it improve. And by doing that we'll get folks out of our hospitals that no longer need a hospital level of care and be able to fill those beds with people that need a hospital level of care. I will say this right now we do not have the right care at the right place at the right time in our system or in the state of Vermont. The system is frozen. This is an expression of us saying we're going to improve on that and it will have a revenue impact. The last one case mix index for three million GME for one point two ish one one point three ish and then some other revenues. This is the CMI pieces improving our case mix index through coding. We think we have room to improve here. So we forecasted into our into our revenue model. So again this totals to one seventy eight point seven. Next slide Jen. This is a detail of the slide I just went over. If you take a look at the darker blue line at about the half halfway mark on the page you'll see that these are the changes from FY twenty two to FY twenty three that I described in the first bucket. And some of the volume adjustments and other revenue drivers that I just talked about the dark blue and the light blue add up to one seventy eight point seven in total. And so now I would go to the top box with the light blue net patient net patient revenue payer changes. And I would call your attention to the Medicare rate increase area. We estimate what Medicare is going to pay us as we build our budgets. For example we estimated about a two point six percent increase in inpatient rates within our network. We now know that the final rule came out at four point three percent. And so what we're proposing and I'll get into this on my last slide at the at the end of our presentation. And this is a this is sort of a big moment in our presentation. So I would call this out to the members of the board. What we're proposing to you is that that we that A you approve our budget as submitted. And then B that we reconcile all government payer changes by November 15th and reduce our commercial rate accordingly. With a completely transparent schedule like this so that no up in our budget that we receive from either Medicare or Medicaid enters into our budget without adjusting the commercial rate because to member Pelham's good point that he has made many times. You know this is a solve for you know we basically know what we're going to get from Medicare. We know we're going to get from Medicaid and we turn to commercial for the rest. We're saying let's come up with a process because we do not have the final rule on Medicare outpatient yet. And we are doing really good work with a very supportive Scott administration particularly Secretary Samuelson's help on trying to draw down increased Medicaid funding that could materially impact our budget. And we we owe it to Vermonters to reconcile that by November 15th. Again I'll talk about that later. Next slide Jen. And so in the in the line graph that I talked about earlier we talked about how our net patient revenue doesn't cover the cost associated. With the care and that pharmacy and other operating the other operating bucket does. What we wanted to do for you in our presentation was try to get to a gross margin almost of what our pharmacy business generates. So this is not revenue. This is actually revenue minus most of the costs associated with running our pharmacy program. It's not all of the costs we have a you know we don't have a model that we can do you know down to the penny here. But this is a good estimate so you can see you know in twenty two what was happening and in twenty three and you can see the growth. In it you know going from ninety four million to one hundred and eight million and this this really helps our budget helps offset our costs to deliver the care that people need. Next slide Jen so. So that was our revenue model hundred and seventy eight point seven million in revenue. Now we're going to move to expenses. And so our budget and every piece of what we're going to talk about in terms of why we need the rates that we need is driven by cost inflation. It's important for you to understand that we are not trying to get a commercial rate increase or use the government payer increases to cover volume increases. Or other costs that are rising in our budget that are not due to cost inflation. So we have a model that we say this is what our cost inflation is and that's what we put into our rates. I call this out because as I spoke about it the mid year in twenty two our inflation input was two point four percent. And obviously that was inaccurate and it has really harmed our finances. You know basically ever since if you want to look at it that way. And so I just want to you know point to this slide where inflation is literally above nine percent realizing it may have come down a little bit in July. But I don't think any of us are celebrating a high eight percent inflation rate. Next slide Jen. So this is our cost inflation. What we did is we took the cost inflation that was above the twenty two budget and the cost inflation from the twenty three budget. And we put them together and that number is one hundred and eighty four point seven million dollars. What I'd call your attention to is the salaries payroll taxes and fringe benefits line. Because if you move across you'll see it's you know the total cost inflation is ten point nine percent. But the way I look at it is that one hundred and thirty four point nine million is seventy two percent of our total cost inflation. Our budget is being driven by the cost of labor. Our financial losses are being driven by the cost of labor. And I'll get into some detail detail on that in a moment. Next slide Jen. So in our budget we have added FTE's. This is necessary to accomplish the volume objectives that we went over in the revenue part. So we want to be transparent about you know what we've added. I would call out the three hundred and twenty nine number. And if you look there's travelers non physician at one ninety two. And so the total in our budget is one hundred and thirty seven FTE's after that traveler number. Now a couple of key points. Almost every single one of these positions is related to patient care. And again these are not in our cost inflation. We did not raise cost inflation dollars to cover the new FTE's. Next slide. So this slide can be a little bit tricky. And so I want to make sure that I articulate this properly. If you look at UVMMC's MD and staff merit and market increase line at five point seven six. Probably thinking I heard they gave the nurses a big raise. You know we renegotiate renegotiated contracts at Porter. We worked with our team at CVMC. We did work with the union at UVMMC. Well most of those big budget hits were actually in twenty two. And we call it out on the on the right hand side of this chart. So for twenty three these numbers are accurate. But here's the question that I have. Is this a budget risk? Will we be able to hold at these numbers? We were not able to in twenty two. And we'll have to watch this because if if we can't hire if we can't attract if we can't retain at these levels we'll have to raise them and that will be a that that will be an impact on our budget. Next slide. So we get asked a lot about travelers. So we wanted to be very clear. I realize there's a lot of numbers on this slide. But but I wanted you to have this so that you could you could look at it. I'll call out a couple things. Sorry for the eye chart. But if you look at FY twenty two budgeted travelers we only had a hundred and three. You look at where we're at annualized in May we have five hundred and thirty four between the three Vermont hospitals. That's a huge increase. We're forecasting for twenty three that we need to get down to two hundred and ninety five. And that's a pretty big difference off of our run rate. So that is also a risk to our budget. If you look we're also at the at the next bucket of numbers you'll see total traveler average cost per FTE. We're also estimating that traveler rates will come down which they have. And so we're forecasting this as our average traveler cost. And I would compare that to the lower bucket. You know two hundred and thirty five thousand dollars a year in our FY twenty three budget for a traveler as compared to our average staff FTE of one hundred nine point eight. So you can see why we prefer to hire you know our own staff. The key point here is when you replace a traveler you don't zero out that amount of money. You still have your original your original FTE cost. Next slide Jen. So we wanted to show what's happening with inflation and supplies. You know obviously our FY twenty two budget at one point five percent was an under understatement so we can see that in the June annualized. I put this here and I just want to call this out that you know. Our leader in this space is Charlie Macelli. Charlie Macelli led the state's response in PPE. And a thousand other things that we did during the pandemic to procure supplies working with Dartmouth working with the National Guard. Charlie Macelli's team is world class. There is not a contract that they don't fight over. There are not think there's nothing we don't do with RFPs. I mean it it is truly an amazing supply chain. It's it's led by Charlie Macelli and led by Rick Vincent. And it's it's it's just an amazing group of folks. You see this growth in costs. Don't think they're not fighting every day to keep this down. Next supply next. So I mentioned earlier that we have average length of stay in our revenue. And this is also in our expenses. And so the problem we have is we used to have twenty folks at the academic medical center to 30 that we're waiting for transfer to a skilled nursing facility. There's been moments in the last couple months we've had over 80. And so that creates an average length of stay problem as people are staying in the hospital longer. Their DRG payment has run out. And we're caring for them waiting for placement. We're going to work really hard. If you see in UVMMC's number we're trying to get down to a five point eight zero. So that will help us with revenue. It will help us with expenses because you know paying travelers to care for folks that are no longer over 80. It will help us to care for folks that are no longer within their DRG is a really bad financial maneuver. And so I just point this out because we talked about this at the mid year. I wanted to show you what it was in our budget this year. It is both an expense driver and a revenue driver depending on how well you're doing with it. And so at this point I'm going to turn to my teammate Rick Vincent and he's going to take us through how these revenues and expenses translate into what we need. Rick. Thank you Al and good morning Green Mountain Care Board and Green Mountain Care Board staff. So what I'll do in this section is just pull out essentially some of the high points from all the underlying budget assumptions that Al just went through what it looks like when you put the combination of those two things together. What does our what does our budget look like. Next slide Jen. So to start in terms of any budget and financial discussion you need some type of anchor point. So for us our anchor point is using benchmark data that tells us where is the level of financial stability that we need to be at in order to one take care of our patients in our our communities today. And also be in a place that we're able to keep pace with the needs of our of our region and community into the future. The key point here in terms of what how we use this data is not the rating itself. It's the benchmarks that are behind this rating. We look at all four of the benchmark surveys to come up with the the level that we need to be at to be financially stable. We don't pick one number from these four we use them in combination. So days cash on hand for example you can see that our threshold for where we need to be to be financially stable in that middle range is 200 days cash on hand. We don't use 273 we don't use 259 it's a combination of all three of those benchmark surveys and that's the same for for all of these. So this sets for us our basis for where do we need to be financially to be financially secure. The one metric that I'll point out on here that we went into a little bit more detail last year that deviates from the benchmark numbers is the very first line on the chart the operating margin where you can see internally. Our target in that middle range for financial stability is 3.25 which is higher than the than the benchmark medians. The reason for that is that we've fallen behind with capital investments and so operating margins include depreciation expense. So if you haven't been keeping up with your capital investments you have less depreciation expense on your on your P&L than if you have maintained. So right now that internal threshold is in the 3% range but over time hopefully as we get back on track with the capital investments that we need to make that internal number will come down. And we'll be more in line with with the benchmark medians operating even a margin which does not include depreciation is given the situation that we're in is obviously a better number to look at. And you can see that our internal target that we have for for that one is more in line with with the benchmark medians. So again this is you need an anchor point. This is this is the anchor point that we use. It's a it's a legitimate anchor point. It tells us that when we get to these levels that we're in a position financially to be able to serve our region and community. The next slide. So this is to show that over time using those thresholds you can see for pretty much all the metrics. We've been well below where we need to be this this shows why the the chart that Al showed at the beginning in terms of our operating margin. In our days cash on hand the trend has been going down. This is to provide a little bit more detail behind that our operating margin in 2017 which was at the beginning of that chart. You can see both from operating margin and operating even a margin we were in a in a solid place and that has deteriorated over time. The other key point from this slide is to just highlight the FY 23 column. So that is our our budgeted numbers. So the budget that you have in front of you we are not attempting to even get into the middle of those those ranges from an operating margin. Perspective in an operating even a margin we're still at 2.1 percent and 6.7 percent. We're still in that danger zone. So we're not trying to make up all the ground in one year with the budget that you have in front of you today. It will take time to rebuild both our P and L and our pattern in our ballot sheet. And over time also impact the number that you see at the very bottom which is the average age of plant. So we've fallen behind in keeping pace with our investments that we need to be making. And so this is this is a budget that is only essentially starting to make progress back to financial stability. Next slide. In terms of what our budgets look like when you put all of the different assumptions that Al just went through this is where the three entities that the board regulates. Where where we stand from a total budget perspective. So UVM Medical Center CVMC and Porter. You can see that the margin the operating margin that is in our 23 budget is 1.9 percent in an operating even a margin of 5.9 again well below the thresholds that indicate financial stability. And you can also see the impact of the cost inflation. What impact that has on our on our total budget. Next slide. This slide is just to again put all the pieces together that Al went through earlier. So our total NPR budget from FY 22 to FY 23 is growing by 178 million. You can see the percentages there of what that growth means for each of the hospitals and what they are in total. As this is one of the the guidance items in the Green Mountain Care Board's regulatory process we wanted to make sure we highlighted specifically what what those increases in our are showing for our budget. Later on Anya will put this number in the context. So this this number is the aggregate increase in our total revenue. What this doesn't represent is this number anchored to the population that we serve as we've done in prior budgets and we'll do again this year. We feel strongly that this number needs to be viewed in that context from a from a per capita or total cost of care perspective. When we look at that increase from one year to the next. That nine point six percent you'll see when when that anchor is applied to the to the hundred and seventy eight million dollar figure the growth comes into into a different perspective in a perspective that when we look at the guidance for the Green Mountain Care Board that we are supposed to be looking at revenue growth on a per capita basis. So we'll we'll get to that a little bit later in our in our presentation. Next slide Jim. So this slide is to try to to essentially itemize the path that we've been on in our budget from when Al and I presented during the mid year to the budget that you have in front of you to try to deconstruct what we told you then to what you now have in front of you today. So to start the mid year rate increase had a total cost inflation that was above and beyond our twenty two budget of one hundred and twenty three million dollars. Since that that number was generated we have and we have since reduced that cost inflation number. Primarily this goes back to the to the chart that that Al showed in earlier in terms of our traveler assumption we are making an assumption that the numbers will go down not just in FY twenty three but we've made an assumption that the number will go down in this fiscal year from what we from what we projected when we put together the mid year rate increase. So we've we've adjusted that initial hundred and twenty three million dollar cost inflation number down by fifty million to get to the seventy three million dollar figure that you'll see in multiple places. Throughout the presentation which is the remaining amount of cost inflation that we're carrying over into FY twenty three. Added to that is the cost inflation that we're projecting will incur from October first through September of next year which is the hundred and twelve million dollar figure to come up with a total amount of one hundred and eighty four million dollars of cost inflation that needs to be covered through rate increases whether that be Medicare and Medicaid rate increases or commercial insurance increases so that the rate increases that we need keep keep pace with the cost inflation increases that we're we're projecting. Subtracted from that we're taking the the impact of the mid year commercial rate increase that was approved by the board to get down to the hundred and sixty four million dollar figure. Then finally from that number we remove the government payer increases that are part of our budget and also the pharmacy increases to get down to the the amount that needs to be covered by the commercial insurance rate increases which is a hundred and forty two million dollars. Again we've we've laid this out in this in this fashion the last few years that that rate for us is a solve for. As Al highlighted earlier that solve for that hundred and forty two million dollar number. We're we're we're willing to reconcile later on if that if Medicare and Medicaid increases materialize but just to highlight again that that that is the the process that we go through and that's the that's the breakdown of where we started with our mid year rate. Increase in where we are today. Slide. This is just a breakdown so you can see by entity what each one of those cost inflation numbers are so the first column is the cost inflation for twenty two that was above the twenty two budget broken down by entity. The FY twenty three cost inflation. And the other the other point to highlight on this slide is that while we have a hundred and forty two million dollars worth of cost inflation that needs to be covered by commercial rate increases because those rate increases only go into effect. Most of them in January the net impact that we actually realize and what's in our FY twenty three budget is that hundred and twenty nine million dollar figure that you see in the in the last column. Next slide. So this hopefully looks familiar from the last few budget cycles. This is our our calculation for how we determine the commercial rate increase. So again we start with the overall cost inflation that we're projecting. We remove from that cost inflation the increases that we are projecting for Medicare and Medicaid to get down to the number that needs to be covered by the commercial rate increases. As we've done in the past we calculate what each one percent of a commercial rate increase equates to for each of our hospitals and that's what calculates the percentage increase that we need. So for the the UVM Medical Center the amount of the percentage increase for for commercial for the cost inflation that is above and beyond the twenty two budget is six point three percent. The amount of cost inflation going forward for October through September of next year is thirteen point five and the combination of those two is is nineteen percent. It's this calculation that again when we have a firm understanding of potential Medicaid and Medicare increases that that may be coming our way we would update this calculation. So those numbers you see in the middle that are listed in the less section we would update this those numbers to reflect the more accurate numbers once they're finalized just to add a little bit to what Al shared earlier. The we do know what the inpatient rates will be for Medicare from what we have submitted in our budget to what we know them to be today on the outpatient side they're actually there's two potentials for what those rate increases may be. One would generate a fairly modest increase in Medicare outpatient rates. Another could generate a much larger number as CMS needs to factor in the the Supreme Court ruling where the cuts that were made to outpatient reimbursement rates on drugs for hospitals that participate in three forty B programs were deemed unlawful. And so and so CMS now is in a position of having to figure out how to build those cuts back into rates and depending on where where that lands again it could be a modest increase but it could also be a much more sizable increase. We hopefully will know that on November 1 in plenty of time to to be able to reconcile this calculation by the by the 15th of November but just to put that put that awareness out there for the board and the and the staff. Next slide, Jim. So this is the exact same calculation for CVMC. So we don't need to go through this in great detail. You have it for your your deliberations. Next slide, Jim. And this is the calculation for Porter. The one thing to highlight on on this slide is you see there is no there is no calculation for FY 22 cost inflation that was above and beyond our FY 22 budget for Porter. That's because we did not submit a mid year rate increase for Porter, knowing that as a critical access hospital, some of that cost inflation gets automatically automatically creates rate increases for Medicare patients. So we we did not submit a mid year rate increase and we're not asking for any of that cost inflation above 22 to become part of the the rate increase for for FY 23. So with that, I'm going to hand it over to on your radar wallet, who will put what you've just seen in terms of costs and revenue into into hopefully a better context for the board to to examine so on you. Thanks, Rick. And good morning, everyone. So Alan Rick have given you a lot of information about how we got into the financial state that we're in and how we built our budget. My task is to talk to you a little bit about our costs and put the current costs in context as Rick said, as a logical next question. After hearing all of this and seeing our sizable requests is can't you cut your costs. And first of all, I'd point out that as as Rick just detailed we have indeed already cut a lot of costs out of our budget on slide 28 he detailed that we've implemented $50 million in cost reductions already. Prior to developing this budget. So that's important to note. But second, I want to talk about the fact that we are low cost providers. And I'll try to provide some evidence to back up that claim. So next slide please, Jen. And next slide. So you've seen these data before we've included them in other presentations. They're from the Dartmouth Atlas, which is sort of the gold standard of assessing provider costs across the country. The Dartmouth Atlas ranks states hospital referral regions and hospital service areas based on total Medicare expenditures per enrollee. This is for fee for service Medicare. It's risk adjusted for age, sex and race. And it's also because Medicare prices are essentially standardized across the country. It's also price standardized, which means it's a really good measure of how the use of healthcare varies across the country. And what you can see is quite remarkable that Vermont is the lowest state in the country by quite a bit in terms of total Medicare expenditures per enrollee. And if you go to the next slide, Jen, you'll see that perhaps even more remarkable the Middlebury, Burlington and Berlin hospital service areas. So the service areas served by our hospitals are the lowest in the country of all hospital service areas. This pattern has persisted for quite a while, probably since the beginning of the publication of the Dartmouth Atlas, which I believe began in the mid 90s. And likely reflects the fact that there is a fairly conservative approach to providing medical care in this state and an efficient approach to delivering healthcare. And that the developers of the Dartmouth Atlas and lots of other researchers over the years have noted as a good thing. It represents the avoidance of what is considered unnecessary care provided in other parts of the country, which is costly, can be unsafe and harmful to patients, and is often associated with fee for service medicine, which rewards higher volume of services. So it's a real testament to the way healthcare is provided in this state that we have such low rankings on this particular measure. Next slide, please, Jen. So next I'll turn to a more comprehensive measure of value that comes from the Lone Institute, but I'm still going to focus mostly on the value part of this because, again, we stand out. The Lone Institute is a nonpartisan think tank that has developed these rankings for a few years in a row of hospitals and health systems across the country, and you can sort the data by hospital, by health system, or by state. And there's a bunch of measures that go into this overall ranking of social responsibility for hospitals. And you can see here the factors that go into that ranking, and it's their definition of what a socially responsible hospital is. So one that's not just providing value, but also addressing equity in the community and providing high quality care in terms of outcomes. Next slide, Jen. If you look at our individual Vermont hospitals, we do relatively well on the overall ranking by loan. So Porter gets an A, and the UVM Medical Center and Central Vermont Medical Center get Bs. What is really striking is that among all the hospitals in the Lone data set, which is over 3,600 hospitals, UVMMC ranked second in value. So again, backing up the data that we see from the Dartmouth Atlas. And the ranking is derived mostly from ranking ninth in avoiding overuse and 108 in cost efficiency, again, among 3,600 hospitals nationwide. You can also sort by type of hospital, and so if you sort by academic medical center, you'll see that UVMMC is ranked first in the country among academic medical centers in value. UVMMC did rank lower in equity, and that's part of the reason for the overall B score. And I just want to point that out because I think it's important to note, and you'll hear more from Dr. Jackie Hunter in a while about our work on that front. And I think important to note that we take that seriously and want to improve where we see weaknesses. I didn't put it on this slide, but I think it's really remarkable that if you sort these data, the Lone data, by health system, so in our case it's the overall UVM health network. We rank first in the whole country in terms of, sorry, eighth in the whole country, eighth out of 307 systems nationally, and we get a overall for the entire network. So that's when you combine our three Vermont hospitals and our three New York hospitals, eighth out of 307 systems nationally for the overall social responsibility index. So clearly some work for us to do, but a good marker of the kind of value that we're providing both in Vermont and in New York. I'll quickly flip through some other examples that are a little bit more targeted. So next slide, please, Jen. So one of the things that drives our low costs is low use of hospital services. Again, avoiding high cost services where we can is an important marker of value. So here you can see that Vermont as a percentage of the US average utilization of hospital services is 77% and we rank seventh in the nation in terms of having low use of hospital services. Next slide, Jen. You can also see that if you look at expenses per discharge, per adjusted patient day in this case, the UVM Medical Center does well. And again, you've seen these data before, the yellow line represents UVMMC and you can see that in general, they've been at or below the 25th percentile of expense per adjusted patient day when compared with other teaching hospitals across the country. Next slide, Jen. UVMMC also, if you use the National Academy for State Health Policy, NASHP's hospital cost tool, you can look at operating costs per adjusted discharge. And what we did here was look at similar institutions in the region that we might consider to be peers. And so you'll see the handful that we chose there that we consider to be our peers and UVM Medical Center is the black line with the dots on it. So again, stacking up pretty well. Next slide, Jen. This is just mandatory stuff that if you use these data sources, you have to include. Next slide. The second subject I'll address is our desire to be regulated on a total cost of care basis. We've made this case again in the past, but want to reinforce it this year because it's very important to us and an important part of our overall strategy to engage in value based care. So we have made this case and I'll take you back through an example that I think Rick showed you last year. Next slide, Jen. The reason we want to be regulated on a total cost of care basis as opposed to a net patient revenue basis, which is how this process has historically worked and continues to work, is that we feel it's more consistent with value based contracting. And the move away from volume based incentives that are inherent in fee for service. So we're trying to move towards contracts with all payers. As you know that pay us on something closer to a per capita basis. Obviously, we're at different points with different payers. And we have not assumed full risk for a population with most payers, although we do assume almost full risk for the Medicaid population. We would like to do more of that because as providers who are trying to be high cost low costs and high quality. We want to be able to shift resources around to really keep the population as healthy as possible and to be responsible for doing that. So on the one hand, having the flexibility in our funding streams to keep the population healthy in innovative ways. On the other hand, being held to quality metrics that make sure that we're doing that in ways that are helpful, not harmful. And so we want to be held accountable for our total costs and our total quality. And we think that the budgeting process should align with that. This would also be more predictable in terms of knowing what we need to, the means within which we have to live. It could be consistent with global budgeting. That term has been thrown around a lot. And I think there's many definitions of what a global budget is, but it seems to be attractive to a lot of constituencies. And this could be married with that concept, I think in a helpful way. Obviously we would need to agree on a methodology. And as I've shared with Sarah and others in your shop, we've been contracting with Steve Cappell of policy integrity to develop some potential methodologies for doing this. And we look forward to sharing that with you when that work is done. Obviously we would need to agree on how a numerator and a denominator would be calculated and on what's a reasonable rate of growth to live within. But that's the way we would like to be held accountable in the future. Next slide, Jen. This is one approach. Again, you saw this last year. Rick took you through it. And I won't go through all the details, but I'm going to go through it at a conceptual level and suggest to you that this is kind of a quick and dirty way of doing this. But might be helpful for you to see just to sort of illustrate what I'm talking about. So on the one hand, there's the population basis that I just showed you from the Dartmouth Atlas, how they calculate costs. There's the way that Medicare does it. Those are both sort of attribution based where you say this patient goes here for care. So we're going to attribute their costs to that provider. What Rick did here was try to simulate that by taking some population information about the counties we serve and making some assumptions about market share. So you can see in the top part, he took the counties that we serve the most, looked at the full population and made some assumptions about market share to develop that overall population number. And then he made some adjustments to that population based on the age distribution because we know that as people age, they tend to use more health care and the costs associated with that go up. And so he tried to allocate a cost ratio to each of the population numbers based on knowledge about the age distribution in that population. To come up with what should be a reasonable calculation of costs. He plugged that in with the net patient revenue numbers that we've been realizing over the last several years. And you can see that he then calculated what our total, if you had used this methodology, what our total cost growth over that time period would be. And I've showed you here both the age adjusted and not age adjusted versions of this. If you didn't do the age adjustment, our average increase per year would have been 2.3%. If you do the age adjustment, it's 1.3%. So big differences between the numbers you see here. If you're trying to do that numerator, denominator, population based approach versus just looking at net patient revenue increases year to year, which is the way that this process has been doing it. Next slide please, Jen. The last point I'd like to make is that the all payer model I think contemplated that this would be the approach that you would take to cost control. And this comes from your own website. And I think is a really nice example of how you could take an overall expectation around cost increases and some overall expectations around quality metrics and simplify the process without having any degradation of your expectations or the accountability that we assume for overall costs and overall quality. And I would say that this is a better way to do it and that it's not only more consistent with our movement toward value based care, but also I think more understandable to the public than the current process. So that would be our plea that we be working together again continuing the theme that others have said today work together to figure out how to improve this process and hold us accountable in a way that we want to be and that I think would be more satisfying both to you as a regulatory body and to the public and allow for more efficiency and innovation in the health care system. Next I'm going to turn it to Jason Sanders, who's going to talk about the quality side of the equation and also give you a sense of how what we're doing internally to be successful under total cost of care contracts, which relates to what I was just talking about in the past. And I think he represents that everything he's going to talk about represents the kinds of initiatives that we are undertaking now but would undertake even more in the future as we move to more value based contracts and if we moved to a total cost of care budgeting methodology. So take it away Jason. Pleasure to meet everyone. Jason Sanders. Dr. Bromstead mentioned I serve as the Executive Vice President of Clinical Affairs for the EVM Health Network. So it's a pleasure to join you today. And I really want to highlight on behalf of our thousands of providers who are currently in the emergency room in the clinic in the operating room in the hospital floors and increasingly doing virtual visits. So as I said for this section, in context, you've already heard today about our favorable cost of care per capita and favorable utilization. For example, you heard about how we reduce through the loan Institute report, low value test and procedures. You've also heard about cost inflation and the challenges we're experiencing and delivering care because of that cost inflation. In this section, I want to highlight again the tireless work for providers and delivering a highly rated care experience and improving population health outcomes. And I hope you'll see the importance of the investment and decision before you and addressing cost inflation so we can sustain the work you've seen we've done and the work we want to do going forward. So the next slide please. We'll talk about a simple framework, which I know is familiar to the Green Mountain Care Board, our commitment to value based care. Our experience often relates to individual patients, population health of course is our communities of patients, they're related to one another and we look at that relative to cost. And as a newcomer to Vermont as well as Northern New York, I appreciate what you highlighted at the beginning in terms of the overall goals and the formation of Green Mountain Care Board and with your first mission based goal being the health of the population. At the bottom under cost I've highlighted what a few drivers are of cost in particular ones that you've heard about just recently from Anya utilization where we feel we have evidence to show we perform well on that consistent with our goals. And yet we've had challenges in two other areas. And these are the lighter blue dot points to the right. You've heard about cost inflation, which is ever present around us in all aspects of the economy, and something which I think you feel you may have seen it in your neighbors and your families and that's the increased prevalence, incidents and prevalence of illness in our communities, whether through complications of COVID and long COVID, mental and behavioral health, substance use delay diagnoses and treatments because of the challenges now in our third year of the pandemic. So that's the population acuity. So I hope what you'll see as we share our recent data on performance on the numerator, care experience of population health, is it taking the context or performance on cost. In terms of more of what we control and utilization relative to what is harder for us to control the externalities of the demand we have from our neighbors with higher population acuity and the cost inflation we experience. I will share thinking to the future and putting in context the ways in which we think about our clinical workflows and our priorities, three ways in which we apply this simple equation to our work. And the first way is to improve care experience and population health at roughly equivalent the same cost. The second way that we improve value is to provide a similar level of care experience and population health at a lower cost. The third way, which I don't think that we talk as much about in population health and via base care but I think is important to introduce to the Green Mountain Care Board is when we deliberately make an investment in the denominator and cost. The proof of concept going to scale that we can get a greater increase in the numerator and care experience of population health that is we say we make a deliberate investment in people are providers in facilities and new testing. New technology because we get a greater impact in outcomes, which is familiar not only to this board but in what is done in other countries. So those three simple approaches for how we approach high value care wanted to introduce. I talked a little bit about the population acuity and I want to provide a couple examples of the challenges we're facing with patient acuity. So increasingly, with the increased demand that we see in our populations of patients what previously was addressed at the home is moving to the clinic was previously addressed at the clinic is moving the emergency room was previously addressed the emergency room is going to an inpatient floor. And so we're shifting from a value based point of view. To higher cost settings as a high value system which you've seen with lower utilization we want to move patients. Back from inpatient emergency room from emergency room to clinic from clinic to home, and yet we face challenges so I want to provide just one data point here. So UVM medical center. We look at our patient discharges a familiar way to look at it. What we observed in actual performance relative to what we would expect an ODE ratio. So when we are discharging patients home in general without services. We perform O to E less than one which is favorable point nine five to be exact. And yet now let's look what happens when we need to discharge a patient home. With a sicker patient population with the cost inflation you've seen investments we need to make and traveling nurses to be able to discharge that patient home. Now we have an ODE ratio of 1.33. We are much higher observed and expected when we need to discharge them home with services. So without services point nine five with services 1.33. Now let's look if it's even more difficult or challenging to discharge a patient. Now we need to discharge a patient to a skilled nursing facility or a long term care facility. Now we have an observed expected ratio of 1.48. Much higher than one. So I hope that shows you the challenges in our value based system we see patients going to higher cost settings. We want to help them transition to lower cost settings and yet we face bottlenecks. I hope last point on this slide is in the context of what you've seen earlier distinguish what we have done are doing as a care delivery system that thousands of providers every day. And yet the externalities we face and the very important decision before you on how to sustain our care delivery system. Next slide let's talk about the numerator some more. So we want to show these data points that we believe third parties validate that our care experience is highly rated. You're familiar with the CMS star rankings that places in the top 15% of hospitals at UVM Medical Center in central Vermont Medical Center. Areas where we're high performance and CMS are mortality such as pneumonia, lung infection, safety such as reduced complications after orthopedic surgery or hospital acquired infections, readmissions for example a patient who has a malignancy who's receiving outpatient chemotherapy trying to reduce that patient from needing an ER presentation or an admission. So high performance there and patient experience with improvement in patient experience pre pandemic and sustainment of patient experience during the past three years of the pandemic despite all the challenges that you've heard previously. U.S. News World Report as you've seen validates UVM Medical Center as number one hospital in Vermont recognizes high performing stroke, heart disease, lung disease, kidney disease, colon cancer surgery, hip surgery and others. The context of this is that we see over 1.2 million patient encounters with Vermonters every year. So all those external pressures. We want to show this that we not only our commitment for our validation to exceptional care experience. Next slide please. I'd like to highlight here that the breadth of our network, and particularly in Vermont Porter Medical Center, Central Vermont Medical Center UVM Medical Center, we provide from care in the home to critical care. And in particular, when we see cost inflation, it makes it particularly challenging to deliver our most specialized and critical services. And just to remind the board and those listening today, what each of us depends on again right now. Today we have providers, our Children's Hospital, our NICU, our level and trauma center, cardiac catheterization for urgent heart attacks, stroke center, cancer center, critical care, surgeries going on now, regional transport system. It's difficult on a virtual call. And again, I'm new to the process so we may have done these previously in our clinical settings. But if not to try to take our minds to what is happening right now and what each of us depends upon. There really does become a matter of life and death in our most specialized situations. And the challenges we face the increased challenges not only with sustainability, but the breadth of our services were committed to. Next slide please. Access is critical to each of our providers. The motivation to help patients is why we went into the health profession. And so we take tremendously seriously the improvement to access we need to accomplish. Part at a very high level you saw previously in the slides on 18 for our physician FTEs as an example from fiscal year 21 to 22. They've essentially been flat from 762 to 765. And yet despite all the challenges. The exceptional care experience provided. And the increased commitment to access these same number of physicians have increased their work effort nearly 10% in aggregate and launched several new initiatives which we want to highlight on this slide. E consults will talk about first to an opportunity to communicate between primary and specialty care. In the last presentation last year, this is launched. We added additional E consults in June. We will add additional ones in the next month and our goals have an E consult across all specialty. So what's an example of an E consult. Because we're trying to get closer to the patients with the growing demand and offer additional ways beyond the traditional in person clinic visit. So one of our primary care physicians has shared how she corresponded with one of our gynecologists for a patient who had a question for cervical cancer screening about the follow up giving findings on initial pap smear and HPV testing. And the feedback was both reassuring to the patient. And in this case was able to do surveillance at a more extended time period, and not an immediate one. Another E consult was from our primary care physicians about a patient with diabetes with worsening kidney function and able to speak with one of our pharmacists directly and do a direct medication adjustment. Readily adjusted dosing and yet targeting the reduction in blood sugar that we want for long term outcomes. Another example of the behavioral health issues that we're all facing is an E consult from a primary care physician directly to one of our psychiatrist to get immediate feedback on adjustment of an anxiolytic medication to adjust the dose in combination with a mood treatment for depression. And to do that dose adjustment and see how the patient then went after that versus needing to wait for an answer or to have an in person visit. So an immediate feedback and communication. So you will see these increasingly. And what we deploy with our commitment to high value care of new ways to deliver care. To meet demands for access telehealth. The one I would really highlight here is stroke treatment. As you know time is brain. One of the scariest moments any of us could ever go through. And with increased illness in the population. So there's many complications of COVID. This is one that stroke unfortunately has many medical and social determinants that result in a very narrow window for diagnosis intervention. And so clearly telehealth across our network in Vermont as well as Northern New York is critical. We have centralized scheduling since the last green mountain care board presentation we now have centralized scheduling for over 3000 patient visits a month that will grow. We have specific examples and specialty clinics in urology pulmonology rheumatology and neurology. We're offering options across our network and a particular CVMC Porter UVM Medical Center. So just one example in urology 239 patients gained access faster UVM Medical Center simply by maximizing our provider schedules. You'll see in the next slide one of the foundational elements of Epic that enables that to happen. Additional 214 patients access care at CVMC who didn't live in Washington County but were offered the option and had a great patient experience able to access care earlier. The last one being very targeted in situations such as we face in all that you've seen for our planning, our strategy, our financial management is to be targeted in an access that's no different. And so we've looked at areas where we could convene our teams with a very specific goal or a short period of time to reduce backlogs in particularly areas that we felt could have even more unfavorable impact on patient outcomes. So imaging is critical for timely evaluation and monitoring and treatment. So with the new MRI UVM Medical Center. Thank you for the approval certificate me which I hope underscores the importance of when we come with request for capital that you can see our lens from a quality of population perspective. So we've reduced the backlog down to two weeks. We're not done, but we feel both from provider and patient and we feel much better about our available our ability to have timely diagnosis. Our CT scanner want to have credit to our radiologic technologist, our radiologist, our teams who have launched over the summer weekend clinics. Because again, you've seen the challenges we have in staffing but highly motivated providers with the challenges we face who said we're going to do a weekend clinic and get the backlog down. So that was 27 patients last weekend. The backlog is from eight to six and a half weeks. We certainly have work to go to get that lower but just so some specific examples of what we're doing despite the challenges and going back to the very first slide in this section. Why we believe as Dr. Rump said said at the beginning, we make the request. This is the rationale behind it and why it's important for these resources to be invested because with the resources we can make specific improvements from what we're already doing and what we can do in the future on access. The last thing I'll say in this section which not and the points on the slide is, you know, you saw back on slide 18 that we want to grow our providers. We want to grow nurses who work with us full time on our on our teams. And same thing for physicians and we want to grow at least 30 physicians next year. We've been able to make these improvements with the challenges in our workforce, but to achieve the goals and meet the patient demand that I hope you've seen and felt and outlined here. These investments are critical to be able to increase our provider workforce. So the last slide on this section. Just highlights the foundational investments that have been made in the health network and here in Vermont for over a decade. Many of them at the inflection point were at it relatively recent. So as you've heard the epic electronic health record. We just in April completed the third phase of implementation. So many of things that we talked about just over the summer or with the consults and things that will turn on for access in the coming months with direct scheduling from a patient portal are just now available. As of a few months ago, the analytics and reporting, which I know today's presentation is more limited and we'll have ongoing communications, but our ability to have analytics on all parts of how we're doing population health is on in discussion earlier to really look at population and risk adjusted data data that's meaningful to truly see performance and to do interventions. That is just now available not only for clinical through through epic, but the analytics software adding on top of that to date data feeds for claims and clinical put them together. Our care management teams working even more closely together and really working as I mentioned earlier to try to address and reverse the trend of patients going to higher cost settings of care to be able to help patients transition from the inpatient setting to post acute or to home or directly from our ED. In our medical group, we talked about our physicians. I want to highlight our advanced practice providers, our physician associates and nurse practitioners. And our medical group is increasingly organized and you see in this presentation is the health network at central Vermont Medical Center at UVM Medical Center at Porter Medical Center, because our physicians by specialty are working more across all of those sites, which is how you can do the work that we talked about earlier for urology appointments. If everyone is working more on a team of specialists, then we have more flexibility and using all of our facilities and assets to their greatest potential. And then lastly foundational elements of our ACO networks and our growing connection of those analytics and reporting capabilities in our own population health services with our ACO partners. And with that and before my transition, Dr. Hunter, I want to highlight what we're really excited about going forward and population health in general with all these elements of their partners and that's health equity to be able to see where our health disparities are and to begin addressing one by one looking at social determinants of health improvements in those health disparities because we have these foundational elements. And we have leaders such as Dr. Jackie Hunter have joined our team. So it's a pleasure to turn over to her for the next section. Thank you. I could just interrupt for a second and I apologize and I thank you very much Dr. Sanders for that really informative part of your presentation. I just want to interrupt and just make to make sure that we have everybody's I think full attention and focus on, you know, these important equity efforts. I think it'd be great if we took a 10 minute stretch and bio break for folks so that everybody can really focus on what we're going to hear in the next part of the presentation. So it's 1017. Why don't we just plan to come back at, we'll plan to come back at 1030. Okay, that's all right with everybody. There's no objections. I'm going to give everybody a little chance to stretch your eyes and everything else. Okay. Thank you, Madam Chair. 1030. Then I think to keep all the trains moving on schedule. I am going to ask you all to, you know, bring up your slides and I think you're going to hear from Dr. Jackie Hunter next if that's correct. Great. Thank you. Good morning everyone. Hopefully I run the reporter off. So really excited to be able to join you all today and talk about health equity. So my name is Dr. Jackie Hunter and I come from the Southwest, right from Arizona. So been here for almost a year. So really excited to talk about health equity and how this is going to impact Vermont. So Jen on the next slide. So as we navigate through, as we've heard about a competitive and evolving workforce and the financial impacts of COVID-19 and its continued aftermath on the system, we really are committed to investing health equity for our Vermonters and our community in the North Country. When we think about health equity, it yields innovation. It yields vitality and it's truly a business and a moral imperative. It's truly the future of healthcare. As we've seen, there's been a lot of talk about health equity. We saw throughout the pandemic, all of the maps that went across and just how the pandemic impacted a variety of different people, especially people of color and their outcomes are different. So as you look at this slide that you see on the screen, I want to take the opportunity to talk about how we are going to bring health equity to life. So a couple of great things that have happened thus far is during the initial COVID-19 vaccine rollout at the end of 2020, as well as into 2021, UVM Medical Center and academic partners collaborated with the community organizations and legislation to stand up the first BIPOC vaccine clinic, which is really critical. So as we think about that and we think about our new American population and others, it was really important to make sure that we got out to the community and that they felt safe to get the vaccine. So this is critical because we all sell back in 2020 and 2021. There is vaccine hesitancy or as I like to call it, vaccine curiosity and a low vaccine rate amongst people of color. There's been a renewed commitment and awareness to health equity to make sure that it's a strategic priority as you can see on the screen here. So we're currently building an infrastructure to help drive health equity. One thing that recently occurred is that the community health improvement team recently came under my leadership. And what's exciting about that is the community health improvement team is that they're responsible for the community health needs assessment. And historically, nationally across the United States health system has used this compliance activity for just that compliance. But we actually want to take it beyond compliance and remove it into strategy. So recently the community health needs team completed the community health needs assessment at UV medical center, and they were very intentional to make sure that they captured a diverse population, not only including race and ethnicity, age, socio-economic status, language, and many more. So what we're going to do is we want to take that methodology and as we work with CVMC and Porter and others and really cast a broad net so that we can make sure that we're getting input across all of Vermont. This is going to help us understand the priorities and come up with an action plan. So the next slide. So as we think about diversity, equity, inclusion, you probably heard that term a lot. We really want to, we really feel that it is the paramount in future of health care. It really impacts everything that we do. So it includes all aspects, not only limited to our patients and families, but also our people in our communities. So what you see here on this slide is that we just recently completed a three-year multi-year strategy with aimed statements that you'll see listed below. They'll be infused across the network. We have three pillars and today I want to focus on one. And that one is going to be in regards to our patients and families and how do we help understand the health inequities that have plagued the United States for quite some time. So what we've done is we recently launched a quality dashboard. With that quality dashboard, we have ambulatory and inpatient measures and they're going to be stratified via race, ethnicity, age, social determinants of health, language, and others. So as you heard from Dr. Sanders previously, we're going to partner very closely together as it pertains to how do you care and population health. One exciting thing, my peer, Dr. Nett Macias-Hogue, our network CNO, and I, we've partnered in regards to a huge language access process. Whenever I first arrived, I heard from our staff, clinical and non-clinical staff, in regards to some of the issues as we think about language access. As our population here in Vermont continues to diversify with our near-American population, we want to make sure that not only those where English may not be their first language, but also want to make sure we focus on health literacy. And so what that means is where English may be their first language, but we want to make sure that people can understand at the education level. So we really are working to make sure that our materials are translated to a fifth-grade reading level. And as we also think about language access, we cannot forget about our differently-abled population, our deaf, blind, hard of hearing, and visually impaired. So this is going to be a long-term project and ongoing. And also a couple other great things that we're working on at Porter. We just recently partnered with the University of Arizona, and we're going to bring forth a training that's called Safe Zone Training. We just recently implemented that at Porter Medical Center, and that's a focus on our LGBTQ-plus population and healthcare. What are pronouns? What are some ways that we can have more inclusive care as we think about our LGBTQ-plus population as we know there are disparities? There. So we're really excited to be able to partner there. At CVMC, we're partnering with Anna Newton's team as they get ready to prepare international nurses coming here next year, early next year for the Philippines. And what's so important about that is that we want to work with local businesses in the area, as well as community partners to make sure that we bring that friendly welcome for which we know Vermont is known for. So as I get ready to close, one thing that I'm very excited about as I talk with other chief diversity and equity inclusion officers nationally is that while we are small and mighty here in Vermont and upstate New York or the North Country, we have a great opportunity to be an industry leader in health equity. We are well far ahead in regards to a variety of work as we think about stratifying our data. And so we're really excited to see what the future holds for the University of Vermont Health Network and health equity really truly benefits every single Vermonter. And we really look forward to your support as we continue to invest financially in such critical and meaningful work. And with that, without further ado, I'd like to pass it on to my buddy, Dr. Steve Lefler. Thank you, Dr. Hunter. And so I'm going to highlight some of the challenges that have been faced at the Medical Center over the past year. I will tell you that FY22 has been an amazingly difficult year for the Medical Center. Since April, the Medical Center's only had two days where we weren't in red census. We break every day into three categories. Red census means that operation is not normal. You have to do extra things to try and get everyone cared for. And pretty much every single day now we're in red. We actually even added a higher category, super red, because red isn't enough on many days. Basically, for the Medical Center, we have trouble getting everyone in who needs to be here and great trouble getting people out who no longer need to be here. Every single morning at six o'clock in the morning, we get a census report for the day. The first thing as a clinician, I look at every single day is how many people are waiting to come to the Medical Center. It's unfortunately never zero anymore. It's always two or four. Some days it's as many as 10 or 11. Our transfer center does an amazing job of figuring out who can wait a little longer. But it's stressful for those patients, their families, and the other hospitals across our region who are trying to get people here. I thought I'd briefly talk about three huge areas that we work on every single day because they're so challenging. Our emergency department has 59 physical beds. That's actually an increase. Before the pandemic, we had 43. We added two extra units in the back hallway for people who have been here to manage COVID patients. Now almost every day they function to take care of other patients who need medical needs. We have 59 beds. It's been common over the past four months that at times we have more than 100 patients in the department who need care. As an emergency physician, I can tell you that is unbelievably difficult and challenging. That means you're caring for people in the waiting room, the family room, you're caring for people in the hallways. You're trying to make sure those 59 beds have the sickest patients. It's impossible to do that all the time because we very often have so many psych borders. Typically, our ED has 15 psych patients waiting to move to inpatient settings. That's about 25% of our capacity. Most of those patients need one-on-one constant observation. When we're okay, we have enough observers to do that. But when not, we have to pull techs or other people to provide that care. Just as a note, it's costing us about $5.4 million a year in observers for our site patients, which is completely uncompensated care. More important to me, all those patients are in beds that we need for other patients who are in the waiting room who need to be transferred here. An ED functions best when people are in beds for about four hours. You expect a four-hour turnover turnaround time for patients to come in, get their care, and out. Some of our site patients have stayed two months. Inpatient site, we've kept the unit completely full as much as we possibly could. We're doing that with travelers, and that's costing about an extra $2.3 million per year to do that. If you look at inpatient, so after people are able to get from the ER upstairs, we have a huge issue with lack of post-acute beds. I think about the world prior to the pandemic. Prior to the pandemic, we often talked to you about having 30 people waiting for the next level of care, ready to leave the hospital but couldn't go. We used to say that was one floor of patients. Over the summer, we've run 50 to some days as high as 75 patients who are ready to be discharged, but there was no place able to accept them to go on to the next level of care. Many days, that's 18% of our med surge beds. Our hospital service is designed to run at peak of 135 patients. Every single day now runs more than that. Today, it's 149. A couple weeks ago, it was running at 167. The service was so high, we had to call in extra providers to care for the patients, and we were concerned that if it lasted more than three or four days, we're going to have to pull providers from some other service to try and keep all those patients cared for. A big part of that is people that are ready for discharging can't go, but there's also our medicine service has been exceptionally busy. We built our budget in 22 around an inpatient census of 410. The average daily census for the third quarter has been running 440. That puts many areas every single day over 100% capacity. During the pandemic, we added 15 additional temporary inpatient beds. And our goal was to close those back down because we're mainly staffing them with travelers. We've been unable to do that. We need those beds all the time to make sure we're caring for Vermonters who need us. Lack of available staffing has been really driving up a need to continue to need a lot of travelers here. We're averaging about 385 per month. Peak over the winter was 438. The cost for our travelers this year is $117 million versus a budgeted amount of 13.4 million. I want to be clear, those travelers are here to care for the patients who are being transferred to us, coming in through our ED, and are staying on our floors longer than we would like them to be here, but they need care. And the third giant challenge we're facing every single day is workforce. About 58% of our overall budget is workforce related. For the medical center is a little lower than some of the other places because we have a lot of expensive drugs, expensive equipment, and things like that. $150 million budget to budget 22 to 23 is directly related to staffing the medical center to care for patients who need us. Hospitals need to transfer patients to us and really being here for patients across Vermont who need our services. Every single day now, every day is a challenge to make sure that we have the staff in the space to care for everyone who needs our services. It's hugely challenging. Having the money crisis be part of that makes it more difficult. As a clinician, as an ER doctor at heart, all they want to do is open more beds and get everybody who needs it. But right now, there's always a third factor in the equation of can we afford it? Can we afford to bring in more travelers to open up the space? And we're doing our best to make sure we're caring for everybody, but it's exceptionally challenging. So thank you. I do want to advocate for the importance of our budget for caring for Vermonters and our hospital partners who need to have a strong tertiary care center to accept patients when they need them to come. Thank you. I'm going to turn it over to I think it's Anna Noonan. Yes. Thank you, Steve. I want to thank Chair Holmes and members of the Green Mountain Care Board for the opportunity to highlight a few key points relative to CBMC. First, I want to underscore that approval of our budget as submitted is absolutely critical for CBMC to continue offering the essential health care services we deliver to central Vermonters. As you've already heard, CBMC is high quality and very low cost. This is actually the third year in a row that CBMC has received a five star rating from CMS. As Anya mentioned, and she shared with you earlier, Vermont is the lowest cost state for Medicare per capita expenditures. And for total Medicare reimbursement, Berlin is the third least expensive HSA in the U.S. Some of the challenges that you heard from Steve are also challenges we experienced here. Earlier this year at the request of the state of Vermont, we increased our inpatient bed capacity by 36 percent. And our med search capacity was increased by 13 percent by converting beds in our women's unit to meet the increased acute care needs, not only for local service area, but for the state as a whole. That increased capacity required staffing with travelers. It's important to note that in FY 22 year to date, we are at or under budget for all non-salary expense lines. Our primary driver for our margin loss is the cost of labor. I know the board is fully aware that in 2018, CBMC launched innovative career pathway programs in which our staff work while they learn and our MS and doctoral prepared nurse leaders serve as faculty. This year in June, we graduated our second cohort of LPNs and knew this year we've invested in an LPN to RN program with two students completing that program. The state of Vermont also approved CBMC to run its own LNA program. Those programs were shuttered across the state because of the pandemic, so we wanted to be able to keep that pipeline program going. We used travelers in the LNA space for Woodridge, which is an incredibly costly endeavor. We also launched a medical assistant program in June so that we have support to staff our 27 practices. As you heard by Dr. Hunter, we're contracting to bring international nurses to central Vermont with the first cohort arriving in March of 23. We're working with a company that has experience to do that, and we're working with Dr. Hunter and others to make sure that when that cohort of nurses comes to central Vermont, they're well received and they can integrate with our central Vermont community. Working with the network will be launching a surgical tech program to support staffing our ORs. Clearly, we would have been much more challenged financially if we had not launched these innovative pipeline programs in 2018 and kept them going through the pandemic. Some additional challenges I want to reinforce is that CBMC is primarily a medical acute care hospital. The majority of our patients are medical patients. Working with the network last year, we did increase fiscal year to date our surgical volumes by 3.5%, but again, our surgical volumes are primarily outpatient. It's great that we're meeting the needs of our community and the needs of the network, but those volumes do not translate to acute care dollars. Our length of stay is driven primarily by the chronicity of the disease conditions we treat. Many of these patients also have an adequate community and social supports, so they stay here. It's important to note that 25% of CBMC's acute care beds are filled with patients awaiting placement to long term care. Woodridge, our long term care and rehab facility has an average daily census of 121. We budgeted 127. We simply cannot staff the beds with a workforce we have despite our innovative pipeline programs. We currently have a 33% RN and LPN vacancy rate. Again, this is with our innovative programs serving as a pipeline. Travelers are being used to maintain that current census at significant cost, again, despite our innovative pathway programs. The other piece I want to mention, as Steve did, is the uncompensated care we provide. Psych boarders are in our ED as they are at UVM every day, and we estimate conservatively a $1.6 million loss for uncompensated care by having those patients in our ED. In the past two years, we've had an additional challenge of neurodiverse patients boarding in our ED. We had a recent case of an individual who was medically cleared on the day of admission and stayed 67 days in our ED due to the lack of appropriate care setting in the community. All but one of those days of that stay was uncompensated, so 66 days were uncompensated. And I know you can imagine the halo impact of having someone like that in our ED, not great for that patient at all or their family, and obviously additional burden for the staff in our ED. I also want to point out that our IPP unit has an annual loss or inpatient psychiatry unit has an annual loss of 4.5 million. That's for nine beds. Again, I cannot emphasize enough the importance of the approval of our budget as submitted. This FY23 budget is critical for CVMC to continue offering the essential services we provide to Central Vermonters. Without the requested increase, CVMC will need to review the current services we offer and make difficult decisions along with our health network colleagues for FY23. Thank you for your time. And I want to hand it over to Tom Thompson, who's the president of Porter Medical Center. Tom. Thank you, Anna. Chair Holmes, Green Mountain Care Board members and staff. Good morning. In last year's budget presentation, I communicated concerns about Porter's proposal. That we likely understated our salary needs, that inflation rates were starting to creep, that our agency staffing levels were at their then highest point ever. In sum, that our budget success was likely challenged even before we got to the start of the fiscal year. Our fiscal year 22 experience is among the most challenged of our small hospital peers. Our workforce challenges have been exceptional, clearly our top operating issue. Oh, excuse me. We're taking a lot of the right actions. We're building staff supports, implementing training partnerships, creating career ladders, enhancing our recruitment approach. We've also continued to improve our wage competitiveness, though the budget impact of our agency staff dependence has made that more challenging. Recruiting new team members to our area is also challenged by issues of housing availability and affordability. Addison County housing supply is down 40% from a year ago. Affordable housing seems nearly non-existent. People buying houses are those who are able to spend 40% more than a year ago. These factors make it challenging to recruit to our market, and our community is putting plans in place to address these issues, but those plans do take time to unfold. At the same time, demands on our care capacity have increased steadily throughout the year. We've realized ongoing increases in patient volumes, acuity and length of stay, coupled with decreased system capacity and the aforementioned staffing issues. While it's not the same experience as the Medical Center or CVMC, the impact we realize with folks being cared for in emergency department hallways is real. About one in six Porter emergency department patients is cared for in an ED hallway due to throughput issues locally and regionally. Like many hospitals, we also have realized increased incidents of patients in acute mental health crisis. About 10% of Porter emergency department care hours are incurred by people in acute mental health crisis who are held in a room we've modified to be a safe room awaiting placement. Often for many days and in a department of our scale that is very impactful. We anticipate that these capacity pressures will be ongoing. Market studies indicate overall Addison County population growth of nearly 4% by 2027, including 19% growth in the 65 plus population. So in spite of progressive efforts at Porter and across our health network to manage care transitions across care settings and organizations each day. Innovate in our primary care settings and redesign care delivery across our markets. Our experience and these market trends indicate we will continue to realize capacity pressures across our system. We believe it has been the right thing to do to maintain capacity this year regardless of its cost. You've heard examples already of bed capacity being increased in staff with agency staff that has been our experience to we have maintained 100% staff capacity in all care settings at all times. This commitment has required extensive use of agency staff that makes up 10% of our staff dollars and 30% of our payroll. We've had as many as 75 agency staff serving patients and residents across Porter's care system. This commitment has resulted in an 11 million dollar budget variance in a 108 million dollar organizational budget this year. Now I've talked a lot about our challenges, but I wish to close by expressing pride in some of our teams wonderful accomplishments this past year, including our ongoing collaboration with community partners to address priority health and operational issues, enhancing our primary care model to better serve care needs of specific patient groups, deploying the epic health information system in our acute and our long term care settings, onboarding 18 new providers to enhance access to care, deploying an organization wide huddle process to enhance safety culture. Implementing DEI education and other programming supportive of a culture of inclusion. I can speak to many more material accomplishments in this year of great challenge, but my goal was to stick to five minutes so maybe we can do that some other time. In closing, Porter's and Vermont's health system face a lot of challenges. We understand these issues and continue to put the right work in place to serve our missions effectively. As has always been our approach, the budget request advanced by Porter and our UVM health network affiliates today is designed to support baseline requirements. For Porter, our budget's most significant operational challenge will be reducing agency staffing dependence from current 30% to 12% of our payroll, which is what is included in our budget. We are confident we're putting the right work in place to gain this outcome. So thank you again for your time and consideration of our essential budget request. And I'd like to turn the presentation back to Al Gobey at this point. Thank you. Jen, you can go to the next slide please. So as we come to the end of our formal presentation, I want to thank the Green Mountain care board and staff for your time and your willingness to let us present from the beginning to the end. And we now know there'll be quite a few questions, but it was really nice for you to give us that opportunity. I want to close with a few points. First, in a way that I cannot articulate through teams in a public meeting with a PowerPoint slide up in front of me talking to a Dell computer, this is a moment in time where you must pay attention to our finances, our mission, the cries of our people, the voices that you've heard today. You must also understand the empathy that we have, not one person on our team wanted to come here with a double digit rate increase today. That is not what we want to do. Every single provider we have is altruistic at their heart and cares deeply about people. We're here today because we have no other alternative than to seek the funding necessary to be able to pay for the services our communities, our friends, our neighbors, our family members need. And so in closing, we've had a long conversation in Vermont about what is high quality, about what is low cost. I think we've done a really admirable job today of trying to explain why we think that we are a high value, high quality healthcare system. But that we are facing national headwinds that are beyond our control and frankly beyond your control. We cannot control the workforce crisis that we are currently burdened with. I cannot imagine having explained it any better than Dr. Jason Sanders when he explained about the problems of acuity that we face and how that's impacting every facet of our operation. These are things way beyond our control in the moment and we are still in that second bucket of the pandemic, that stabilization bucket. And that is why we need your approval of our budgets as submitted so that our finances can be sustainable and we can accomplish the mission that all of you want us to accomplish. The last point I want to make and it's on this slide and these slides were submitted to you, I believe on the 10th of August. So this was a commitment we made, you know, several weeks ago in our meetings that every single dollar that we get from the government payers above what we thought we were going to get in our estimates that we have to do based on the process. This is not like bad estimating on our part. We will, we would ask that you work with us to reconcile those by November 15th, but the deal has to be this. You have to approve our budget as submitted and they have to be evergreen dollars one time money will just cause a hole for next year. And so if we can work on that together, that's the type of trust that Dr. Brumsted described and that's the partnership that I've been trying to describe so that we can have that type of health care system in Vermont that we know will be there for us when we need it. Again, thank you to the Green Mountain care board and staff and thank you for listening to us today back to you, Madam chair. One more point, one more, one more point, Madam chair, if you're going to ask questions, I just ask that you go through me and I'll kick it to my colleagues because with teams and it's going to be kind of hard. We will get to anybody you want to get an answer from, but if we could just do it that way, it'd be great. That sounds wonderful. And actually what I think I am going to do though is I think what we're going to do is this is a lot to process. It's been a long morning already. I know we had a short break, but I think the best scenario here is to take this moment actually take an hour here, have our lunch break. It'll be a little bit of an early break, but it'll allow the board members to really process everything they've heard consolidate their questions for all three hospitals. And we can come back. Let's come back at noon unless there's any objections from the board. Okay, seeing none. So I think what that's what we'll do and we'll come back here at exactly noon and we'll kick it off with those questions from the board and the staff. And we can absolutely go through you, Mr. Govay. That sounds great. Thank you, Madam chair. We'll see you at noon. Sounds good. See you all at noon.