 Good afternoon everyone and welcome to the Green Mountain Care Board. My name is Kevin Mullen, Chair of the Board, and I'm going to call this meeting to order. Our Executive Director is on vacation this week, so there'll be no Executive Director's report. We're going to go immediately to the minutes of Wednesday, July 13th, is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, July 13th without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor of the motion, please signify by saying aye. Aye. Aye. Any opposed, signify by saying nay. Let the record show the motion carried unanimously. And now we're going to turn to the business of the day, which is an initial review of the hospital budgets for 2023, and I'm going to turn the meeting over to Sarah Lindbergh. Sarah, you're muted. You're able to see my screen? Yes. That's great, and now you can hear me, so we're all ready. Sarah Lindbergh, I'm the Director of the Finance Team here at the Green Mountain Care Board, and today we're here to just give you a preliminary overview of the fiscal year 2023 hospital budget submissions, as we have seen them through July 20th. So as a refresher, the process began when submissions came in on July 1st. Today we're going to give you this preliminary review. Hearings will be the weeks of August 15th and 22nd, with deliberations starting September 1st, and decisions finalized by September 15th, and written orders due by October 1st. So we have not received any public comments to date, but there is currently a special public comment period in order for the board to consider those comments. They need to be submitted prior to August 31st. So anyone interested in making a comment may use this link or find it on our website. You also may find on our website the individual hospital submissions, as well as the documents, highlighting what we asked for for fiscal year 23. There also is a high level overview of the hospital budget review process available on our website. So just to kind of orient us in the bigger picture, the state of Vermont is working in its entirety to continue health reform goals. One major recent addition was Act 167 of 2022. And some of the work in that legislation that is relevant to hospital budget review is that it charges the Green Mountain Care Board with developing an allowable rate of growth for Vermont hospital budgets with a myriad of conditions to make sure that they are helping to sustain and support our hospitals. And we also are in collaboration with AHS working on developing value-based payments and promoting the long-term stability of our healthcare system. So that is doing things in order to bring people together and think creatively about the problems facing us all. And just always helpful to remind ourselves what is in the Board's purview and what is outside of it. So the way that reimbursements to hospitals or any provider work is that Medicare establish is its rates through federal rule. There currently are some proposed rules for federal fiscal year 23 on the inpatient perspective payment system and calendar year 23 for the outpatient perspective payment system and the physician fee schedule. These are proposed rules. There are no not finalized and there's actually quite a bit of back and forth request that Medicare reconsider these proposed rates. But right now where it stands is a 3.2% net change in the Ips reimbursements, 2.7 in the Ops. And the physician fee schedule is expected to take a significant hit. A lot of that is due to and the expiration of a COVID related reimbursement increase of 3%. There's additional strife about some upcoming statutory requires sequestration as part of the pay go act. Which would add an additional 4% cut potentially to providers. So all that to say is that Medicare rates are a source of stress on the system. The way that Medicaid reimbursement works as Medicaid or I should say the Department of Vermont Health Access establishes the payment rates, but any changes to those rates must first go through approval of the state budget. So the legislature is the one who actually approved those. So any changes that would hit this fiscal year would theoretically occur in the state fiscal year 24 budget, which means that by the time those would kind of be on the table, it wouldn't be until Q4 of the hospitals fiscal year. Now there are wild times call for wild measures. So last year the budget adjustment act did include a change that allowed rates to be effective January 1st, 2022. So that is certainly something that might be possible, but all of this of course is the Department of Vermont Health Access and the state legislature, not something that Green Mountain Care Board directly influences. So for commercial and self-funded plans, essentially the Green Mountain Care Board's decision-making here sets two different amounts of change that are allowable. One is for the overall net patient revenue and fixed perspective payments for a hospital. And the other is the requested change in charge and that is again, the charge associated with the services. Those are then translated to negotiations between the hospitals and their different payers. So it's not necessarily a one-to-one increase and furthermore, different groups have different plan years. So they typically are from January 1st to December 31st, but by no means is that universal. And so there's a little bit of lag in trying to get all these reimbursement changes to kind of marry up. So that's just one of the challenges that people face when they're trying to develop these budgets for us. So in terms of what is within our wheelhouse, the guidance that was submitted to the providers, to the hospitals who submitted their budgets, was that the aggregate growth rate. So from fiscal year 22 to fiscal year 24, the board was suggesting an aggregate growth rate of 8.6%. So there was not any idea about whether all 8.6 would be used in fiscal year 23 or any other guidance in addition to that. However, the board also said that they would consider other requests as long as there was support for that request given within the submission. And the factors, the board and the guidance established it would consider the hospital budget submissions based on is a long list. So bear with me while I read you a slide. But the first is kind of typical financial metrics of a hospital such as days cash on hand and other typically collected metrics and ratios. And that assessment may include looking at year over year comparisons or benchmarking that information with other hospitals. We also said that on the table for consideration would be growth of operating expenses and any offset by reduction in conjunction with the NPR and FPP. That's unmouthable. We also were able to consider hospitals other operating revenue in connection with their operating expenses, what the hospital's long-term strategic and financial plans are for sustainability, data and information provided by insurers and other third party administrators regarding actual and projected utilization and price changes, as well as the impacts on Vermonters and employers in the commercial market. And that includes our self-funded employers and our other payers, Medicare and Medicaid and what payment changes might mean for them. We wanna look at how any payment changes are gonna work in confluence with these budgets. We highlighted some of those expected changes that we know to date already, as well as any guesses about what might happen to the rate of uninsured Vermonters. We're looking at previously approved changes in NPR and FPP. We are able to consider population or demographic data and this lists some of the reports we currently have available such as patient migration and the supplemental data that we provided related to the census information. Also looking at the variation in reimbursement data that we have based on both cost and cost coverage. That's what I think of as kind of the analysis that Burns & Associates did for us last October. And then looking at data relative to payments to similar hospitals. So how in line do our hospitals seem and that includes trying to estimate medical inflation. And then as dictated by law, we have to take into consideration the extraordinary labor costs and investments and the impact that has on the affordability of healthcare. And if you catch all any other relevant factors proposed during the review process. So that is what we have on our menu for consideration this year. So to just tee up some high level themes in the budgets as we're reviewing them. First and foremost is there is a consistent concern about the financial health of our hospitals and they establish or put forward their concern about their ability to continue to provide necessary services. And so many of these budgets are directly framed as providing stability and trying to stabilize the system in order to be able to continue to provide that necessary care. The main drivers of expense increases, which were substantial or are budgeted to be substantial has to do with that inflation. So the cost of supplies increasing and also labor and workforce more broadly as a major driver. So it's not just having to use more costly temporary labor like travelers and locums, but also some unbudgeted increases to salaries in order to attract and retain staff, which is an investment that theoretically would cut down on the higher investment for more temporary staff. In addition to that, even though we already knew travelers were expensive during kind of this supply crunch, they were even more expensive in fiscal year 22 than anyone had ever seen before. So some issues related to operating revenue. So there are definitely continuing effects of COVID on our providers. And that is going from kind of delaying capital investments to having provider burnout. The toll that the mental health crisis is taking on staff is also acute, more violence in the workplace. So they're still kind of dealing with the aftermath of the pandemic and what it's put us all through, but with drastically less relief funding to help with some of those restressers. Also the federal 340B program is continuing to show net declines to the system. So we're losing about $25 million over the fiscal year 22 budgets. And that has to do with pharmaceutical companies kind of pulling certain pharmaceuticals from participation in that program. But we are also seeing an increasing revenue from specialty pharmacies. So that added 99 million to the other operating revenue in the budgeted fiscal year 23 over fiscal year 22. Other themes, changes in case mix. And there's a few different ones that have been showing up in the budget requests. One has to do with Medicare Advantage. So that's affected us in a couple ways. One is that we want to work in the future to make sure that revenue is booked consistently in the same place. So I think it's sometimes appeared in commercial and now has moved over to Medicare. So we just want to make sure we have that cleared up. But also payment changes can often be lagged with the Medicare Advantage business. So that's just a kind of factor that's shown up in some of the budgets. We are seeing the continued effect of aging here in Vermont. So more people relatively being covered by Medicare than other payers. And then there is the anticipated redeterminations once the public health emergency is over federally which would affect the Medicaid caseload. And so that's just another uncertainty facing the budget for 23. We are seeing a pretty consistent increase in ER and ED visits as well as imaging which might be an indicator that some of the care deferral that was true in the past may be subsiding. However, there does seem to be recurrence of that suppression of care whenever there's a surge. So if we do have another big bump in COVID this fall we might expect to see that drop again. So here are the rates that I'm sorry to be precise. These are the requested change in charges. So this is over the charge master which is not specific to anyone payer but that is the basis for the amounts that are billed and then negotiated discounts over those. So you can see that there's quite a range for fiscal year 23 going as low as 3.65% with UVM's commercial effective rate of 19.9 being the top. The weighted increase here would be about 16% change if we use the commercial rates for the UVM health network hospitals. So these are, you can see higher than we've typically seen in previous years but we can kind of visualize that here. So on slide 11, we can see the range min and max of approved change in charges from fiscal year 17 to fiscal year 22. We can see that over this time period the range of those approved changes has been quite wide but the median tends to be around 5% or less. So even if there's been a lot of variation the median tends to be close to that. And if we looked at what requested charges have looked like from 17 to 22 with an X marking the spot for what the request in 23 is we can see quite a few X's far off to the right so that's kind of evidence that these requests are higher than typical but we also are seeing expenses that are higher than typical. So just to put that into context. And if we look at approved increases in the overall budget so that's the net patient revenue and plus the fixed perspective payments we can see the 8.6 there was the guidance value and we see some hospitals are below that some are above it but we see that in most cases the request is higher than we have seen in the past six years. And here are some nice slides of numbers. This is showing the budget to budget increases so from fiscal year 22 to fiscal year 23 but I think quite notably we see that we are also displaying the change from the projections for 22 versus the budget and we'll see that quite a few hospitals are quite above their 22 budget. 22 budgets were very difficult to make just because of all the uncertainty so I'm not surprised that they are off but I think that it's gonna be really important as we evaluate these asks that we also consider what that projection to budgetary ask is as well. So if you look at some of these the number in the third column is quite a bit different than the number in the first column. And finally we can see the compounding growth rate from fiscal year 20 to date. So overall our PPS hospitals are growing at 6% average growth annual growth rate and the critical access hospitals at 6.3 overall 6.1. And here are the numbers back up our calculations on the previous slide if anyone wants to check our math. And here we have the payer mix. So this is gonna be an imprecise science for anyone. So fun fact is that a lot of the revenue doesn't actually track the individual so we do our best to estimate this by payer but even the same hospital system might not track these funds exactly the same way but on average we're seeing about half of the case mix being in commercial over the past few years. We do see a projected jump in the fiscal year 23 budget up to 57%. One thing I definitely wanna make sure is that we're all booking that Medicare Advantage business the same way that I just wanna make sure that's true apples to apples increase but also part of that is gonna be expectations that people move from being covered by Medicaid to a QHP. And we see that the case mix does look quite a bit different for our PPS hospitals as compared to our critical access hospitals by design. So they tend to have a higher proportion of Medicare people patients that they're taking care of. So we see that the commercial population is relatively higher in our prospective payment hospitals or in bigger hospitals. And when we look at our fixed perspective payment as a proportion of the NPR and fixed perspective payments we'll see that it's been relatively stable since fiscal year 21. We haven't seen any major increases in this. I will note that we will be polling the hospitals to hear learn if they are planning to continue to receive the all-inclusive population-based payment from Medicare. We wanna remember that that is more a cash flow mechanism than anything else because those payments are ultimately reconciled to the fee for service equivalent. And so some hospitals may not choose to continue receiving that. So that proportion might change even though nothing would be different about the dollars at risk or anything else about that. It's just really changing the cash flow. And here we see the proportions and numbers that back up the graphs that we just presented. So other operating revenue, one story here is that if you look on the left hand chart we see that lighter blue cap on the other operating revenue that's our COVID relief funding. That is really drying up. There's not expected to be much more there. You can see that that was a really helpful mechanism to help make hospitals whole during the past few years. And also we see the relative proportion of the specialty pharmacy and how much that's contributing to the revenue. So here's the other operating revenue in numbers again just in case you wanna check our map. And they're operating expenses. But what was helpful for me to break this down is to kinda look at the major buckets of expenses and how they've changed. The way to read this is there's an expense category in the far left. So the first one is wages and compensation. So if you look at the budgeted change from 21 actual to the 22 budget, it was 3%. But if you compare the 21 actual to the 22 projection so what's actually happening this year you'll see there's actually an 11% increase. So that goes to some of those unbudgeted increases in having to pay for travelers and increasing salaries that weren't necessarily budgeted. And when we look at the change from the 22 projection to the 23 budget, it's a 4% increase instead of the 14% from the 21 actual. So just trying to put some of these expenses into contact. So they look like, I think bigger increases from actual to the 23 budget than it seems like they are along the way. We are gonna keep an eye on those projections because they can continue to evolve as we get more information. But I think that they're giving us a better signal than the 22 budget at this point. Makes sense, you've got more information. So similarly pharmaceuticals from the 21 actual to the 22 budget was projected to increase by 1% but in the 22 to date, we're seeing more of a 20% increase which is expected to basically be another 18% on top of that into fiscal year 23. So that's another major driver of expenses in the system. So supplies are one that are also increasing. So we actually were expecting to see a slight decrease in the 22 budget from the 21 actual but it ended up being a 2% increase to date with expenses budgeted to increase by another 4% into fiscal year 23. And travelers, that's the one that really stands out. So negative 62% is what was budgeted compared to the actual but it actually increased by 58%. We are seeing those costs starting to stabilize and come down a little bit. So if we look at the 22 projection compared to the 23 budget, we're seeing another decline of 36%. So we're hoping to see that some of those efforts to retain staff are actually successful. And then just overall similarly, the budgeted increase of 3% is looking more like 11% and to the year over year from the projection to the budget at 4%. So some of these costs are definitely midstream and are gonna be relatively less dramatic from the 22 projection to the 23 budget. And so this shows that even with those projections to date, we're still expecting a system-wide shortfall in an operating revenue as compared to the expenses. And again, that COVID funding that was helping fill that gap is not expected to continue. So that's a kind of critical component in trying to tackle these 23 requests. So red is not great when you see a negative operating margin. Notably, we see some of our largest hospitals in the red here. So the University of Vermont Medical Center is at negative 2.5, Rutland at negative 3.8%. Central Vermont at negative 5%. So these are some large providers and seeing those operating margins being projected to be in the red is a concern. In dollars, you can see that, you know, yeah, that there's a lot of zeros in red, unfortunately at the moment. And when we put this into context, looking back to fiscal year 18, we typically show our all our hospitals, how just our largest hospital looks and then what the rest of the system looks like without that large hospital. And here we can see that, you know, UVM's loss is kind of pulling the system down a little bit, but that there's consistency in the budgets for a 2% operating margin, which I think is consistent with past decisions. And here we see our total margins, also a lot of red seeing some pretty high negative numbers. So as far as how these kind of financial metrics, a lot of these pressures are not unique to Vermont. They're not, you know, by any means. So we want to just provide as much context as we can to you in these difficult decisions. And so some things that we're getting for that is we are seeking help from some of the state's expert economists to get their take on the near-term forecast for medical cost inflation, with a particular emphasis on that inflation that is really outside the control of the Green Mountain Care Board or any state actors. We are looking at the price increase for qualified health plans in the publicly available filings through HIOS. We would love to see what negotiated prices hospitals are getting in the competitive market, but unfortunately a lot of that is not available it's proprietary negotiations or confidential negotiations. So unfortunately this is kind of the best we can do to get a sense of that. And then we're also trying to build out on some comparative workforce information starting with the Medicare cost reports. Again, just to add context for Vermont. So I'm going to walk through some previous key financial metrics that we the board has looked at in the past. One caution before we get started is that the most recently available metrics are for 2020 calendar year 2020, which is obviously not an ideal comparison point for anything, but it's again the most recent we have. And here's where I'll put a plug for while relative information is super helpful also having some kind of guidelines for what we would like to codify for financial health I think would be a good opportunity for improvement in the future. So here we'll start with those operating margins. So we have separated our critical access hospitals and our PPS hospitals the larger hospitals. So for those larger hospitals we're using Fitch Solutions for a Northern New England and a larger Northeast benchmark. We also have our average of Vermont hospitals so we can see that on average that line is below zero by quite a bit and we are seeing that back in that was back in 2020 to be clear. So we were doing poorer than our Northeast benchmarks back in 2020. And so we also have for critical access hospitals the flex monitoring we have a Northeast critical access hospital and a U.S. critical access hospital benchmarks. I would say as you would expect because of the similarity in how they're paid the deltas and the cause tends to be tighter for these reference benchmarks than it is for the larger hospitals. But we'll see seeing some negatives is never good on an operating margin and not seeing things that look pretty low here. So if we look at the total margin again looking at 2020 but we're seeing some hospitals not many hospitals are exceeding kind of the regional benchmarks from 2020 and that's also alarming for our critical access hospitals relatively more are kind of above the relative benchmarks on our perspective hospital system on that total margin. These cash on hand. I think that's a really important one to make sure that we're tracking. So those were somewhat inflated. I think by the COVID relief funding. So I think we're starting to see that drop is that's expiring. So seeing some of those numbers come down always want to remind ourselves that Southwestern's does not include their larger company. So that number is not necessarily want to freak out about right there. So these receivable looking a little bit more robust but still seeing these numbers lower than might be ideal. These payable again Vermont average is significantly blew the Northeast peers back in 2020 both for the critical access and the PPS hospitals and we're not seeing them catch up to 2020 levels here. Long term debt to capitalization. This is going to look really funky again due to having to kind of postpone capital improvements and other projects due to COVID. So this one's going to be maybe one of the hardest ones to interpret out of the box this at this moment. Similarly our debt service coverage ratios. This is going to be a really critical measure for kind of the ability to borrow in to catch up on some of that improvement. So still seeing Vermont well below the Northeast average is for 2020 starting to see a little bit more recovery here but probably more work to do in that area. Age of plant is one where again that's a little bit difficult to interpret at the moment but we are starting to see some certificate of need applications starting to come in for modernization and attaching attacking other necessary improvements. Yeah, so those are kind of sorry to whirlwind you through those but again worry about the 2020 comparison so might not be the best place for us to focus this year. So here's the ACO participation almost everyone in for Medicaid. Quite a few people participating in Medicare and the commercial business and we have a couple of participants for the self funded market as well. This is how it breaks out still have mostly governmental payers and we are expecting a bit of a decline in the Medicaid participation and that again is mostly driven by the redeterminations and the expected continuing decrease in enrollment in Medicaid. All right, that was a lot of talking. So next steps will be the hearings so we're going to work on you know producing you the typical material that you would see your binders if you will and we'll start on Monday, August 15th with Southwestern in the morning and Brattleboro in the afternoon on Wednesday we're going to get three in Grace Cottage at the beginning of the day, Springfield mid-morning and North Eastern in the afternoon Friday the 19th is the UVM Health Network and the following week we start with Rutland and Mountain Scotland Monday, North Country and Gifford on Wednesday and Copley and North I'm sorry that was Northwestern on the 17th and NBRH on Friday the 26th. And again just for reference some key indicators so seeing where these summarized values are and a glossary of terms so that's mostly for posterity I'm happy to hear any questions, comments that you have to share this moment Sarah great work and I just want to point out that I think there's a critical piece missing and all these numbers are based on the way a hospital is managed currently and you know we've all seen where in the non-medical world where one business has failed in a location but someone else has been able to operate it differently and be successful and I thought that there was a lot of very useful benchmarking numbers that were sent in in a public comment and it's something that we don't necessarily look at but like productivity measures like the performance the number of patients per employees things like that and I just think that my biggest fear is that if rates are approved in Vermont both for hospitals and for insurers that are too high that you're going to drive up bad debt you're going to force for monitors to make decisions that they shouldn't seek care and that may cost more in the long run and I just look at this as a recipe for disaster with the same knowledge that we need to make sure that we're going to have healthy hospitals so that's my comment I just think that there's a piece missing other board members any comments or questions I don't have any comments or questions at this time I know we've got a lot to dig into and Sarah I appreciate this big overview I'm looking forward to all the binders and dig it into all the narratives so Sarah one area I have a question on is Medicaid it's my own personal view as I go back through the joint fiscal offices record on Medicaid and its contribution it's basically been flatlined for the last five years in some ways for reasonable reasons caseloads go up during the pandemic and then they come down so you expect some volatility there recently we just got the notice that the 1115 waiver has been signed and with the old waiver and I'm sure for the new one there is a spending neutrality cap and I guess I'd like to know in this process where Vermont stands relative to the spending neutrality camp because that would be spending neutrality cap because that would give us an indication as to whether or not our reimbursement rates are where they could be I mean maybe they are perfectly structured maybe they're not but Medicaid is one of the major partners and it would be good to know exactly how that 1115 waiver is working yeah I definitely don't think I can speak for our colleagues but I think that they are also critically concerned about the stability of our health care providers and it might be worth inviting them in to talk to you about their perspective on this especially in the near term another area that I've raised this concern I don't know and concurring opinions are dissenting opinions I forget probably in both but is the level of growth of fixed perspective payments I understand there's change in Medicare that's happening I still see little if any growth with commercial payers and I'm just wondering you know I mean there's a lot to be done out there I'm sure at the hospital levels but do you get a sense whether or not hospitals are seeking actively seeking to grow their fixed perspective payment component or whether or not it's something that's on the back burner until they address other issues like travelers and pharmaceuticals and some of the other major drivers gosh I think I'm going to owe you some homework here where I can kind of distill how that was addressed in the narratives we can consolidate that for you and if there are follow-up questions we can certainly help broker those if no other board member has any comments or questions I'm going to open it up for public comment does any member of the public wish to comment at this time Kevin this is Mike Del Treco I'm having a hard time raising my hand but yes I do. Mike I'll call on you first go ahead. I apologize for that I was trying to raise my hand the computer wouldn't allow me to so certainly these are trying times there's a lot of Vermonters that are having difficulties paying their bills and we at the hospitals recognize that however I do want to start my comments with some accomplishments I don't think we recognize them enough and I think it's important to first all of our hospitals participate in value-based models this really demonstrates our commitment to progress affordability and the patients we care for if you look around there's very little or no other states doing the work we're doing in this space we have significantly bent our cost curve from the inception of the Green Mountain Care Board we've reduced our growth rate our net revenue or an FPP growth rate by almost 4% I know that this doesn't always feel like it saved anybody money or affected premiums but this is real money and it adds up to provide some context if we had grown at about the 8% prior to the Green Mountain Care Board we would have a spend or growth rate of $2 billion higher we led and we continue to lead one of the best and most aggressive campaigns against COVID-19 there's certainly a cost to that but it's been a really important part of how Vermonters have have survived and managed this pandemic we've been very innovative we recognize many needs in our communities and we've expanded our definition of a hospital well beyond bricks and mortar you may have read my column this week but it addresses things like housing, food insecurities transportation and it's all around how do we build and have vitality within the communities and vitality is economic vitality as well as healthier communities one thing that we also don't talk about is we have a 98% uninsured rate clearly there's some under insured but we have a population that has 90% insured that comes with a cost and we really need to understand that the list goes on but unfortunately on the other side of the story there's a group of hospitals that require your help and assistance at this time we have 10 hospitals more than 10 hospitals with negative margins for 22 so without other operating revenues our delivery system would be decimated when you add on top of that or consider violence in the workplace workplace pressures related to workforce and shortages of nurses and through the entire delivery system to cafeteria workers and other areas of the business it's a very big problem we have as Sarah mentioned we have very high traveler expenses at this time then you lay on unprecedented inflation in other areas our deferred capital maintenance you might even look at this picture and say how are we even providing the services that we're doing and surviving in this moment furthermore our hospitals deliver care in a system that doesn't have appropriate resources for mental health and long-term care patients and to make matters worse those delivery systems are stressed as well not only is this the most expensive way to care for people but more importantly it's the worst place and it's the worst way to care for these people they deserve better during any given week our hospitals some of our hospitals at our 100% capacity a real challenging situation and scary at times as far as our rates go I think we need to be careful not to perpetuate the idea that our hospital increases represent a dollar for dollar increase in premiums we know this is not how it works we know that insurers don't pay that way and we know that there are other variables such as volume and acuity into this equation so there's a lot here a lot of good, a lot of challenge I can tell you that my discussions with the VAW's leadership we are committed to this work but in this moment we need your help and I ask that when you go through this process that you approve these budgets as they've been submitted thank you for your time and I appreciate it thank you Mike next I'm going to call on Walter Carpenter thanks Kevin you said what I had on my mind so I won't reiterate it as to Michael's comment about 98% uninsured we should not forget that 44% or so of those remonters are underinsured and if they do go to one of the hospitals at either these rates or older rates there's something called medical debt that we'll be facing them the only thing I can say is listening to all of this and the questions and Michael's comments and stuff is that Bill Schuber had a piece in the Vermont Digger called time to rethink Vermont's health care system and I think we are at that time we have to start rethinking it or this is just going to keep going on and on and on Kevin is right that Vermonters will not be able to access care anymore because it's going to be simply too expensive and access has always been the problem of access because of cost has always been the major problem of this health system that we have been unable to solve with a market-based form of health care like we have now it's time to rethink our health care system I yield the floor thank you Walter next I'm going to go to Hamilton Davis Ham thank you Kevin I'm not sure there's a technical thing but I couldn't see the slides that Sarah was showing I'm not sure where they are but I'd like to know how we get full access to all of her slides so that we can see the numbers maybe the members could see them here maybe I'm the only one we could see them and sometimes if there's low bandwidth in a location you don't get somebody's video or their slides like for example in a number of meetings other people have seen people that I didn't see so I think it's really a bandwidth issue Ham because they were pretty clear to most of us at least Sarah can you post those to the website so that Ham can access those and email him a link already drafting it perfect thank you Sarah Kevin thank you and Sarah thank you really thanks Sarah she's doing all the work Ham I need somebody else to do a lot of the work okay Mike Del Treco your hand is up well I figured it out one thing I did want to say to Sarah and I omitted Sarah I know you have a brand new team and I know you're working hard on all this and I just wanted to acknowledge that thanks Mike is there other public comment is there other public comment hearing none is there any follow up from the board hearing none Sarah thank you in your team and I'm sure we'll be asking you a lot of questions so thank you and this is a trying time it's tough to be on the green mountain care board in the summer is there any old business to come before the board hearing none is there any new business to come before the board hearing none is there a motion to adjourn so moved thank you Tom for a minute I didn't think anybody wanted to leave all those in favor of the motion please signify by saying aye aye any opposed please signify by saying nay thank you everyone have a great rest of the day