 I'm going to convene the meeting of the Green Mountain Care Board. Susan, I'm going to ask you to delay the executive director's report until after Secretary Smith's testimony. And also at that time, you could take attendance via the phone numbers that we don't know. But I just want to keep Secretary Smith on track with trying to do some other work today. So with that, Mike, I'm going to turn it over to you. Welcome. And thank you for everything. Well, thank you, Mr. Chair, and thank you for allotting some time. I just wanted to we hadn't talked in a while, and I just wanted a lot has happened. And I just wanted to give you an update on a couple of things that we have done here and things that we're thinking of doing in the very, very near future. And so I thank you for the opportunity to address your board. I want to first take the opportunity. And because if I don't do this, I will get lectured to at home to thank the thousands of workers in the health care system who work tirelessly and bravely through this pandemic. You know, I've heard some of their stories and, you know, it's truly inspirational what some people did to make sure that we were ready not only in the surge units, but really in the hospitals and what they did it because you got to remember what we did during this. And you all know this, but during this pandemic, we basically shut down operations in our health care system. And that caused some stress in our health care system. So during this time, we've had two main objectives in regard to this pandemic. First, during the height of the pandemic was to keep the health care system financially and operationally viable. And and I'll talk about that in a minute in terms of what that means. And then the second objective was after the height of the pandemic, and I hope we're past the height of the pandemic. I truly believe that now, giving everything that I've seen, how do we stabilize our health care system as we go into the future? And I wanted to convey some thoughts on that as well. And also as if I can get some help at some point in terms of some data that I may need as we sort of work with the legislature to develop what I would call a stabilization package. And when I talk about health care, I know that the Green Mount Care Board has specific areas that they look at. Mine's more expansive when I when I look at the sort of the health care system. It's pretty inclusive. It talks about long term care facilities, visiting nurses association hospitals, which you are quite familiar with DAs, SSAs, independent docs. Those that are licensed through the OPR, the Office of Professional Regulation, like eye docs, chiropractors, physical therapists, the list goes on. FQHCs are included in my definition of a health care system dentist and even the EMS emergency medical services are included in sort of my definition of health care. What's included in the health care system. So let me sort of go back to seems like years now, but maybe it's only a few weeks, but go back a few weeks during the height of the pandemic here in Vermont. We stood up five to ensure the ongoing financial viability of our health care system. The first directly relates to some of the things that you look at as well with one entity in particular that I'll talk about that is providing financial relief to hospitals that were in desperate need. And this is the first part of our what I would say we stood up in terms of making the ongoing to ensure in the ongoing financial viability of the health care system. And let me just take you back a few a few weeks, a month or so ago now. But everything was shaky at that point. I mean, we had to stop all inpatient all that. You know, there were no patients other than emergency that were coming through the door of the hospital system started to get requests from various hospitals. The two major requests that we got that we follow through on where the Brattle will retreat, which we obligated 7.2 million dollars to and Springfield hospital, which will get 1.3 million. We did say if they got some CARES money or some hospital relief through the federal government that we would offset our obligation to them from that money. But I will also say that in the case of Springfield hospital, I don't expect that to be our only payment to them. I think we were very optimistic at one point that Dartmouth and Springfield hospital would be partners going down the road. I think at least in the near term that prospect is not viable. And the reason being is that, as you know, Mr. Chair and members of the board, Dartmouth along with everybody else lost significant amounts of money during the COVID-19 crisis. And so they're looking at that plus their merger in southern New Hampshire. Springfield is not something that they are the feedback that I'm getting from and not particularly on their front burner. So we're probably going to be in the process of trying to make sure financial viability at Springfield hospital, at least to get them through this crisis. And to a point of break even, which looking at some of the cash flows, they should be able to do if we come back to any sort of sign of normalcy. In terms of the Brattle Board retreat, we obligated 7.2 million. And we did both of these obligations, both Springfield hospital and the Brattle Board retreat based upon a careful review of their financials. As we looked at their financials with the Brattle Board retreat, we also put in place an agreement that basically says we want to take a deeper dive into their financials. We want to take a deeper dive into their operational aspects to make sure that they're viable over the long term. And I asked for, and I asked to look at all options that are on the table. And one of the things that I asked for was a report back to me by the first of the month that talked about how does the Brattle Board retreat move forward in a financial plan and operational viable way. And that report is due to me every week or so. The next program, so that's one of the five programs that we stood up. The next program that we stood up is what I will call a retainer payment program for non-hospitals. And that was everybody under the sun. That was non-hospital. That was independent docs, dentists. There was EMS providers that came in under this program and about $4 million in terms of doing that. The third property is having the ability to, and you've got to remember, everybody was scared during this period of time, a package of $7 million for what I call enhanced pay. Some people call it hazardous pay, but I call it enhanced pay. And $4 million that's similar to the retention program that we stood up for everybody else that is application-based and is based on replacing those costs that were from COVID-19 or lost revenue from COVID-19. The next category does sort of wander back into your category again because hospitals were eligible for this was the prospective Medicaid payment program for May and June. And we, for these prospective payments based upon what their normalized Medicaid payment would be versus what they were actually projecting for lost revenue during that period of time. And it was an opt-in program. You didn't have to come into the program, but it was for flexibility for cash flow. We had allocated $24 million, which is interesting. We didn't get the participation that we thought we would get on this. I think we're going to end up allocating over $13 million, but it's not perhaps going to be the $24 million that we sort of budgeted for as we move forward. The other and last program, number five was a what we call an Extraordinary Financial Relief Program, and that was for nursing homes. And we stood up those costs again. It was an application-based program. It was about $4.6 million. And it was for the cover-to-cost of the crisis that was causing really some financial hardship along the way. All of these were stood up during those crisis periods that we were seeing in order to stabilize, like I said, well, to make it viable for organizations to continue to do business. And this all has a cascading effect. I mean, I think you as board members recognize this. If the DA's sort of emergency rooms and the emergency rooms, if we would have had a surge, the emergency rooms would have been packed. And then the beds in the hospitals would have been packed. We really packed our capacity in the hospitals and wondering what we were going to do. So stabilization of our current system was imperative as we move forward. We also, by the way, just as an aside, we also extended the Health Connect enrollment period, have extended it to June 15th. I suspect we'll probably extend it past the June 15th deadline as well. But here's where we're starting now to shift towards the future. And we realize that there's much more needs that need to be met out there in order to, what I would say, stabilize the system. We kept the system from collapsing. Now we really have to stabilize it over a longer period of time. And you will probably hear many talk about this. Certainly, we are hearing from many in terms, including hospitals really need to do this. So we're committed to design a program that stabilizes the health care program and the health care system. And we have reserved a fairly significant amount of money in the Coronavirus Relief Fund in order to accomplish this first purpose, up to $300 million. We are in the process of designing an application-based program right now that takes into consideration revenues lost and increased expenditures as a result of the pandemic. Those eligible would be those entities, again, it's more expansive than perhaps you see on a normal basis in terms of your overview, but maybe not. You know, it's those entities that I named right out of the gate, you know, long-term care facilities, visiting nurse association, hospitals, DAs, SSAs. Those DAs that are under the OPA, you know, high DAs, chiropractors, independent DAs, F2HCs, dentists, EMS, as we look forward. And so we're in the process now of trying to put that program together. We would also consider any money that they have already received from either us or the federal sources in determining their allocation of money. And we would design a program that would have verification and accountability built into it. So there will be a review process of this application-based program, and the program must sort of be there that can be audited. So I don't want to surprise anybody that may be listening to this. There will be strings attached to this money. First, you know, the first string is you got to use the money in the way that you said you're going to use it, and get the things done that you said. The other, we are looking at parameters now in terms of other things that we may propose or we may not, but some of the things in the mix are- What are the opportunities out of, you know, receiving this money? What are the opportunities to improve health care quality? And what are the improvements that can be made in terms of the advancement in any sort of reform effort to health care reform, whether payment reform, quality reform, or other sort of reform that's out there? I hope to have the financial aid package to the legislature by, with this financial relief package, where the expectation is that the financial burdens just won't be passed on to Vermonters, that if you're receiving money that you're not passing on financial burdens to Vermonters as well. And as an aside, because this does come into your purview, and it doesn't necessarily come into the financial relief package, but it does come into your purview, as an aside, and completely from my perspective, and this is my perspective, the expectation of either minimizing rate increases extended to the payers as well. And I haven't- it's just something that's on my radar screen that sort of may or may not be outside the realm of this financial package. So I, you know, I'm trying to work cooperatively with the legislature on this financial package. I want to work cooperatively with the Green Mountain Care Board with this, because I don't know all the ramifications of all the aspects of the healthcare system I'm hitting with this. So I'm- I gave clear this morning to the Senate and the House Healthcare Committee and the Senate Health and Welfare Committee and sort of broadcasting this to the Green Mountain Care Board to let- so that we can do what's best for Vermonters and try to figure out a way to make sure that we don't lose important aspects of our overall healthcare system that we've taken years to build up and make sure that a crisis doesn't destroy. So that is basically what I wanted to spend my time talking about, and I certainly will welcome any questions. What I'll do, Mr. Chair, because of the feedback that we're getting, I'll put myself on mute, listen to the question and take myself off mute if that's okay. Thank you, Mr. Secretary. And again, thank you for everything that you've done for Vermonters. It was reassuring during uncertain times to know that no hospital was going to close because the state was watching them very carefully, and we certainly understand that going into this crisis, Springfield was on very rocky financial footing, and if it wasn't for some backup by the state of Vermont that doors could have been closed. So thank you for that. And I just want to say you mentioned at the beginning that you may wish to reach out at some point for analytics. I want you to know that our analytics team and the hospital finance team are available to assist in any way that they can. And we look forward to working with you in any capacity that you need. I just want to caution board members. The last really set of statements that the secretary made about limiting rate increases, we do have five or six open rate cases. And so I don't want our general console to be having heart palpitations. So just be very, very careful if you decide to ask any questions in that area. I will say, Mr. Secretary, that it was interesting to see how things were handled in insurance in a number of areas where people with car insurance got rebates. And actually United Health actually did rebates to their consumers. And obviously this board will try to make sure that we mitigate any impact on Vermonters. But at the same time, as you know, the statute is very clear that we also have to protect their solvency as well. And so we'll walk that fine line. And I guess I better not say anymore without causing Mike Barber some headaches. So with that, I'm going to open it up to board members for questions for Secretary Smith. And I'm going to call on you in alphabetical order just so everybody will be able to mute themselves. So I'm going to start with board member Holmes. I really want to echo Chairman Mullin's comments about a thank you to you. I've been watching the press briefings almost daily, maybe not every, you know, every time. But I really want to thank you for all the hard work you're doing. And I can only imagine the overtime hours and the thoughts with which you and your team have put into these decisions. And so much appreciated questions and then maybe a longer question. The first one is with the timing of this stabilization program that you're talking about, particularly as it relates to hospitals. I understand you're going to have this in the legislature by mid June. So assuming that they approve this plan. The reason I'm asking is our hospital budget season is now. And so, you know, coming in the summer months. And so to the extent that this is going to be significant funds that may be made available to hospitals. As they're thinking about commercial rate requests and other types of, you know, their own revenue projections. Obviously, this is going to be an important component. I'm trying to understand when the timing might be of the application process and the awarding process. And whether there might be an opportunity for us all to work together to think about this financial sustainability as we're looking at hospital budgets. The timing on everything has been off. The one thing that I will say, we're, you know, the way that I see this is we've got to give time for the legislature to look at it. Obviously, we've been we've been ticking off the things that we think, you know, we need to do, you know, this is a major part of the economy. Of course, the the economic package was another major piece of the economy that we sort of have to get going and get running again. I will certainly I will certainly make sure that we stay coordinated as we as we move forward. I don't know what the timing is going to be, you know, other than the internal timing that we're trying to get it to the legislature and then, you know, what the passage in the legislature is and then what we will take for an application process. I can tell you, we're pretty well versed in the application process through this crisis, whether it's with Springfield, with all the programs that we set up, most of them are application based. So it is we've become very well versed in the application. So I think we'll mimic some of the things that we've already set up and I don't expect it after approval that it's going to be all that long for money to get out the door. Am I echoing again? No, now I'm good. Okay. Yeah, I think that would be fantastic as we can if we can coordinate those efforts, at least make each other aware of some of the things that we're thinking about. The second one was I'm curious about the low uptake of the Medicaid prospective payments offer that, you know, AHS made in April and May and if you had any thoughts as to why hospitals didn't take advantage of that opportunity. This surprised the heck out of us, to be honest with you. We thought the uptake would be a lot more robust than what it is. And we're doing a sort of a post mortem on that to find out why that wasn't taken up because there was little risk in that uptake. I mean, we designed it to have little risk in terms of the uptake. So I don't know the reasons for it, but it's as I'm as curious about it as you are why the uptake didn't happen. Hopefully we'll learn more as you uncover that. And I guess my last question is sort of a bigger picture question, but I think about major disruptions, especially these unforeseen kind. They often expose the fault lines in a system. And to me, fever service is one of those fault lines, right? Not only do we know that it encourages the wrong incentives, but it doesn't protect providers, right? From some of these financial consequences of a pandemic. I guess one of the questions I have as we go forward, you know, what are the lessons that we're learning from this? And are we are you thinking, what are you seeing as health care reform efforts going forward? We're going to double down on the all-payer model and try to have more fixed perspective payment. I mean, how do we think about what we can learn from this? And how might AHS and the Green Mountain Care Board work more closely to sort of learn from this experience, move forward and try and achieve some of those goals that we originally set out? And I know that's a big question coming back to that and talking about that further. But I'm just sort of wondering where you're at now or where the administration might be at now as we're thinking about it. You know, I find that if it weren't for payment reform, the system would have been in a lot more trouble than what it is. We were able to use payment reform for mechanisms to get cash out the door in various ways. So if I wasn't a believer in payment reform in the all-payer model, boy, I sure became one during this crisis. And it's something that, you know, what it looks like is going to be interesting, I think, as we move forward. What does it mean? How does it structure? I mean, those sort of things we really have to think through. But I'm more than happy to work with anybody that's interested in doing this because I think, you know, the structures, we're just going to have to think through the philosophy of it, helping. We're going to work with you, hopefully, on this as we can think about coming out of it. On the board, yes. Thank you, Jess. We're going to move to member lunch. The work that you are and your team are doing during this unprecedented time. Quick questions to build off of Jeff's issue. I think there's a couple of things for us all to keep in mind. So as you probably know, after we talk with you, we're going to be finalizing hopefully or soon to be finalizing hospital budget guidance with the hope of potentially getting submissions at the end of July. And we typically have to make our decisions by September 15. So I'm hopeful that that timeline will be be late enough in your process that we can get the details of the grant application because I think that would be extraordinarily helpful to have those details. And similarly, I think having a good understanding of the money that's already gone out the door to hospitals, what, whether that's offset by federal just so that when we're looking at the financial picture, we're very clear. So I appreciate your willingness to work together with us on that because that'll be really key for us moving forward. Unfortunately, on our free on the insurance premium side, there's those decisions get made in July. So I'm not sure how that will all interface, but hopefully we can make that all work. I on the Medicaid perspective payment. Am I my assumption from what you said is that that program was essentially taking the non attributed lives and doing a similar payment methodology for those folks. So outside of a program, hospitals have a bunch of folks on Medicaid who are currently in service and sort of pushing that over. Is that I just wanted to get a little more detail about what that actually let me do this. Let me get you an outline of that program so that I don't say something that is that I make up. So let's let me get you an outline of that program so that you can see how we did it from from the sort of from the global aspect of it. We did look at what, you know, their payments were on a on a perspective basis and made up the difference. But let me get to the specifics. I appreciate it. I'm just checking my notes to see if I had any other questions I wanted to ask you about that. I just wanted to flesh out a little bit more with you. So I think we can pass it on to the next seven. Great. Thank you, Robin. Next is member Pellum. Hello, Michael. You sure know how to pick a retirement. Thank you so much for what you're doing when I having worked with you all these years. I know how diligent and, you know, caring you are about your home state and it's a gift to have you and that instead of retiring here you are again. So I have just a couple of areas. One, I think that goes to Jess and Robin. There was, you know, as I'm sure, you know, instability in our hospital system, you know, before COVID and in 20, if you're looking at 2018 and 2019, there were a number of cases of COVID. You know, instability in our hospital system, you know, before COVID and in 20, if you're looking at 2018 and 2019, there were eight hospitals operating in the red out of 14 and in 2019 seven operating in the red. And I have come, you know, I'm not 100% there, but I'm far down the road and believing that, you know, the cost shift and payer mix are kind of chronic diseases within our healthcare system. You know, and if you just kind of look at the data, you find this kind of inverse relationship between hospital service areas that are have an intensity of Medicaid folks in their district are generally ones that also are, you know, prone to operating the red. And if you look at the other end of it, the hospital with the with the greatest, the best payer mix, which is UVM Medical Center at 60% versus only 10% Medicaid, they accumulated over the last five years, 90% of all the positive operating margin in the state. So I think clearly there's an imbalance here, but, you know, the solution to what I think is where Jess and Robin want to go, which is in a fixed payment system that can kind of neutralize that fee for service system. And that's still a long way down the road in terms of prospective payments, I think for hospitals, it's around 17 or 18% statewide. So it's not that we have a system, you know, that that it works for the majority of the revenues to hospitals, it's still a minority. But I think if we can in this process address the issue of payer mix and cost shift, and I know on cost shift, it's not about more money, it's about how that money gets distributed. And I kind of see it as a parallel between the property tax issue when you had gold towns and non gold towns, you know, and it took a while to fix that system. But once it got fixed from a child's point of view and education point of view, it was better. So that's that's kind of one opportunity I see here is is the ability for state leaders to pick up the issue of payer mix and cost shift. The other is just a more general question. And, you know, it's a perennial question in times like these, when, you know, I'm looking at the information that Adam Gresson's putting out and Steve Klein's putting out. And, you know, overall, Vermont has $1.59 billion worth of federal COVID money that has come to the state. And as you noted, $1.25 billion of that is, you know, the COVID relief to the state. And I just I think my guess is that a cautious approach would be to assume that we're going to have a little bit softer that we need a soft landing here over the next year or two. And so I'm just wondering what your thoughts are in terms of, you know, the approach to the legislature to engineer that soft landing, soft landing. At the same time, not building programs that once the federal funds go away, you know, we're, we're still on shaky ground. Yeah, I can make sure to tell them that those are really good questions. First of all, remember who was the secretary of administration when we eliminated the gold house. But the one thing that I just want to be cautious about, remember, this is one time money. We're not going to have this on an ongoing basis. So this is one time money that really got to be spent wisely and you're going to think what we did. We shut down the Vermont economy, you know, and so we've got to we've got to we got to restart that Vermont economy. And we put a lot of there was a lot of pain that was that was caused by that. And we've got to restart that Vermont economy to make any of this sustainable for for the future. So I am very cautious about the 1.25 because it sounds like a lot of money. It isn't a lot of money. I mean, the governor's economic package is 400. We're talking 300 here. We've probably spent 300 in response to this or will spend 300 in response to this virus and getting ready if there's a resurgence, resurgence. And we haven't even talked about higher ed yet. And so, you know, what I'm trying to do with this. And I hear you with ongoing sort of concerns that we have in terms of expenditures. But I'm trying to look at what one time money has the biggest bang for the buck and what will what will have the most stabilizing effect on the health care system. But realizing this, this is one time money and it's not ongoing. So I understand what you're saying and the sustainability aspects of this in terms of how we use the money and how we move forward into making sure that our system is sustainable. I think are critically important. And what you're saying is is well noted, at least with me. Well, thanks again, Mr. Secretary and good luck to you. Okay, moving on, we'll go to member use of her Maureen. Thanks. First, thank you, Secretary Smith for everything that you're doing. And I also see the briefings three plus times a week. So they've been very informative. I first want to say, you know, we echo that we also want to keep the system viable. And, you know, the stabilization of the health care system is very important. I'm going to talk, everyone knows I probably talk numbers a lot. I'm going to talk a few numbers here. You know, the hospital system is about half billion dollars. And so it's roughly a little over $200 million a month that's running through that system. And we know that it's been hit about 50%, if not more for the past couple months. So each month that could be down $100 million just for the hospital. When we look at kind of the broader health care system that you're talking about, which obviously needs to all be incorporated, you know, we're upwards of $6 billion. So half million dollars a month. And I would say probably some areas went to almost a complete standstill and are down only 50%. For round numbers, if we say for the system, we're down about 50% a month for three months is $750 million. And we also are seeing that things aren't coming back that quickly. So $300 million will certainly help and on top of the federal money that we're getting. But, you know, I think it's going to be a challenge probably to bridge that gap, you know, in with this package and just, you know, why try to get a perspective on what other thoughts there are. And of course, some of this volume might come back in the future. So if it was pent up demand and it comes back, you know, there might be an expectation that this year things are a lower number. Next year it could be higher, but that assumes that COVID doesn't come back and that people do come back for elective surgeries and things like that. So just try to do we stabilize the system? How do we continue to keep, you know, the system that we have and how much money will it really take to get us there? And so I'm not sure you can answer that or not, but I was just trying to put in perspective that, you know, we could have a really massive shortfall when we're looking at across the whole system for what's happened because of that sandstone. And I agree with you the money that Vermont has received the $1.2 billion is not enough, especially when you carry that across all of the industries and we're just focusing on one right now. So certainly don't envy you and hope for, you know, we can get as much as we can. But 300 million on top of what we're getting from the feds will be enough. So it's more common. I don't know. Well, massive challenge in many respects, the response was a challenge, but the restart is going to be just as important on how we do this and how we move forward, making sure that we what we built here in Vermont and concerned about, you know, the dollar amount. You know, I'm talking 300 million, the feds have, you know, ponied up some money for the hospital systems as well. Certainly not enough. There may be more that's coming. But it's been sort of interesting on how the money's been distributed. And first we got kind of penalized because of how we how we reimbursed the second part. We got kind of, you know, UVM didn't get what Dartmouth got, for example, because UVM considered a metro area hospital versus Dartmouth being a rural hospital. This doesn't make any sense to me, but this is, you know, some of the things that we have to do. So I don't have an answer. I do I do have the answer that we're trying to do as much as possible with the money that we have to stabilize this system. Yeah. We know we know that's mainly what we're focusing on. Certainly had, you know, some of them were stronger financially than others and had whether it's cash on hand or whatever. But it doesn't make a healthy system if we just deplete all that cash and they didn't really get in anymore. And they get some of this money, but it doesn't really go into that role. So, you know, we all probably going to be a multi-year process. But thank you for everything that you're doing. So you're on mute, Mike. Your lips are moving, but we're not hearing anything. You're on mute. Are you there, Mr. Secretary? You can scare him away. Now I've lost the video. Hopefully you're coming back, Mr. Secretary. We'll give it a second. Hopefully he's trying to reconnect. We tried to mute anybody, did they? No. Thank you. Well, just went out at AHS. We should be coming back on now. Yeah, this is Candice. I just, all of our Wi-Fi just went offline. So we will rejoin, rejoin once again. And Candice, might hand Paul in if he needs to. Yeah. Yeah. All right, one sec. We'll look at it and hook up on that. Can you go do that? Mr. Chair, Mike Smith back again. I apologize. No problem. Welcome back. We're having a lightning storm here. And it took our internet out. And I'm wondering what net locusts we moved for. So I think Maureen's was more of a comment. Yeah, but I'm off that. So thank you. So, Mr. Secretary, you talked about $300 million towards the broad spectrum of health care providers. And you said that there would be strings attached and you said that it was an application process and they would have to spend it on what they said they were going to in the application. I was just wondering if you have any garb rails for what you're looking for, for the expenditure of these songs. Yeah. Mr. Chair, I don't think at this point, we sort of have really broke that out. I think very shortly we will in terms of what we're looking for. We're also looking for input from the various organizations and from the legislature as we move forward and from the Green Mountain Care Board as we move forward, particularly with hospitals. So, you know, this is sort of the first step in sort of reaching out and saying, okay, we know sort of the top-level parameters that we're talking about application-based, those sort of things, but what are some of the things that we really need to pay attention to? And one of the things, the questions I asked the other day, where does it have the most impact? And I think that is going to drive sort of the program design of where does it have the most impact, the money that's going. And that's as far as I've gotten so far. Well, that's understandable, and you're having to work at work speed and the timelines are against you. But at this point, I'm going to open it up for public comment. And again, any member of the public, if you could direct your comment through me to Secretary Smith. Hi, Kevin. This is Mark. Hi, Mark. Mark Stanislaw from the University of Vermont Health Network. Just a couple of thoughts as you think through. I mean, I think it's going to be very important and this may carry over to other health services outside of the hospitals, but it's going to be important to create an overall strategy of not only how do we stabilize the Vermont Hospital Health System from the current, but make sure there's enough foundation that it can carry into the future. So, you know, I think having that overall strategy and figuring out how, you know, this funding, you know, could add to that strategy is an important way to think about it. And, you know, one of the dilemmas and when you spoke to this, and I just want to reiterate it, is, you know, we really need to think about, you know, what's a one-time investment versus an ongoing. And, you know, I almost put it, you know, is it an ongoing stabilization or is it just to get up, you know, get them onto the current balance? And, you know, one thing that struck me in, you know, one of your thoughts was that you shared is that as we think about the commercial rate setting process, I think we need to remind ourselves that that truly is an ongoing impact because it's compounding each and every year. So, you know, as we think about these one-time funds and if there happens to be any carryover to that, I just hope those two things are connected because there is the compounding impact of the commercial rate setting process. But, you know, thank you so much for your time, Secretary Smith, and we appreciate this feedback and we appreciate you coming to us and asking, you know, for our input. Thank you, Mark. Other members of the public? Members of the public? Hello, Kevin, Mike Fisher here. Welcome, Mike. Thank you, Board, and thank you, Secretary. I would be remiss if I didn't say out loud that the other side of the coin, yes, indeed, our provider network is incredibly strained. And, yes, indeed, there are some real serious financial challenges that we need to actively address. I'm in full support of that. The other side of the same coin is a law set of the monitors who are not getting care. And we did an informal survey, a survey where people are not a representative survey, but of those who responded who needed care, 72% said they were either delaying care themselves or were unable to get the care they needed. And so I hope that as we seek to address the financial challenges that our healthcare provider networks are challenged with, that we also, I believe there are ways to do that where we also address the challenges that the monitors are facing, the barriers that the monitors are facing in accessing care, and I would be happy to talk more about that. Thank you, Mike. It is sobering when you're watching the news at night and you see the lines of cars just trying to get food and it's hard to keep a dry eye. So we have to keep in mind that some people have been hit a lot harder than others through this pandemic. Other comments from the public for Secretary Smith? Hi, this is Jessica Barnard from the Vermont Medical Society. Welcome, Jessica. Hi, thank you. I just want to thank the Secretary for everything he's doing and for starting to think through the use of this $300 million were very optimistic or pleased to hear that there is some money potentially being put to medium-term stabilization of the healthcare system. And I know some of the representatives of the administration are coming to meet tomorrow morning with a group of provider associations, which I think is really important, especially hearing the underutilization of the prospective payment program. We really want to make sure that it is designed in a way that it can get to where the need is most felt. And I know there were some types of providers that felt that some of the quality measures that were part of the prospective payments were more difficult for them to accomplish or at least didn't apply to them as much. So I think, again, just that provider input in the design of the program to be really important and we're grateful that he's coming to meet with us tomorrow. So we look forward to that. Thank you, Jessica. Other members of the public for comments for Secretary Smith? Hearing none, I really want to thank you, Secretary Smith. And, you know, it's... we pledge to have much better communications when you took over your office and it's been one thing after another since you walked in that door and it's made some of those communications a little bit harder than usual, but we appreciate your reaching out today and sharing with us what your plans are. And with that, we're going to let you get back to work. So thank you, Mike. Thank you very much, Mr. Chair and members of the board. Thank you so much for having me. We'll talk soon. Bye now. Bye-bye. So with that, I'm going to turn to the executive director's report, Susan Barrett. Sure. Thank you, Mr. Chair. I have a few announcements. First, that on our upcoming meetings for next month, we will have the schedule posted within a couple of days. But I wanted to note that we have a data governance council meeting on June 2nd. That's from 2 to 3.30, as well as a general advisory committee meeting scheduled on June 8th from 2 to 4. We're also looking at some ACO budget guidance as well as vital budget work throughout the month next week. Next month is a very busy month for us here at the board. So just wanted to draw folks' attention to that. It's on our meetings page on the Green Mountain Care Board website. I also want to mention that I believe, once Abigail has different information that we have not received any new public comments since last week's meeting. We have three so far that they are posted on our website under our agenda from last week's meeting. So to date, we do not have any additional public comments. And that is all I have to report. Chair Mellon, do you want me to go through the phone numbers now or do you want to do that after the minute? Let's go ahead and do it now. Okay. So I'll start at the bottom of the phone numbers. I have 1-4-6-0. Yes, that's Jessica with the Medical Society. Okay. Oh, I think there might be. Okay, great. And then 1-2-3-2. Dana Leahy from CVMC. Great. Thank you. 7-6-3-2. Thank you. Hi, Jeff. Welcome. 3-2-1-2. Hi, Kathy Maloney from the Board's General Advisory Committee. Thanks, Kathy. 1-9-7-0. That's our office, I believe. 8-2-8. So I think that's Jeanine. It's me. Yep. Hello. And then 5109. Christina DeGrasse Murphy from UVMHN. Great. Thank you. 6-5-8-1. On to 1-0-4-2. Robin Alvis, CFO. Northwestern Baptist. 5-8-3-5 is Abigail. And then 5348. Kathy Fulton, Vermont Program for Quality and Health Care. Hi, Kathy. 8-8-7-8. All right. Jennifer Trent, Porter Medical Center. Thanks again. 1-9-5-2. Stephanie Brough, Northwestern Medical Center. Thanks, Stephanie. 0043. Becky Blundowski with DRM. Thanks, Becky. 7-4-3-8. I am Davis. Hi, Pam. 3-7-6. Now you're 2-5-0-5. Stan Collis, UVM Medical Center. Thank you. 4-2-6-2. Maggie Lennon, Illinois Public Affairs. Thank you. 8-7-0-3. Mike DelTrico, Vaz. Hey, Mike. 8-9-1-3. Lori Giancerco. Hello. And then 5-0-0-1. Julia Shaw with the health care advocate. Julia. And the else is listed. Abigail, so you can see their names. And I can turn it back to you, Mr. Chair. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, May 20th. Is there a motion? So moved. Next second. It's been moved and seconded to approve the minutes of Wednesday, May 20th without any additions, deletions, or corrections. Is there any discussion? Hearing none, all those in favor signify by saying aye. Aye. Aye. Aye. Any opposed? Thank you. So the next item on the agenda is a carryover from the previous week, and that is the hospital budget guidance. As we try to develop guidance that is slimmed down in scale, recognizes the effect that this pandemic has had on hospitals, and tries to make it easier but still brings the relevant information that's necessary for transparency forward, and hopefully begins to get us on a path toward sustainability for our health care institutions. And we have been fortunate in Vermont. We have not seen a health hospital close due to the pandemic, and we're hopeful that we can keep it that way. So with that, I'm going to turn it over to Patrick Rooney. And Patrick, whenever you can take the screen, go ahead. Thank you, Mr. Chair. Can you see my screen and can you hear me? Yes. Okay. Great. All right. As the chair alluded to, this is a continuation of last week's meeting, and this is the third board meeting we've had on the abbreviated guidance. And so to start, we're just going to do a quick recap of some of the changes that we made right off the top from our first meeting with an inventory list of items that we've removed, altered, or pushed to a later time to provide that flexibility for our hospitals to navigate the budget cycle over the course of the summer. And so these are some high level items of consideration that we have removed or postponed or consolidated. And there's been a couple of minor changes on this sheet from the beginning, and one of them relates to the capital investment cycle and more specifically the CON. Per the statute, we discovered that we do have, we did have to bolster that a little bit. So there was a change to that over the last three weeks that we had to make to inform the board, but it will be a submission that comes at a later date. And also we did add back, as we discussed in the last meeting, section on risks and opportunities. And that's not really a detail-heavy discussion point. That really depends on the hospital and how much they would like to discuss about the specific risks and opportunities to them. However, some of these items do entail a considerable amount of detail, and they have been removed for flexibility purposes. And several of those fall at the very bottom of this list in the appendices. And there's a lot of numbers that are placed into some of those tables and also the, you have to remember, too, just figures that the hospitals are putting in, then they have to describe it in their narrative and then also have it ready in presentation format, too. So by removing some of these items, we're not just removing one detailed item, we're moving three times the work in some cases. So we just want to make sure that that is still being considered by the board as some of our recommendations moving forward. And that has been a good faith effort between us and the hospitals to refine the budget reporting for this year. So recapping the last meeting, the board directed the staff and legal counsel to work on some language around the guidance. That guidance was posted on Friday 522. And specifically that language was to occur around change in charge, the 3.5% growth limits for fiscal year 21 and 22, and two-year budget growth. Additionally, we have a recap so far of items that we've checked off as discussion points for the board. And as we move through the slide deck, we will continue to push on some of those matters that we're all aware still need some closure around language and discussion. So the first item up around language has to do with the two-pronged approach for NPR. As everyone recalled on March 18th, the board did establish an NPR-FPPE growth limit, 3.5% for 21. And that growth limit reaffirms the tentative two-year growth limit that the board approved in fiscal year 20. The board will also consider an additional temporary NPR-FPPE adjustment to compensate for fiscal year 20 utilization that was not realized due to the COVID-19 impact. And the hospital must justify the NPR-FPPE portion of its request using factors that will be coming in future slides. Additionally, around change in charge, there's also a two-part approach that's being proposed. The hospital can request a second part on top of their initial request that reflects standard price growth. And that second request would be the time-limited charge that we've discussed over the last couple of weeks relating to commercial revenue losses. And this would be reviewed and adjusted based on fiscal year 21 year-to-date revenue and utilization data. And again, the hospital will need to justify the impact of COVID-19 on that portion of their request. Relating to both of those items around justification would be actual and projected utilization, revenue impacts on fiscal year 20, and utilization assumptions affecting fiscal year 21 revenue along with changes to payer mix. This language is reflected again as it was last week around some of the proposal considering factors that should be considered and that will be hospital solvency, expense reduction plans, long-term strategic and financial plans for sustainability, insurance information regarding actual projected utilization, impact on the monitors and employers and the commercial market and other relative factors. There is still an open item on enforcement. It was discussed last week that the board may issue enforcement at a later date and reserve the ability to do so. So continuing the discussion today is around the abbreviated guidance in total, the NPR growth type target proposal that has been put forth in the guidance. Change in charge guidance proposal, both are two-level options. The enforcement policy discussion, along with any reporting or monitoring for all hospitals on a regular basis and also proposed COVID-related alterations to the OPE, as well as alterations to the budget timeline. And for next steps to be a possible vote by May 29th and then we would distribute guidance to the hospitals and post to the website as well. So that is a brief recap of what is on the table for today's discussion and I'll turn it back over to you, Mr. Chair. Thank you, Patrick. Questions from any board members? Hi, this is Maureen. Just one thing, Patrick, and I know that it's in the more detailed specific instructions, but I think on slide six or at least the following slide, we should include, you know, particularly in light of the discussion that we just had, you know, that will be a factor in potentially how much a hospital may need to bridge the gap. So I think, you know, I know in the instructions, I think we actually put it in other factors, but I think if you go to slide six, you know, I would just like to, you know, say I really think it belongs there to put, you know, the stimulus funds received federally. We may not know what they're going to get from the state, but at least it's a factor that will go into considering both the change in charge and the FDR. Patrick, if I can add to that, I think in light of the conversation that we just had with Secretary Smith, I think an additional piece of information would be asking the hospitals if they've submitted a request for funding from the state stabilization program and if so, how much? And I think even if the outcome of that application is unknown, it would be important for us to know if the hospital is planning on submitting an application and for how much. Okay. You know, and I think to that point, Jess, I think we also have included, you know, in the instructions that there may be some mid-year adjustments that may occur next year, both for, you know, I think the expectation might be both for underperformance or overperformance. And so, you know, if we didn't know at the time of when we were going through the budgets what specifically a hospital was going to get and if they ended up getting more or less, that may be something that we could, you know, also adjust in the future because, you know, we know that in this process there's going to be much more speculation than there typically is because we don't know what's going to happen just with general COVID and if people will come back for elective procedures and so there are lots of assumptions that the hospitals will need to make and that's okay because that will, you know, they can compare against those assumptions and make whatever changes are necessary and I would imagine next year we'll probably see a lot more changes to what the budgets that are submitted as far as those are when they come in. A lot of moving parts. Okay, there's a number of open areas and maybe we could take them one at a time and try to make some progress. And again, this is just my guessing what might be easier than some of the others to get off the table but I'm suggesting we start with the change to the oath or the attestation that has to be signed. Does anybody feel comfortable making a motion on that? I actually wanted to suggest I saw that there were some adjustments that were made to accommodate the fact that there was uncertainty with COVID-19. I wanted to actually change the language a little bit so I'm not sure how you want to proceed with that, Kevin. Well, you could change it by making a motion with the change in your motion. Okay, so that in Appendix 7A which is the verification under oath form that's completed by the hospital CEO and CFO. Jess, let me just pause there for a second. Patrick, could you put that up on the screen? Yes, I will. Thank you. Go ahead, Jess. Okay, is number three given the uncertainty related to the COVID-19 pandemic to the best of my knowledge, information and belief, the information contained in the budget submission is true, accurate and complete and does not omit material facts necessary to provide a full and complete understanding of the hospital financial standing? I think understanding where the leadership teams of the hospitals are with respect to the uncertainty, I would propose the flight modification which is given the uncertainty related to the COVID-19 pandemic to the best of my knowledge, information and belief, the information contained in the budget submission is currently the most accurate prediction and does not omit material facts necessary to provide a full and complete understanding of the hospital financial standing. So basically I'm removing the true, accurate and complete and replacing it with is currently the most accurate prediction. I think that reflects where I suspect some of the hospital CEOs and CFOs might feel because that's actually what we're asking them to do. We're asking them to submit the best accurate prediction of their budget. And the second piece I would say is that I think in the appendix 7B which is completed by the hospital's board chair I would add some symmetry. So in number five I would say given the uncertainty related to COVID-19 pandemic I have in good faith, et cetera, et cetera and where the language is true, accurate and complete in that section five I would again replace it with is currently the most accurate prediction. Is there a second? Okay, before we open it up to board discussion I'm going to open it up for public comment. Does anybody wish to offer public comment at this time? Kevin. Go ahead, Ham. I've got a question but I don't think this is the point. Are you going to come back to the public at any point or are we open for the public? It's open to the public for the purposes of discussion on the oath and attestation only. Thank you. Well, I don't have anything on that. Thank you. Okay. Does anyone have anything for the oath and attestation discussion? Okay. Turning back to the board. Is there discussion from the board? I like Jess's suggested changes because I do think it more accurately reflects our unique circumstance that we're facing this cycle. I thought the best efforts clause should be in there because it's just a movable environment and I think Jess's suggestion well answers that issue that we are in a volatile environment. I'm okay with the changes as well. Okay. With that, I will call the question. All those in support of Member Holm's motion referring to the oath and attestation signify by saying aye. Aye. Any opposed? And again, I will do voice votes unless I hear a negative vote and then I'll turn it over to Council Barber to do a roll call vote. But it appears that this was a unanimous decision. So with that, let's go to the change in charge discussion and I'll turn it over to board members for their thoughts or motions. The way the new guidance is written in terms of allowing for a two-part change in charge. Obviously this won't be an exact science, but I think it will allow for some flexibility to think about ways to ensure sustainability without also baking in for time in memorial charge increases. I'm happy to make a motion or happy to let people make comments and then make a motion? Go ahead and make a motion. That would be great. I move that we approve the two-part approach and the current draft of the hospital budget guidance related to changes in charge. Is there a second? Seconded, yes. So we've had a motion and a second. And before I open it up to board discussion, again, I will go to the public for any public comment related to the change in charge portion. Does anyone from the public wish to make a comment as it relates to change in charge in the budget guidance? Hearing none, I'm going to turn back to the board and is there further discussion on the motion to approve the two-part approval related to change in charge as outlined in the updated postage guidance? I support this. I think it will be helpful to have a split between COVID charge and non-COVID charge. Because my guess is that as we go through the hospital budget process, we're going to be asking about that anyhow because it is such an important player in our decision, at least on an interim basis. So while the request might not be scientifically precise, it will be helpful, I think, for the board to have that information. Thank you, Tom. Other discussion from the board? Hearing none, the motion is to approve the two-part approach as it relates to the change in charge outlined in the most recent posting of the budget guidance. All those in favor of the motion signify by saying aye. Aye. Any opposed? So that motion carries. So next we'll move to the net patient revenue fix perspective payment portion of the discussion. Anything from board members? I can make a motion if we're ready for that. I can always make a motion whether we're ready or not. All right. I'm ready or not. Here I come. I move that we adopt the NPRSPP approach outlined in the budget guidance, which maintains the 3.5% growth target but allows for additional temporary adjustments to compensate for COVID-19 related item. Second. It's been moved and seconded. So again, I'm going to open this up to the public for comment on the motion to adopt the change in the NPRSPP as outlined in the updated posted guidance. With that, I'll open it up to the public. Hi, Kevin. This is Mark here. Just to clarify, a little further down in the guidance that you make a reference to other ask, I believe, other potential items that could impact. I think Patrick is trying to put it up on the screen for you, Mark. Let me try to find it also. I was referring to kind of, I don't know the slide numbers because they're not numbered, but I think slide 8, where it refers to the following factors, maybe considered hospitals with solvency, expense reduction plans, long-term strategic and financial plans for sustainability. Yes. We've got that slide on the screen. Go ahead, Mark. So I think the question is, going back to that other slide, does that long-term financial sustainability live under part one of that or under part two? Because long-term solvency in my mind is a little more than temporary or potentially doesn't live under both. And if a portion of that potentially lives under one, I think prior to other year submissions, I think you've left it up to hospitals to make that argument to go over that growth limit if they could convince the board and if it made sense. So Mark, at least the way I interpret it, and again, that's dangerous because each of the five board members interpret it differently. I believe that it applies to both components. Okay. So I was just asking for that clarification. So we know if that's the response from the board as a whole, then I'm good. Well, Kevin, I can just chime in. This is Robin because I did work with the legal team on structuring the guidance. And I think the thought was that splitting out that long left of factor was actually meant to make it more clear that we would consider those factors in both pieces of the hospital budget process. So I'm in agreement with you. Any board member have a contrarian viewpoint on that? Hearing none, I think that's your answer, Mark. Okay. Thank you for that clarification, Chair. Other members of the public? Hearing none. We have a motion on the, I was going to say on the floor, but I guess it would be on the web. It's made by member launch to adopt the change in the guidance for the NPR FPP guidance as outlined in what is currently posted. Is there any further discussion? Hearing none. I just wanted to comment that, you know, I think the way this is structured, you know, gives the flexibility of starting, you know, what would have been the base for the budget for 20, going up to three and a half percent. And then having this temporary component related to COVID that hospital could request. And I think it helps clarify what the starting point would be for 21 going into 22 as well, because that component assume temporary would have backed off and we would have had a base to begin with. So I think this helps some of the discussions we were having last week about how could we look at things to accommodate the loss revenue in 20 that may come back in 21 and therefore might have hospitals exceed what was the three and a half percent guide. So I'm supportive of it. And you know, I think it is should be helpful and hopefully to the hospital and their submissions and for us in the future as we look forward. Okay. Any other discussion? Hearing none. I'll call the motion to adopt the changes and guidance as it relates to the NPR FPP. All those in favor signify it by saying aye. Aye. Any opposed? Okay. So next is a discussion on enforcement. And I know it's not part of the guidance, but again, I would hope that at some point we could actually make a change to the 2020 enforcement policy. But of course that would require a motion from a fellow board member. But I'm willing to take a motion on either 20 or 21 or any part of enforcement. So that's a proposal around 21 enforcement, but maybe we should start with 20. So I, I, where I am at with 20 is I've come around to the idea that realistically we would be doing fiscal year 20 enforcement next March, which I just to me seems like it wouldn't, it's just going to be tough to do that given sort of the situation that we're in. So I would move that we wave enforcement for fiscal year 20. I'll second that. It's been moved and seconded to wave enforcement for fiscal year 2020 due to the uncertainty created by the pandemic. So before we open it up to the board, I'll open it up for public comment if there's any. Kevin, can I make a comment? You certainly may. I understand the idea behind changing the system quite a bit in order to accommodate the whole COVID thing. But I'm curious the reality is as both as people keep saying and as Secretary Smith said in his comments that they, what they, as they manage the COVID system situation. They need to do things that make sense for the long run. And my question is basically this, that you've had the, you had the orders in at least six hospital budgets that were passed in September of last year. And I'm wondering whether there's anything left at all of things like cost benefit analysis, whether, whether, whether given services make sense, whether there's enough volume there to engage in, you know, encourage quality. The reality is that those aren't going away. You're going to have, for example, you have already on your agenda the question of whether to, in effect, finance a enhanced ICU at St. Albans. That's just one. There are questions like that that run all through, especially the small hospital systems or maybe the big ones too. And so I wonder Kevin, if you could just sort of articulate, do we drop a whole year of reform here or not? That's my question. So the answer to that is no, we do not drop a whole year of reform here. And in fact, as you know, the board, is moving towards sustainability plans for the hospital in hospitals. And that dovetails into really what we've been talking about here all afternoon, which is really the long term sustainability of these institutions. And that's what's going to make this summer very, very difficult. We had to back away from some of that sustainability initiative for a period of time because all hands were on deck dealing with how to handle this from the outset. But we have not backed away from reform. We still believe that we have to move away from fee for service. And this is, I don't think by waiving enforcement for 2020, we're taking a step back away from reform at all. We're just recognizing the fact that each hospital was hit differently by the COVID pandemic. It depended upon what their service line was and what they had for an impact from the virus. And so I think that this motion definitely should not be any type of a signal whatsoever that we're moving away from reform because we need reform more now than ever before if we're going to have a system that works for the long haul. And that's the goal. Did I answer your question, Jim? Yes, it not only answers it. I think it's enormously important. And I think that because I think in the way you articulated it, it runs counter to a significant amount of different kind of reading. Not on your part or the board's part, but by some people. So I think that the statement you made is on the record. I'm writing down every word. Thank you. Good. It's always good to be on the record. Other comments from the public? If not, I'll open it up to board discussion on the motion to waive enforcement for the 2020 budget year, which is the year that we're in now. Sure. I have some comment. I personally want to start out that I am not trying to be insensitive to what the hospitals are going through or to be unreasonable about talking about enforcement. But that said, you know, I do not feel comfortable about saying that there will be no enforcement for 2020, which ends in October, and we review in March. And specifically, as we were just talking to Secretary Smith, we have no idea what type of money the hospitals will receive. And it may be disproportionately received by each by the hospitals, and that most likely will come in this fiscal year. And it could come in after we've approved budgets even for 21. So I feel that we have not been unreasonable with the enforcement that has happened in the past. It's been fairly limited. I just don't see the point of giving that up right now when there's so much that's going to happen. And gee, if we look back right now, I mean, we didn't even know about all the COVID issues three months ago, right? And in another six months, a lot will have changed. Either things will have returned. They won't have returned. Money will come in from the feds. Money will come in from the state. There's just a lot that could happen. And again, I don't look at as an enforcement as just the hospitals that exceed on the top line. It could be, you know, really missing. And in order to stay financially sustainable in the future, there might need to be some enforcement to help that along. So I feel like I'm the only one that thinks that, but I just did want to get that out there that, you know, it's not trying to be unreasonable. We do this off their actuals, which they have to submit. And we'll be done, you know, their actuals are done in October. We do this in March. So for nine months down the road, I just don't really see the point of giving that up right now, particularly not knowing how much money is going to come to the hospital. And we may see some get too much and others get too little. And how do we correct that if we're giving that up? So that's just my point of view and trying to give an example of things that could happen there. And I also have not seen in the past, in my mind, and maybe I'm wrong that the hospitals are significantly worried right now about enforcement and what we might do and how that might impact them. I think we're trying to do what's best for the system. So that's my point of view. I do not support not just waving enforcement at this point. Do I think when we get to that point in March next year, when we have a much clearer picture that we absolutely might say we're not doing anything here? Absolutely not. There's nothing that we can do. And we're not going to do anything. Absolutely. That could be what happens. But to not to give it up now and then either try to come back later and say, oh, we should have fixed this, but we can't. I think it's wrong. But I would just say that I don't think that we're giving up much what we're giving anything that any of the points that you've raised can be addressed in the normal budget process and in future years enforcement. So it's just recognizing the fact that this is an event that nobody could have possibly been foreseen coming and just trying to take some stresses off of people who are running the hospitals. So other board comment. Yeah, I just want to say I agree with you, Kevin. And I appreciate your point, Maureen. But to me, enforcement connotes a punitive action against some undesirable outcome against over which somebody is supposed to have had reasonable control. So you're enforcing against something that somebody should have been able to control. And that's not the world that we're currently living in. We know that the fiscal year 20 budgets that were submitted are not what actually manifested. And so enforcing and some punitive action, you know, or, you know, this doesn't make sense to me. So I but I don't think that we've given up levers that we have to Kevin's point. We have levers to make mid-year adjustments. We have levers to, you know, change next year's budget to reflect what actually happens. So the following year's budget. So I think I'm comfortable with the motion on the floor to waive enforcement for fiscal year 20. Yes. I'm kind of prone to support waiving fiscal year 20. I think that we've kept to the, and I hope it's a small see the three and a half percent to your guidance in place. I think that, you know, there's going to be a lot of activity over the coming months that I just don't think hospital staff, especially at the smaller ones, should be worried about enforcement six months down the line. You know, Secretary Smith just profiled the $300 million program. And, you know, I think that the financial staff at hospitals should be oriented toward or have as much flexibility as possible to address those kinds of opportunities. That said, I'm prone to keep enforcement in place for 2021, which is, you know, comes into play in March of 2022, especially given that we have the three and a half percent guidance. And we will know the facts. I mean, you know, we will be getting the actuals when we get them. And we will have a visibility into 2020. It's just that we aren't, we're taking off the need for hospital staff to have to worry about it for 2020. This is Robin. I would, I would normally be with you Maureen and wanting to keep my options open, quite frankly, given all the uncertainty, but I feel like by doing the bifurcated process in fiscal year 21 and allowing ourselves the option of figuring a mid-year review on the charges in particular, that that basically is a way to monitor the situation and have some flexibility because normally we don't have the option of triggering a mid-year budget adjustment. That's typically by statute require something the hospital can ask for. But I feel like in the 21 guidance, we've given ourselves some additional flexibility and enforcement on top of that, which I think would be to accomplish more or less the same type of conceptual issue in a soft way is redundant. So that's, that's how I got myself over to where I am. All fair points. Any other discussion? If not, Consul Barber, I guess you better call the roll on this one. Member Pelham? Yes. Member Holmes? Yes. Member Yusufer? No. Member Lunge? Yes. Mr. Chair? Yes. So I believe that the next change that is up for discussion in the guidance that's in front of us today, the proposal is for 2021 and the proposal is pushing that decision off to a future timeline. And I believe, Robin, that you had an alternative proposal to what was there. I don't know if you want to make that first or how you wish to proceed. If I would you, I would go ahead and just make my pitch and then we can have a discussion with both options perhaps. My proposal for fiscal year 21 is to maintain a budget performance and enforcement policy with a more scaled down approach focused on the budget performance. And so what my proposal would do is recognize that when we set the fiscal year 20 budget, our information may or may not be very good. And so enforcing against a budget based on information that isn't necessarily very good seems counterintuitive. So what I would propose is that we keep open the option of reviewing the performance for fiscal year 21 as well as prior performances to Maureen's earlier point that hearing what the right face is when we get to fiscal year 22 is going to be somewhat tricky given all the different moving parts. This would allow us to ensure that we're looking back over that to come up with the right budget in fiscal year 22 and make any adjustments based on the budget performance in 21 in 22. Now with that said, that does take off some of the options that we typically have when we look at enforcing the budget such as doing an enforcement related rate request or other types of actions like we've done in the past. The reason why I am proposing this now is because I think it provides more certainty about what to expect moving forward and allows the hospitals to develop their budget understanding sort of the process not just for this year but also how it's going to flow into fiscal year 22. So that's what I was going to suggest. That would I think give everybody certainty now. But of course if everyone else would rather hold off and develop enforcement later, you know, I can roll with that too. But that's my rationale for the proposal. Okay. Is that a motion or just discussion Robin? That was just discussion but I'm happy to put a motion out there and then see if I get a second. Maybe I can be in Tom's club of not getting seconded. I move that we adopt a budget performance policy for fiscal year 21 which would allow for adjustments based on fiscal year 21 and historical budget performance in the fiscal year. You trailed off a little bit at the end, but I think we have the gist of the motion. Is there a second? I'll second it. We can continue some discussion of it. I know we can do that for discussion. Okay. So discussion. Do you want to hear from the public first? I think it would be wise. Public comment on the proposed fiscal year 21 budget enforcement appendix five. Hearing none, we'll open it up to board discussion who would like to leave it off. I'm happy to just have my my initial reaction to this is I think that what I like about this is that it talks about budget performance and it signals an appreciation of the fact that these budgets are being drafted under extreme uncertainty due to the pandemic. Enforcement seems to be there's not a somewhat removed from the language of that budget performance. There's an ability to make adjustments in a in the fiscal year 22 budget process for actualization of the fiscal year 21 budget and what we see. So I like all of that. It feels like we're just using the typical levers that we typically use in our budget process. Again, remove some of the punitive levers that we typically use in a year when I don't think we should be applying those punitive letter levers. The piece that I'm a little uncomfortable with is the last paragraph. In addition, the board may issue further guidelines after consultation with stakeholders and discussion in a public meeting to help provide the hospitals with clear expectations concerning application of this policy. Part that concerns me is does that give the hospitals an understanding of where we're going or are we potentially moving goalposts? So it seems to me that's opening up what this might look like in ways that might reduce some of the certainty that I think Robin you were trying to achieve. So that's that last paragraph is where I wondered maybe if you could talk a little bit more about what you meant and what you're thinking about with further guidelines. So that is a standard paragraph that has been in the enforcement policy in the past. I'm not sure that we've necessarily used it, but so for example, I thought it's perhaps we needed more definition around which type of performance we would look at, but that could be a subject of future discussion. But I didn't have anything particular in mind. It just since it was a standard paragraph that existed in the existing policy, I just left it in. It really was no deeper than that. Okay, thank you. And Jess, just to forewarn you, Thunder has started here in Rutland so if I get kicked off, please take over the meeting. Okay, great. For discussion from the board. Yeah, I think one of the things that was on the table is whether we delay this discussion about enforcement or what that would be for 2021. And, you know, I think that makes sense. And if we were going to delay it, I would propose delaying it until we approve the budgets in October. And the reason for that is not to try to move the goalpost and things like that, but because I think the expectation this year is that the request could be very varied. When we look at them, you know, typically we're going to get, you know, plus or minus five percent, let's say, to their current year budget is the average that we're getting for each of the hospitals. And I think there could be much wider swings and there could be different things included that we approved this year. So I just thought it might be good to give us some flexibility to understand what's actually being approved this year to then be able to move you, but to move it quickly after that time period. I'm torn on this one. There's something that says to me that, you know, the 2022 enforcement period is quite far down the road from a timeline point of view. We do have in place the two-year, three-and-a-half percent. And, but it is, but it's not, you know, steady as she goes. I mean, we have a, you know, a volatile situation here that's going to affect the 2021 budget too in unknown ways. So, you know, my original thinking was to not have enforcement for the 2020 budget and have enforcement for the 2021 budget. But I think the way that Robin has presented it, it still leaves it on the table. Not as solidly on the table. So, you know, I can support the motion. Other discussion? If not, I'm going to call on Mike Barber to take the roll on the motion. Member Holmes? Emma Yes. Member Pelham? Emma Yes. Member Eastford? Tom Cheese. Maureen, do we have you on the line? I'm sure. chewy. I'm ducks. Copy. I'm muted. I actually said I'll go with it. We go down. No, again. I mean, we're going to be... Chairman. Mr. Chair. Yes. Stop. We didn't think you were going to vote against your own motion, but it would be proper, With that, Patrick, are there, is there something I've missed here or we discussed all the open items now? One open item. Oh, sorry. No, go ahead, Justin. No, go ahead, Patrick. Maybe I shouldn't have interrupted. Go ahead. Oh, my only piece was on the timeline, but I'm not sure if that gets wrapped up into a vote on the overall guidance or how that works. Because that's only proposed as of right now that we move everything to submission date to the 31st and then there's the matter of the remainder of the timeline as well. Yes, I'm going to ask you, was yours a substantive discussion or is it something that could be discussed in the overall vote on the whole document? It's actually, it's substantive and it relates to the timeline. It's a piece of information. Okay. My, I just wanted to bring up section F of the guidance, which relates to one care Vermont participation. And it relates to the timeline. If we're thinking about a July 31st timeline, I wanted to raise the possibility of allowing for a delayed submission by the hospitals, potentially of one care participation. Simply because I think there are some, you know, we've just seen my just allowed for a delayed submission of the provider list. And to the extent that we're still waiting for some responses from CMI to some of our outstanding requests related to the all payer model and one care Vermont. I'm just wondering if is should we think, you know, differently a little bit or allow some flexibility, not too much flexibility because obviously participation will have an impact on their budget. I'm just wondering if there's any, if anybody has thought about that component of the timeline with one care Vermont participation. I have thought about that, Jess. And I think that I would be supportive of a change in that date. I think it's still information that we need before we issue our decisions. So I'm not sure what the correct timeline is. But, you know, if it was September 1st, I could live with that, but I don't know what you had in your mind. And I didn't have a date in mind. It was just more of a recognition that July 31st seems very soon to be making that decision with some of this uncertainty still outstanding around BMI and all of that. So just wanted to put it out there. And as it relates to the timeline. Don't have a date. Sorry. Other members of the board with thoughts on the timeline for the one care participation. I also think it makes sense to put that out, given that the provider list is now not due until the end of September. I'm not sure the right date. September 1st seems good. We can certainly do it as a no later than date. So that if somebody had decided at the time that they submitted, they could provide it or at their budget hearing, they could provide it because certainly having that as part of the discussion would be valuable. But certainly I understand that a little more time may be necessary. I think that a no later than date makes a lot of sense Robin and I'll have to keep putting myself on mute because my dog is not liking the thunder. Other members of the board. I go to no later than date as well. I think that makes sense. Sounds like a good solution. Would someone like to make that as an form of emotion? Sure, I can do that. I move that we modify the timeline to allow for a submission of the data related to one care Vermont to no later than September. Open it up to the board discussion. I'll open it up to the public. Does anybody wish to comment on this motion? None. Is there further further discussion? Mr. Chair. Yes, go ahead. This is Susan Aaron from the Vermont Developmental Disabilities Council. This is more of a question for yourself or board member homes. She referred to the communications with them. CMI. Are those available anywhere to the public? Sorry, Susan. I was trying to get my dog to calm down. I think your question was about whether something was public. Did another board member get the full question? Chairman Allen, this is Susan Barrett. I think she was asking about what Jessica referenced in the letter that the state of Vermont sent to CMI, which is on our website. And I can send that to you, Susan. You're welcome. Thank you, Susan, for the help. My dog is not appreciating the thunder. It's getting pretty dark here. It was sunny as we started, but it is getting darker. So is there a motion on this? Yes, I made a motion that was to do a no later than September 1st date. Jeff seconded. I think there's no more. I think we went through public comments. So now it's in the other board discussions. Thank you, Robin. Is there any other board discussion? There's another item to be brought up emotion on the entire document as amended with the previous votes this afternoon would be in order. Would somebody like to make that motion? I will. This is Robin. I move that we approve the abbreviated hospital budget guidance as amended today. Is there a second? Open it up for public comment or discussion. Does any member of the public wish to comment at this point in time on the vote on the entire guidance document? Yeah, I'm not sure if it's positive or negative. The public is early discussion by the board. This is Robin. I just want to say thank you to our staff and actually at all of our fellow board members and the public who have commented as well, because I feel like, you know, given all the uncertainty, this was a harder than normal task. And I feel like people really worked hard to add some flexibility, ensure that we were getting the information that we need and could make as informed decisions as possible while recognizing the current situation. So I just want to say thank you. Members of the board. I'll just second that. No further discussion. I'm going to call a vote on the motion to approve the entire budget guidance as laid out and as amended this afternoon. All those in favor signify by saying I had anticipated. And I guess at this point we can remove the Friday morning board meeting from the schedule. And we'll move on. Thank you, Patrick and Lori and everyone who's worked on the guidance. This has been a very trying process this year. And you have really done phenomenal work along with the legal team to make sure that we continue to try to make our best efforts forward in a very trying time. So thank you. With that, I'm going to move to all business. Is there any old business to come before the board. If we're signified by saying any opposed, and I guess I would have said stay cool. But now I'm going to say stay dry.