 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullen, Chair of the Board, and we are about to get started. The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you, Mr. Chair. A couple of announcements. First is a reminder that we are currently accepting public comment in conjunction with our partners at AHS and the Director of Healthcare Reform for AHS on a potential subsequent agreement with CMMI for an all-payer model. The information is located on our public comment part of our website, and we are specifically asking for written comment, both from our primary care advisory group and our general advisory group, but certainly are always taking public comment from the general public, so please send that along if you would like to comment. In terms of our schedule for the month of March, it's really the hospital team and the discussion of hospital budget guidance for FY 2022. For much of the month, we do have on March 8th a prescription drug technical advisory group starting at 2 p.m. in the afternoon, and then we also have a primary care advisory group on March 17th at 5 p.m. And if you are interested in coming to that meeting, you must wear green. I'm just kidding. Does that complete your report? What did you say? That concludes my report. Thank you. Thank you and happy early St. Patrick's Day. The next item on the agenda is the minutes of Wednesday, February 24th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, February 24th without any additions, deletions, or corrections. Is there any discussion? Hearing none, all those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show that the motion carries unanimously. So at this point in the meeting, I'm going to turn the meeting over to Patrick Rooney from the health system finance team for a discussion of actual financial performance by the hospitals in 2020. Patrick. Thank you, Mr. Chair. Good afternoon. Good afternoon board members and members of the public. Mr. Chair, will you please let me know when you can see the presentation? I can. Very good. I will do my best to announce the slide changes as we move through. But if I fall back on past practices and do not do that, please halt me and I will restart again. I want to make sure everyone can follow along from home. So again, thank you. I was doing a little reflecting this morning thinking back of when I was sitting at the auditorium last year doing this and needless to say it's been quite a sobering year for our little state and the country at large. And I think the results of this reflect that there's certainly the overlying aspect that COVID has created quite a fluctuation in our health care system and that's not yet done. So I hope folks will remember as you as we walk through this that this is a moment in time. And the results of that are continuing as we speak. So hopefully a year from now we're talking about better times, but we may still be reflecting on the impact of where we likely will be reflecting on the impact of this pandemic on our state's hospitals. Navigating down to the overview slide. Here's a brief look at what we're going to talk about today. We'll give an overview of the responsibilities of the hospitals and the board and how we come to this meeting today and also some of the board actions that they had to take in the wake of COVID regarding enforcement. We'll navigate to a system wide analysis of the financial results and then we'll move through each individual hospital on a high level. And following that there's there's some appendices that we've attached to this with a lot of financial information budget to actual analysis key financial indicators and five year results and such and that's more supporting documentation than anything else but we feel that we've put together a solid report that captures the financial performance of our hospitals and hospital system for the fiscal year and 2020. So the 2020 year end review the hospitals are required to report their fiscal year actual operating results to the Green Mountain care board and where pertinent we do ask that hospitals report their parent organizations audit consolidated financial reports as well. And in the work of transparency this information has been posted to the Green Mountain care board site. And that link is on slide three. One overlying note here is that Springfield hospital had not submitted their actual results their audited actual results at the time of this report. So we've used their unaudited year end information to round it out so if there's any holes in the Springfield information it's because we do not yet have the audited financial results. And under normal circumstances we'd be about that time of year where we'd be considering if any some enforcement action. But that was waived last year the board had to change a few of its processes last year because COVID had some major impacts on those regulatory requirements so we wanted to make sure that we put that out here front and center for the board and members of the public to recall and we've posted a a link to those meeting minutes as well. So there will no there will be no enforcement on the fiscal year 2020 results that we're going to present to you today. And that will be the reason why it will become clear as we move through. So slide five we're navigating into the system wide analysis on slide six is is really the big picture on the top left there is the actual to budgeted NPR FPP results. Those actual 2020 results in NPR FPP differed from their approved budgets by almost $300 million, which equates to almost an 11% variance actual to budget, meaning the actual results came in almost $300 million under where the NPR FPP results approved the budgets from the hospitals down slightly from that you'll see operating expenses those came in almost on target there's only about a 0.4% variance there of about $12.2 million. So there's a lot of reasons reasons for that that is that I think we have someone on the phone who may want to mute themselves. Moving to the right of there we have the actual to actual 2019 over 2020 and there's still a large nine figure variance there $163 million, which equates to a negative 6.3% year to year actual negative growth or lack there of in NPR FPP so the board sets out every year with NPR FPP and they set a ceiling on that and so this came in well under the 3.5% that was established for 2020 moving slightly down from there you'll see the operating expenses. Those came in over budget by about $85.5 million at 3.1% and we'll talk a little bit more about that, but where hospitals lost utilization, for example, and therefore, we're able to reduce their operating expenses as it relates to supplies that was then offset by the need to acquire PPE health scanning equipment sanitizing and if you recall back when this pandemic first fell upon us the demand for those types of supplies outgrew the actual supply chain itself and there was a lot of increased pricing going on so our hospitals did pay more for those supplies that under normal circumstances they would not have and that's just an example of what impacted operating expenses in the past year. And below that we have the operating margin. 2020 is 3.2 million or 0.1% of the $2.4 billion of NPR and it is quite amazing to look at this figure and see that it's actually positive. I think if we were to go back to June or July and look at may result many of us would not have forecasted a positive result for this hospital system and as we move through this report you'll see the impact of the various forms of funding and propping that system up. But also I want to note an asterisk there we'll talk about this as we move through as well is that the federal guidance on those CARES Act funds continues to evolve and with that potential evolution. I think it's in its third iteration now I could be wrong about that but that has caused hospitals to interpret that guidance very differently. And should that change again we may be looking at a system that has to restate some of its fiscal year 2020 financial information so that number potentially could move. There are requirements in the auditing world about having consistent reporting and if there's material changes there may have to be changes to that reporting as well. So we asterisk that to keep in mind that the situation is very much evolving very influx and because of the volume of dollars that were pumped in the system from the CARES Act it could have a material impact on some of the organizations. Here's the hospital system view from a quarterly perspective. We provided a report back in the summertime that showed a month by month perspective here but that would have been quite a bit looking at 12 months. So we moved it into a quarterly perspective and you can see that quarter one which is October through December was a mixed bag of results. But quarter to January February March we begin to see the losses from covid's impact and the cessation of non emergent medical procedures really hit the system hard. Order three April May and June we begin to see the federal dollars begin to flow into the system. The governor begins to turn the spigot little by little and the system returns to profitability in quarter three and then in quarter four a combination of quarter threes impact and returned confidence on behalf of the population here to seek health care in their organizations brought the organization back in a major one. So if you're looking at this chart on top on slide seven and then you're looking at the operating margin chart on the bottom of slide seven that quarterly information for each one of those bars will roll up into the end result for FY 20 and that bottom operating margin. And then we have that that 2020 year compared to its prior year fiscal year. The system I pair mix for 2020 despite the impact of covid didn't move very much as you can tell it stays pretty consistent with prior years. We did see more fluctuation on a hospital by hospital basis with the net result ultimately being that it came out relative to its prior year comparables for commercial Medicare and Medicaid. So we have another perspective here on the fiscal year end results for MPR we have the actuals for 19 budget for 20 and actuals for 20 and the variances for each hospital. We've already noted the almost 11% budget to actual variance and then the actual to actual NPR FPV variance of negative 6.3% and this just provides you with dollars and percentage variance for each hospital across the system. Continuing on that message for the NPP sorry NPR FPV growth. You can see here the NPR growth approved by the board in blue and then the actual growth in green. Now we have several years here 16 through 19 where they've been relatively close either above or below what the Green Mountain care board has set. And then we have 20 and we can see covid significant impact on the NPR FPV growth during that period and that's that hole there is what the CARES Act and other funds sought to fill with the emergency funding. So here we are we have a brief message about the uncertainties of that CARES Act funding. And I'll read that verbatim on slide 11 for the folks at home in collaboration with hospitals and the respective auditors treatment has differed on recognition of CARES Act funding revenue due to the potential of changing guidance. The financial metrics for FY 2020 could be impacted as a result. Please refer to the hospitals narratives in the link below for further discussion. And the reason we did that was that the hospital there's a lot of interpretation that can be had from that federal guidance. It's pretty broad. So the hospitals working with their auditors interpreted in their own way within the parameters of that guidance at that time. So should that change that interpretation might change as well and that could have an impact on the results. But given each hospital made that decision from an operational leadership perspective we didn't want to put words in their mouth because each hospital treated it a little bit differently. So we do encourage folks to go to that link and read the narratives of a particular hospital that you're interested in if you have questions about how they treated it and what that might mean. But most of them have the coffee out that it could change and it could change materially. But most of all of the hospitals were in agreement with their auditors and vice versa. But the accounting community has not reached a conclusive perspective on how this should be treated and everyone is really waiting on the government to issue some sort of final statement on how this will be handed down. Last year we began to focus on the increasing reliance on other operating revenues and its relationship to the sustainability of organizations. That certainly did not change this year and this is where CARES Act funding was posted for the hospitals if they realized those dollars on their income statement. So you can see here some pretty explosive growth almost a doubling of what it was last year. And you can see in the light bluish green there that's NPR and you can see that that blue other operating box that is stacked on top of it grew pretty large and most of that as you will see in the coming slides was derived from the CARES Act funding that was realized on the income statements of these hospitals. This is a look that we provided on slide 13 last year where we broke out other operating revenue by categories and you could see on the left the basically a $230 million growth in other operating revenue into the right you can see the categories that drove that growth. And we've specifically called out the COVID-19 and other grant funding which is almost $190 million worth of revenue to help plug that NPR gap really taking over from those other categories that have historically been there. However that said specialty pharmacy which is entirely UVM has continued to grow and that actually those revenue dollars have outpaced the 340B program and 340B continues to grow as well as other pharmacies are contracted and brought on. One item of note that we did read throughout several of the narratives is the cost of those drugs is going up and if the cost of those drugs is going up. It's very likely that the revenues from those drugs are going up as well. But that said the dominating factor here is the COVID-19 stimulus and grant funding that's been realized by the hospitals thus far. So we're moving down through these individual items as if moving through an income statement. So we've passed through NPR and FPP and other operating revenue and now we're getting into operating expenses. And as we talked about at a much higher level before this is just another look of the budget to actual and actual to actual variance per hospital and you could see some of that variation trickling through into those bottom line results budget to actual. There wasn't a whole lot of movement but from 19 to 20 actual to actual every operating expenses did grow by a little over 3% margin results. We touched on this the system wide 3.2 million dollars that the system produced in the past year is certainly down from its prior year historical comparables. But there is still a mixture of red and black on here and again this could shift hospitals treated CARES Act funding in different ways within the parameters of that guidance. So there is the potential that some hospitals in the red might be able to move into the black if there are significant and material changes to that that caused those numbers to shift. But as things stand right now we're looking at a 3.2 million dollar operating margin across the hospice for fiscal year 2020 operating margin and percentage. Again this is just another way of looking at those dollar operating margin results. I will point out for this and the next slide the total margin slide those totals at the bottom are weighted averages on the total dollars of operating margin. So you're not going to get an average looking straight down fiscal year 20 from the 0.6 at Brattlebrook to the negative 0.3 at the University of Vermont Medical Center. We'll make sure to caveat that in the final version that we post to the Green Mountain Care Board website but I thought I'd point that out as it was pointed out to me earlier we should be clear about that. So the operating margin percentage of 0.01% is a weighted average based on the dollars of operating margin. And the same thing goes for this as well. Total margin results I'm sorry. Total margin results as well. You can see quite a bit of variability there and we'll talk about the impacts of that compared to the operating margin. There's certainly a lot less red on there than there is in the operating margin slide previous to this. So moving to slide 18. We wanted to show another perspective that the system wide MPP decreased by 6.3% and you can see the variability across hospitals here. However, it is relatively consistent around six as the system wide average proves out. But most of these hospitals fell well short of that 3.5% growth set by the board. COVID has certainly had quite an impact on this. We haven't seen this type of decline. I don't think ever in the work of the Green Mountain Care Board and it's it's pre eye opening to see what this pandemic has brought to the hospital system in the state of Vermont. We also wanted to touch on the balance sheets really quickly any activity that occurs in the income statements ultimately rolls out into the balance sheet for these organizations and you can see here that current assets assets do within one year to the hospitals exceeded $1 billion. That's a $394 million variance at the time they close their fiscal years and the point here being is that these hospitals are holding on to a lot of cash. Whether it's advances from public and private payers or some of this cares act money that they've yet to realize. There's a ballooning effect here on balance sheets and you'll see this as I move through the next couple of slides that that of course relates to debt as well on the liability side. And it's all and most of it's all it's occurring largely in those current portions which is due to do from within one year's time. So we'll move to total assets and you'll see the total variance is 450 million. So of that 394 is coming from current assets and a lot of that is that cash that they're holding on to in the form of those advances and remaining cares act funding and other grants that they've received. And that of course relates down here to some of the hospitals realized most of their cares act funding because they believe within the interpretation of the guidance that they could justify that. Others book some of it to deferred revenue where they may use it over time if they can justify it or their concern that they might have to pay that back. There's also a lot of advanced money sitting in this current liability because Medicare and Blue Cross and whoever advanced funds these hospital eventually are going to go undergo a reclamation process, whether through future claims or a full pullback on what they lent the hospitals in this case is anyway I'm not sure of the specifics of that I would leave that to the hospitals to discuss but again similar theme here. Total liabilities went up 382 million majority of that occurring in current liabilities related to those those debt items that we just spoke of moving into the hospital profiles on slide 24. If we supply almost every single year we provide the actuals for MPR FPP and then their percentage total of the system and of course we know where the outliers are here with UVM at 49.5% of total MPR and then grace cottage at 0.7%. And then we have the budget to actual variances next to that to show the reduction there and what they had been approved to achieve for an MPR level and then what actually happened. So we wanted to instead of diving into each hospital like we did last year because we had more useful trends from which to speak of. We're going to provide some financial highlights and we still have that hospital by hospital look so that board members and stakeholders and members of the public can see how the hospital in their area was affected but we pulled out a bunch of common highlights for this year and even within those there's a lot of variance as to why things happen so covid has had a very broad brushing approach on these hospitals within each one of their own communities and each one of their own organizations. They've had to react differently or the way the year played out for them may have been different than their neighbor hospital so that really makes it difficult to do any sort of true trend analysis as to the reasons to why because a lot of what they were doing. When covid came down was simply reacting it was survival mode and they were having to find ways to cut costs and to keep their organization safe and to keep their patients safe and whatever so there's a myriad of reasons as to why the financial results shook out the way they did so. We thought the safest way to go would be some common financial highlights and then show you some examples of what we're talking about and we say the variances and it's really on a hospital by hospital basis. So we do have as we just got done discussing days cash on hand you're going to see in each one of these hospitals. They may have lost money but their days cash on hand grew excessively from year to year and that is the covid relief funding whether it's those advance funds or federal grants state grants that will pass down. So that's a common theme throughout capital projects. Most of these organizations froze capital projects that were not essential. There there's a need in uncertain times to retain your capital for operations and so a lot of these organizations chose to put some of these improvements or renovations on hold to maintain that capital for the unknown. On the income statement and PR and FPP was greatly impacted by utilization and volume throughout the spring and early summer months. There was a rebound of that as people's confidence grew through July August and September but the truth from March to June was that these hospitals took a major hit in utilization. And that's not a that's a very common theme but you'll see how those numbers as we move through the hospitals shift substantially hospital to hospital. Bad bad debt was very mixed patients losing employment less revenue for bad debt to be incurred on less staff to monitor collections causing delays. And also FASB issued a revenue recognition change effective July 1 2020 where the hospitals have to assess potential bad debt at the moment of admission. So there's some fluctuation there as well in bad debt and how much of that was impacted by covid I'm not sure that would be something that we'd want to hear from the hospitals. Furthermore, pay revenue was really dependent on the hospital's experience as to how exposed they were to covid so where UVM Medical Center really took a lead early on in caring for covid patients there were parts of the state who really didn't have much covid inpatient care until mostly November December January and February of this year so it really depends on on what happened on a per hospital basis. So other operating revenue common highlights cares act funding was obviously too big to ignore continued expansion of 340 b retail programs was also a common highlight that we saw throughout that. Added to the revenue bucket on slide 26 continuing this narrative here on common financial highlights for operating expenses. Salaries were a bit of a mixed bag. Some were lower due to lower volumes voluntary furloughs and hiring freezes. But some of that was offset by traveler usage. The cost of travelers growing exponentially through this crisis is really no secret to just this industry the cost of travelers have gone through the roof. So that is certainly putting pressures on these organizations. If they can't recruit or had to pause recruiting but still needed help from the traveling community then that's come certainly at a much higher premium than it did even a year ago. Fringe benefits were mixed due to each hospital's experience some had higher health claims. But in many instances lower salaries led to lower taxes on fringe benefits and contributions etc. So it really does fluctuate on the hospital hospital basis. Depreciation was pretty common. As we alluded to the suspension of those capital projects certain limits any move any upward movement in depreciation expense without new equipment or buildings etc. Coming on a renovations. So that was suppressed medical supplies were lower due to volume as we've discussed already. But some of those other operating expenses were offset by COVID related costs as PPE sanitation screening etc. Certainly impacted those hospitals. On the non operating revenue side investment returns for hire the market has been surging and the hospitals have definitely seen some benefit from that. If you look back at those operating margin versus total margin slides that we have migrated from prior to this discussion now you'll note that some of those hospitals that were in the red returned into the black because of some of these returns that they were seeing. However, bond swaps appeared to be lower due to interest rate fluctuations in the bond market. So if if an organization had bond swaps going they some of these organizations lost money on those as well. And an encouraging sign here is that several hospitals reported higher community support. Their communities came to their aid and their time of need understanding the benefit that they provide to their community and several of these organizations see many more community support dollars than they have in the past. So through every trial and tribulation there's always some sort of light and these communities several of these communities came to the aid of their hospitals. Operating margins were mixed overall and we've talked about the federal COVID-19 guidance. Some of those margins may have appeared positive going into our budget season. And then with adjustments for the changing guidance may have ultimately resulted in a loss. So that could continue to change. That's entirely up to how the federal government wants to treat that. And then total margins vary due to the discussions above on non operating revenues and we've got another link for the narratives here should anyone be interested in reading about a particular hospital. On slide 27, we began to move into the individual hospitals starting with Brattleboro and you'll recognize a similar template here as to the hospital system analysis and that was done on purpose. But you can see how each one of these organizations was impacted. Brattleboro's budgeted revenues were in excess of 88 million in 2020 and came in under 76.6 so they had a 13% variance in their NPR budget to actual and budget actual operating expenses came in at 1.4% over. Their actual actual experience was negative 8.8% and operating expenses was positive 6.4%. So there's a lot of variance there where an organization could have taken a very large loss had it not been for the fusion of those dollars in various forms from the federal government. Ultimately, Brattleboro posted a half a million dollar operating gain for fiscal year 2020 or 0.6% operating margin. So as we move into slide 28, you'll see payer mix utilization change and days cash on hand and age of plan. So keeping in context with what we've talked about so far, the hospital the hospital shift in payer mix as you can see here Brattleboro had a little bit of a shift compared to their prior year experiences. Utilization change is pretty significant. As you can see here physician and office and clinic clinic visits dropped 60% from fiscal year 2019. So there's going to be a lot of negative variances on utilization as we move through this but they're going to vary depending on what that hospital experience so. There's not going to be a whole lot of consistency besides some of these areas are are regularly negative but some areas also saw positive variances to their few and far between but it also depends it depends on hospital. And again looking at the days cash on hand, you'll note that Brattleboro only produced a half a million dollar operating margin, get their case days cash on hand group from 157 to 219 as a year end. And that is those remaining funds that they're holding on to that is ballooning their cash on their balance sheet. So, you're going to see that common theme move throughout this hospitals who aren't producing massive, excuse me massive operating margins or total margins, but yet their days cash on hand is really is growing by large amounts. And that will change as we move into the next few months and year ahead. Central Vermont is on slide 29. They had about a $24.2 million variance budget to actual and their operating expenses came in almost on target with only 8% variance. Actual to actual they had a $14.1 million negative variance from 19 to 20 and operating expenses again came in higher than their actual 2019. This hospital, however, did continue a positive trend from its past couple of fiscal years where it produced a negative margin at one point negative 1.3 million but that's a seismic improvement from 2019's negative 4.6 million loss and 2018's negative 7.8 million dollar loss. So hopefully there's a positive trend occurring there where this hospital is beginning to get itself back on track financially. But that's yet to be determined with all of the uncertainty facing the system in the months and years ahead. And again, here we have central Vermont, they have relative consistency in their payer mix. But if you look at their utilization on slide 30, again, a lot of variation there in change from the prior year. And you can see that impact as we saw with Brattleboro continuing, but it does shift depending on the hospital. Brattleboro had a negative 10% variance and ER visits. This hospital had negative 15. So it's really tough to figure out why and what caused all that it's really a hospital by hospital basis. Days cash on hand again, this hospital had a negative 1.3 million dollar loss but yet those days cash on hand grew 36 days year to year. So, like I said, you will see that as we move through. Copley hospital had variances relative to what we've seen the budget to actual was negative for NPR FPP operating expenses budget actual was a positive. So if the person with the last four digits seven or 38 compute themselves, we're getting some terrible feedback for you. Thank you. Thank you, Kevin. So Copley's actual actual experience was positive variance of 3.2%. But also operating expenses outstripped that with a positive variance of 5%. And Copley did produce a 2.7 million dollar loss, however, I believe they were conservative in their interpretation of that federal guidance. So should that change materially for them, it may have an impact on that final number. And as I've discussed before, you know, here's another hospital with relative payer mix but utilization again, it's in the negative but it's all over the place and it's really not comparable to any of its counterparts as we'll see and again, this is probably one of the drastic jumps we've seen in days cash on hand. They were at 62 at the end of fiscal year 2019, and now hold almost 200 days cash on hand so it's really important for folks to realize that these hospitals are holding a lot of money that potentially may have to be paid back if it cannot be utilized or in the case of those advances will undergo some sort of reclamation process. A Gifford hospital, they experienced a negative 9.8% budget to actual variance in MPR FPP and almost a positive 6% in operating expenses and actual actual negative 5.6% variance in MPR and positive 5% in operating expenses and yet still produced a positive operating margin. Gifford was one of the hospitals who interpreted the federal guidance on CARES Act as yes, we can absolutely justify the use of those funds and took the majority of that to their bottom line and produced a gain on the year. And we sat here last year and discussed Gifford's rebound from 18 to 19 and they were at some point, mostly through the year before this happened, they were on track to produce a positive margin. So Gifford Hospital really has turned the financial aspects of their organization around with or without the COVID piece. They were definitely tracking in the positive direction prior to COVID. And here's another hospital. They did see a reduction in commercial payer mix and Medicaid did pop up a bit. There could be a few reasons for that. It could be that their FPP related to Medicaid took on a larger portion of their MPR FPP because of the suppression of commercial utilization in their payer mix. And it also could be that folks have lost their employment and have shifted to Medicaid for health care. So there's a variety of circumstances that are unfolding for these hospitals and there's some shifting and some not. But this is a great example of utilization change. They saw a 26% increase in physician office and clinical visits and 11% in acute admissions, yet acute patient OR and ER all came down by large percentage amount. So these first few individual hospitals, you're starting to get an idea about the variation that they each experienced. And so that's why it's very important to pay attention to that and it makes it real difficult for trend analysis to pick up anything of substance there. And again, Gifford has been in a strong position from days cash on hand and with the aforementioned advances and remaining grant funds that number has gone up over 333 days. But yet again, this is a hospital who as we pointed out last year has an aging physical structure that eventually is going to need some upgrades. So they are about 18 years on their age of plant. So those days cash on hand, although balloon from COVID related funding are being stockpiled for the likely renovation of portions of that building. Grace Cottage, you know, following similar trends to their peers around the state on budget to actual at a negative variance, their operating expenses actually did come in negative as opposed to some hospitals budget to actual at negative 1%. They are actual to actual results again, almost negative 9% and operating expenses as is the theme with other hospitals did grow theirs at 5.8% actual 20 actual 19. And they did produce a negative $380,000 loss, but this is one of the hospitals who has had a lot of support from their community. And COVID did not keep that from from occurring. So again, communities coming to the aid of their health care organizations as kind of a highlight of the COVID crisis where communities came together for the cause of their health care providers. Grace suffered a little bit of a reduction in Medicare but made up for that. Pay or mix shift in commercial, they did express to us back in April and May that they were seeing a lot of second home owners move here full time. And it was very early on so they weren't committing to what that might do to their organization, but it's possible that here they are starting to see the results of that care being delivered from folks who have decided to move to Vermont and stay here as it's viewed as much safer for them. More than other parts of our country. And again, the utilization change here they had some upticks and acute admissions and acute patient days and physician office clinic visits at ER was down and ER is down across the board and some of that is likely visits that probably shouldn't have happened anyway but it flushed those out. And then unfortunately also kept COVID also kept those who are in need of emergency room care away from the hospital as well. So if that's happening acute admissions may be going up a little bit if people put off their health care which nobody wants to see happen but again the knee jerk reaction to COVID was people wanted to stay put and be safe because folks really didn't didn't understand the environment out in the world. But again here we have another prime example of the days cash on hand balloon that we've discussed throughout going from 92.5 and 2019 up to 266.7 grace cottage is another organization who has an aging infrastructure here. That will need to be upgraded in bits and parts at some point. So we should point that out that's not immune from COVID but again, the longer any capital freezes occur, the more we can expect to see the average age of plant of these organizations rise so once they get to a point where they feel financially stable again and things return to some uncertainty they will begin to engage in those plants improvements replacing equipment renovating structures, etc. Mount of Skutney again, following along the lines of their counterparts here in Vermont actual the budget negative 7.2% on MPR they also kept their operating expenses under what they budgeted. And again as you're seeing hospital by hospital basis depending on what what occurred to them and actually actual they fell negative 1.9% under that's one of the better ones that better performances that has been seen on MPR actual to actual and operating expenses came in over as is the case with almost every hospital. But they did see in 2020 a return to profitability they posted a profit margin just over half a million dollars which is a return from the negative 42,000 they posted in 2019. And they've had a little bit of fluctuation in their Medicare payer mix, most of that was made up for in the commercial sector and again on slide 38 here, looking at the utilization change you can see that variability. Once again, their ER visits didn't really come down as much as others and their acute admissions and acute patient days rose significantly. And as we see here, this organization actually has a relatively younger age of plant and those days cash on hand again ballooned over 207 from 144 the prior year. North country, again similar themes. Negative variance on actual the budget. They also had a negative variance on operating expenses that negative three. Keeping those actual expenses under budget. And their actual to actual revenues came in at almost negative 5% and operating expenses came in almost on point with prior year. And again, we were sitting here last year talking about how North country hospital had recovered from its consecutive years of significant losses and we see that trend continuing here in 2020. Of course, that caveat still exists. Some of that may be the interpretation of that federal guidance and that's yet to be determined, but it's still a positive trend. And I believe that was another hospital that coming out of prior to COVID was on a positive track before the pandemic hit. Again, another hospital with some variability and pair mix 2020 returned to numbers more similar to 2018. They did take a significant utilization percentage reduction across these five areas here that we capture. Again, variability in that day's cash on hand they were in a pretty solid place at this time last year, but of course holding on to those extra funds. And that is, is causing that to balloon, but they are, they are an average Asia plant for most organizations in the state at around 14 between 12 and 14 years so they're in pretty good shape from that perspective and again, most of these hospitals underwent capital freezes so those numbers may climb depending on how long those freezes last in each organization. Northeastern Hospital, they kept things almost on point across the board here with the exception of actual to actual operating expenses there. NPR to FPP budget was only negative 1.7% operating expenses were exceeded by 0.4% or almost right on the mark actual to budget. NPR and FPP actual to actual was 1.3% over for 2020 and operating expenses follow the rest of the hospital system coming in over 4%. This organization has really been a model of consistency on operating margin as you can see on slide 41. They've gone from anywhere from a high of 2.2% operating margin to a low of 1.3% this year but those figures tend to run within a relative plus or minus of each other so they've posted as you can see some pretty respectable numbers year over year over year that are consistent. They did see an influx of commercial in their payer mix and that came with reductions in Medicare and Medicaid but again that utilization change varying they probably had one of the bigger hits on emergency room visits at negative 25% and similar trajectory here for days cash on hand. And they're a little on the higher end of the median for state of Vermont for average Asia plant as we can see in the graph there at the bottom of slide 42. Northwestern Medical Center did have a pretty large variance actual to budget at negative 15.7% operating expenses came in almost on point at negative 1.3. The actual actual variance from 19 to 27.5% and operating expenses actual to actual came in very close just 2019 comparable at 0.9%. And this hospital had been on a downward trajectory in fiscal year 2019 and it has been very progressive in making changes to their hospital and the way they are looking at the future and that did results even with the COVID monetary impact did result in a significant improvement in their financials. 2019 as you can see on slide 43 was almost a $9 million loss and they finished FY 20 at a $1.1 million loss. So it's not back into the black yet but that is a significant improvement over prior year and hopefully is the beginning of a new trend that we've seen in some of their Vermont hospital counterparts above where they reached an end and now they're working to get themselves back into positive territory. This is a hospital whose paramedics remain relatively consistent year over year and with their prior year. They did see quite a bit of reduction in utilization across those areas of acute admissions all the way through ER visits. But physician office and clinic visits actually rebounded and put on a 5% positive change. They have always been a very high days cash on hand hospital and theirs probably grew less than most. If that makes any sense they actually grew a lesser rate than most hospitals have. In respect to some of the variances year to year days cash on hand now currently sitting at about 290 days as of the end of fiscal year 2020. And they are relatively low on the average days or average age of plant for a hospital and they have currently I believe restarted their work to revamp their emergency department. So in time that average age of plant will probably begin to come back down as those reservations take hold at the hospital. Porter hospital had a negative 11% actual to budget variance and negative 4% on operating expenses. Their actual to actual was almost 9% in the negative for NPR and their operating expenses actual actual came in at negative 0.6% compared to prior year. This is another hospital who over the years has produced pretty consistent positive margins 19 and 20 being the highest of the period on the screen in front of us. Anything preceding 2015 there were several years of operating losses that were incurred by the organization but in that time they've produced very positive operating margins and 2020 was no exception. Porter on slide 46 had a slight shift in payer mix and some significant negative utilization changes across these data sets that we have them report on and again similar to other hospitals a jump in days cash on hand. Due to some of the COVID relief funds advances and grants and their average age of plant is right about the median for hospitals in the state of Vermont. How Rutland hospital suffered a negative 10.7% variance budget to actual which is right on the mark for the system. Operating expenses came in a little bit over 0.7 an actual to actual experience on NPR was negative 6.7% operating expenses came in 2.7% over and the result of much of that was a $500,000 gain. This hospital has seen their margins erode over the last several years it should be noted that after 2016 they did come in for a correction so that dip there was purposeful but yet in the last few years it has continued to erode slightly and 2020 ending at a $500,000 gain. On slide 48 they have relative stability in the payer mix and obviously utilization changes the same negative effects varying across areas but also the days cash on hand again the balloon and their average age of plant is beginning to take up again. As it has for the last few years. So slide 49 a couple of things I want to point out here we did. Error was pointed out to us this morning on fiscal year 2020 so if you're holding a report from us that says 3.7 or something in that range for operating margin we have corrected that. And what you see on the screen now is the accurate figure for fiscal year 2020 for Southwest and Vermont Medical Center and that reflects the figures you'll see in or you've seen in the slides above when we look at the individual hospitals of the system. So I wanted to point that out before we move on. They suffered a similar experience to Rutland on the budget to actuals at negative 10.6% operating margin was under by negative 2% budget to actual. And on the actual side, their NPR FPV came in at negative 6% under prior year and operating expenses did exceed their 2019 comparable by 1.5%. Again, we have a hospital here who has produced relatively consistent margins over the years as you can see. And maintain positivity throughout as far as margins are concerned there has been a bit of a downward dip the last couple of years but it's it's very gradual it's nothing steep or extremely concerning so all is positive from that perspective. Payor mix hasn't shifted very much. Again, the utilization changes from prior year. This hospital was consistent across these areas between negative 12 and 15%. There's no huge outliers like we've seen at some hospitals. And their days cash on hand for the Medical Center currently sits at 70.6 again this hospital. This is not counting the days cash on hand that this organization has with its parent company. So don't be alarmed by the comparative low level of this with the other hospitals. We point this out in every report that we do that. This is not all the cash that they have access to. It's only the cash that they keep within Southwestern Vermont Medical Center. And this is an organization to whose average age of plant has been climbing over the years it's remained above 17 for several years and has climbed in recent years they are also preparing to undergo some renovations in their organization which once that takes hold should begin to bring that number down a bit. Springfield again here this is on audited information we're working with. So it's very important to understand that this could change in the future. They had a negative 18% variance budget to actual on MPR and negative 1.5 on operating expenses actual to actual they had a negative almost 16% variance in MPR and almost 13% variance in operating expenses to the negative which means they came in 13% under 2019 expenses. And they produced a negative margin of $3.1 million which is an improvement over the past several years. It's also important to know that since their fiscal year closed Springfield has completed its bankruptcy and is now out of bankruptcy. So this picture should change substantially or I should say the balance sheet picture should change substantially next year at this time. The organization is hopefully back on track to put themselves into a solvent financial situation and be around as a hospital for the years to come. Payor mix there was some shifting going on here because of the bankruptcy and COVID. The overall situation that has been brought about by either of those are both. It's potentially have an impact on their payer mix as everyone knows they've had to shift their. Operations with regard to some of the care that they provide so that will certainly have an impact on some of this. But this is all preliminary as we don't have any final numbers as of the date of this report. So it should be noted that several factors could be impacting that downward trend but until we see final results that we should hold that with a grain of salt. And then this is an organization that a year ago from a days cash on hand perspective was in pretty dire straits having only 16 days to operate if everything came to a halt. They are at 47 now and I believe their position will improve as they move into fiscal year 21 and hopefully a year from now we're looking at a more stable situation there. But again we couldn't produce this average age of plant because we don't have final figures for that. University of Montt Medical Center they had a 11% variance the equivalent of $148.4 million from actual to budget. Their operating expenses came in pretty close to their 2020 budget at 1.2% for overage overage of 16.6 million. Their MPR actual variance was 85.5 million or variance of 6.7% and you can feel the impact of the weight of this organization on the rest of the system when you see that actual to actual variance. And if you recall the system was negative 6.3% growth in the variance for UVM came in at negative 6.7. So with UVM so goes our system looks I would say and operating expenses they had an overage of 4.1% or 57.1 million dollars over their 2019 comparable. So this is an organization that as the others dealt with a lot during the past year. And the work they've done to react to COVID along with the other hospitals has certainly had an impact on that operating margin and that margin has been in decline for several years now and as a fiscal year in 2020 resulted in a negative $4 million operating margin. However that said payer mix has been relatively stable. You can see the utilization changes they did have our procedures 3% over its prior year but ER visits physician office visits and acute admissions were down from their prior year comparable and similar trends with days cash on hand rising. However their their age of plant has come down UVM has had some major projects come online from 2019 to 2020 with Epic and the Miller building opening up so both of those have had an impact on that age of plant coming down from about 13.5 to just under 12. So that really concludes the presentation here. The rest of this is data for support of what we've talked about today with key financial indicators compared to its prior year. And that patient revenue five year results operating expenses five year results a lot of information should folks be interested to follow the trends over the last couple of years and the glossary of the terms we have on and in this reporter have used today. So Mr chair that concludes our presentation on fiscal year in 2020 operating results and I will turn it back over to you. Thank you. And as you really noted this was a view of a point in time which was September 30 2020 and we still have had much that's occurred since then that has resulted in volatility to the 21 budgets. I'm going to go and reverse alphabetical order when I ask for questions from the board and I'm going to start with Maureen Maureen. Thanks. A lot to unpack here for sure and thank you Patrick and the team for putting this all together. You know the pandemic has certainly taken a toll on the state and on hospitals and particularly when we look at the hospital budgets on their top line they're down about 10.7% while operating expenses have stayed flat. I probably don't have as pessimistic of you for for year end September 30 on how financially the hospitals look and we really aren't going to know until we get through you know next year and to really see how things truly shake out. But the reason I say that is there's three things you know that I would really focus on to look at their financial health and that would be you know cash the total margin and the balance sheet. So when we look at the cash chart and maybe Patrick you can pull up the appendix first chart where it has the days cash on hand. And I will caveat that absolutely there were a lot of advances made for Medicare and other things that you know are increasing this. But when we look at the system wide cash every hospital is up. So that's good that's that's going to be a strong point and I know we you know we need that on hand but you know every hospital is significantly up and even Springfield which shows a zero there I think on the actual slides I think it showed we had 40 days. So that that's that's hope. Then when we go into the balance sheet and I think Patrick if you look at slides 19, which will really look at where all the total assets and total liability sit across all the hospitals. It was 19 so there's one so here's the current assets are up $394 million. And then if we go to the next slide which has total assets. They are up. I believe 415 million. And then when we look at the liabilities and again these things should all be capturing. You know all of the if there's Medicare advances everything else that's all sitting between these the total like current liabilities are 273 so our current assets versus current liabilities were up 120 million. And then if you go to total liabilities there up 382 million where total assets are up 415 million so if you look at the offset of those two. Not doing it by hospital by hospital but in total our total assets are slightly above the total liabilities so that's a good thing right I mean you know we know we got hit certainly on top line. And then I took it another step one one chart we don't have in here which I think would be good to have is total margin you had a total margin percentage chart. But when you look at total margin because each of the hospitals classified all of the COVID funding differently some put it in other revenues some put it in non operating revenue below the line so it. So each each of them did handle things some differently some are still on the balance sheet some are still hanging things up on the balance sheet versus others. Just a point there I'm not aware of any hospital who put their COVID money in non operating revenue. Maybe one or two I went through all of the financial statements on the audited statements but we can look at but I still think it's important to look at total margin. And when you look at total margin for the 14 hospitals. Every single hospital is up and we do have to factor in if they do budget for total margin and at the end of the day part of it was due to returns on investments but every hospital was up significantly except for three. So if I look at Brattleboro their budget was 1.1 million their actual was 9.7 million CBMC was 4.2 million their actual was 11.2 million. Copley was 1.3 million their actual was negative 2.3 but they have 5 million hanging up on the balance sheet for their PPP loan which if that gets waived that would offset that differed 2.4 million budget 3.3 million actual grace negative 500 budget 861 actual manaskutney 800 budget 6.2 million actual north country 2.8 million budget 7.8 actual northeastern 1.6 to 3.6 northwestern was the other one down 1.4 budget they're down 1.3 but they had a 4 million error in their FPP. That shouldn't have been in their budget. Porter was about flat 4.1 versus 3.9 Rutland 13.2 versus 15.4 southwestern it was 4.7 versus 8.1 and then UVM was really the big outlier with 64.6 and they're down to negative 17.7. Again we're not going to know how everything will shake out until we get truly everything that happens with all of the COVID relief money. But I think we do need to look at where hospitals are netting out financially on a total basis. Most of them are are faring better now some some have some pension issues in that bottom line and that's why they're above but but that was only a couple of them. But I think a key thing in another follow up I'd like to to have for all the hospitals is reconciliation of all of the COVID money that they have and and how they handled it both this year last year and then through this year. And a really good example on that we could maybe use is Southwestern had a chart in their narrative where they took eight funds of money that they receive Medicare advance Vermont Blue Cross advance Vermont healthcare stabilization Vermont Medicare retainer Vermont hazard pay Vermont unemployment credit cares workforce provider relief funds. They didn't have PPP but you know each fund they had they put the amount received the amount recognized in 2020 the amount recorded as a liability in 2020. And then you know we really should put the next year on top of that to 2021 and let's see you know what happens because I think 2021 obviously you know this the pandemic is still continuing and these gaps may widen so I'm not trying to paint a picture. That everything is is good what I am trying to say though is when you look at the bottom line of almost all of the hospitals they are much improved. Including assets and liabilities when I look at the financial the consolidated financial statements for UVM their total assets are up 70 million in total so takes takes in consideration again all assets and liabilities. But I think as an outlier UVM clearly clearly did not receive it appears the funding to offset. All the losses that they had but I think as we look at most of the other hospitals from a financial basis obviously they didn't have patients coming through but at the end of the day. All of the money that was received and how they accounted for it did benefit the bottom line as well as returns on investments which which did happen so that that's made them stronger in the end so I just wanted to put out there. Not such a negative position on the actual looking at the actual financial statements including all the balance sheets right now knowing there still has to be a lot of reconciliation for the relief money. Whether some of that has to be paid back and there's a lot of advance money in cash for Medicare and Blue Cross that you know ultimately will flow through but that's balance sheet versus cash flow so so you know trying to look at the two of them. I think it's really just if we could you know follow up on a couple of things one would be having a total having the budgeted operating margin against the total margin for the 14 hospitals both operating margin and total margin to look at the budget for the two of those. And then and this is not immediate I mean this is going to play out over this whole year but having some type of reconciliation on all of the money and all of the grants that were received and you know there's at least probably 10 sources. And again what got booked where it got booked and and then what happens this year because some of it may have to get paid out some of it may actually hit the P&L favorably right if people are hanging it up as a PPP loan and they actually get relief that will come through as as income. As well as if they had other COVID relief money a lot of people had money hung up on the balance sheet. And so we're just going to have to follow that through you know completely to see what happens and clearly the pandemic is continuing clearly in this fiscal year. We may not be getting all the relief funds to help offset it so again I'm not trying to paint a picture that everything is rosy I am trying to say though if we look at the financial statements with all of the offsets of money received. And with returns on investments and other things almost all of the hospitals are in a much favorable position and that can be seen on total margin can be seen on cash and it can be seen on the balance sheet with the net of their assets and liabilities. And again if these are hung up as liabilities that you know they haven't pushed them through and that's positive as well so. Just so you know we'll just follow through in this fiscal year to see what happens and you know obviously we're all in this together and we want hospitals to be financially strong and stable. So we're going to have to watch it you know really really carefully you know the net for me is that a lot of the funding which was warranted needed did what it was supposed to do which was you know help helped us. Stay in business and helped us you know continue to have balance sheets that are even or stronger than they were you know pre pandemic as of September 30. So granted we're now six months ahead of that and things may be be quite different right now but all I can look at is the year end numbers and just wanted to put that take on it as well. So but thank you you know for the presentation and I'm sure there will be some comments on my comments at some point but that's okay. I think it's you know we need to have that out there in the conversation. So that's really all I have. Thanks. Thank you Marine. Really valid points. Tom. Thank you. And Patrick thank you and your team for putting this together. It's it's quite a feat to have it in presented in such an orderly way that and is very helpful. So I don't have many questions is because especially given you know listening to Maureen and to you and others the volatility of this is kind of hard to ask questions when it's still a little bit of a box of sand. So but I do think it paints a picture one area I just like to get your insight and comment on and I think it might be slide 15. Which was the operating margin totals over five years. Yes. You do. So this this this slide last year and this year has always kind of caught my attention in the sense that the last year. If you looked at the five year operating margin total or UVM Medical Center relative to the total five year operating margin across all 14 hospitals. UVM Medical Center was at eighty nine point nine percent of the total. So with this slide kind of sliding things forward a year and with twenty twenty still volatile let's say the if you add up the the five year total for UVM Medical Center and compare that to the five year total for all hospitals. The UVM Medical Center is at two hundred and sixteen point two million versus a total of two hundred and twenty one point two million which is ninety seven point seven percent of the total. And that that's always struck me as somewhat you know given that the UVM Medical Center is like fifty percent of the hospital pie. It's always struck me as somewhat skewed and I'm wondering if you have any thoughts on that. You know both in general but and whether or not you think the FY twenty twenty will will will change. I mean I guess this is based on audited statements so it's probably not going to change that much. But what you're thinking about so much of the operating margin over a five year period going to the Medical Center and a lesser share a far lesser share to the other 13 hospitals. Well I'm not sure I'm real qualified to weigh in on an opinion there because of the differentiation in the way each one of these hospitals has run their organization. Insights to which I don't really have much to much input on admittedly. But UVM certainly brings economy to scale to the system. And that twenty sixteen if I recall twenty sixteen twenty seventeen they were they were building up margins for future efforts to make major improvements to their system and that would be the Miller building that we spoke of an epic so. It's hard for me to weigh in on that not having been a part of that that build up or having as much context around it as maybe I should. But it certainly is obvious that they have become they were a large point of the system to your point on the audit. There are requirements about. Having consistency in reporting so if there are potential material changes on the horizon that may shift that number with UVM into positive territory. They might have to restate that audit so and that's in an effort to have those those prior year lookbacks and make sure that everything is consistent and it's got to be a material change. And they would be working with their auditors on what that might be. But as far as the overall picture. It's certainly concerning that they're now operating in the red and I hope that's a fluke and I hope that is. That that is because they didn't get to Maureen's point they didn't get the funding that they required now post twenty twenty. I do believe they did receive some extra funding from Vermont's AHS to the tune of 30 plus million dollars. So I believe that's still sitting on their books today. I don't know if they've realized any of that yet. I know the cyber incident had repercussions with their financial reporting that maybe they haven't been able to realize that information yet. But to your point it's fluid. It's going to keep evolving and what ends up shaking out is anyone's guess. Well I just I just raised the issue because I'm still unsettled as to whether or not there's some structural imbalances in our system that need to be thought about. This is this is a five year period. It's not a five month period. The war a two year period. It's a five year period and forgetting about the noise in fiscal year twenty twenty. The percentage was eighty nine point nine percent and this year with twenty twenty and whatever volatility that might be bringing with it. We're up to ninety seven point seven percent. And so it's just it if there's a structural imbalance that I mean you don't want to see any hospital in the red. But and it's it's it's it's not a good thing that that UBM is profiling itself in the red. But there are other points of red on that chart. And I'm just just worried about you know is is the is the system balanced in a way that everyone's got a fair shot to a positive operating margin. Another question I have is the level of FPP in twenty twenty. I think it was projected at around forty fourteen to fifteen percent of a total NPR and twenty twenty one is in that same ballpark. In fact twenty twenty one a budget is less than twenty twenty actual. And I'm just wondering as you went through your analysis did you find any changes or anything of significance relative to the fixed perspective. Payment levels because those are the cornerstone of health care reform. And you know the whole moderate mild capitation that we experience in Vermont. And I'm just wondering if if from what you've seen that the FPP levels for twenty twenty will actually come in at the fourteen or fifteen percent of total NPR. I don't recall if we did or not. We can get back to you on that one but I'm not sure if we did. The fixed perspective payment. There's a lot of nuance in that title as I'm coming I'm coming to learn so it definitely had a mitigating effect on the impact of the pandemic but it wasn't huge. Because as you pointed out it's only fourteen or fifteen percent. So it's not yet at a scale where it would offset some of the utilization and revenue losses that were incurred by the hospitals. But we can get back to you on whether or not that fourteen or fifteen percent that was budgeted held to its actual level in twenty twenty. Well thank you for that and I wish us all luck and I wish you luck as we put together the twenty twenty two budget guidelines. Given the uncertainness here and volatility of where we've been and where we are right now. But it's certainly a transitional period out of this COVID environment and it's going to be interesting to develop a budget process. It accommodates the hospitals you know on the ground issues and the sustainability project and just getting us to a responsible twenty twenty two budget cycle. So thank you. Thank you Tom Robin. Thank you Chair Mullen. Thank you Patrick and Laurie and Caitlin for all your work on this presentation. It shows your depth of analysis. So thank you. I don't have a lot. I just wanted to follow up with on some of Maureen's comments by suggesting that at some point and this could certainly be closer to the budget process. It might be helpful if we could get a little bit of an update on the status of the different sort of rules around the COVID money just so that we can have an understanding of the timing and those sorts of things. So that would be I think helpful going into the next budget process to just have that background information updated at some point. I think we did something like that maybe last year. The other area that was sparked in my mind from some of the utilization numbers was whether telehealth implementation is reflected in some of that variation because certainly in the budget process last year we heard folks talk about either how quickly they stood up or how robust or not robust that their telehealth programs were and how quickly people were coming back in person or not. I don't think there's really follow up to do on that but it was just an area of interest that I wanted to note out loud because I could see us having some interest in maybe talking about how that's going during the next budget process for example. So that's it for me. Thank you very much. Thank you Robin. Jessica. Great. Thank you. The reduction in utilization is truly astounding as you see those charts go by. And of course I can't help but thank thank goodness for the CARES Act funding because I think clearly the hospitals would have been in really dire straits without that funding. So I echo Robin's comments about understanding the timeline and the clarity on the criteria for potential repayment of those monies because clearly that could really shift how we look back at this year if some of that money is going to be clawed back. So I don't know Voss could at some point weigh in on what they know to date about that criteria and the timeline and over some period of time be helpful to get an update on that. This was a great summary and I really appreciated all the hard work that you know you know Caitlin, Laurie and Patrick you've done to pull together these summaries. There are a couple of things that would help me I think in understanding the story if there's a way to update some of these tables. One is because I just think the story is a little deeper than in typical years. So one was I was going to ask if on the on the tables 15, 16 and 17 you talked about denoting that those are like weighted averages of operating margin and total margin. I'm wondering if you could add a median to that because there is such a variance across hospitals in some of those measures and when you waited it's so heavily weighted by UVM's performance that it would be helpful to break out and see what the median hospital looked like. So that would be helpful to me. The second thing would be to if you could at some point this maybe maybe this is a closer to when we actually review hospital budgets for the upcoming years is more to Robin's point but in this slide deck it would be helpful to know how much money each of the hospitals receive from the various sources. Care is money, AHS money just to really understand what's behind some of these numbers because you see some of these hospitals with their days cash on hand increasing tremendously in other hospitals less so it would be helpful to know how much of that is infusion of some of these CARES Act and other funds. So it would be helpful to have a summary table of that. And then I guess I would ask to if it's possible to add the total margin to the hospital profiles because I think to Maureen's point by just having the operating margin on the hospital profiles it doesn't tell the full story and understanding how they did total margin is also helpful. So those were some just hopefully not such major adjustments to the table but I think you know since we always go back and look at these tables. It's really helpful I think to have that kind of full story there. I wanted to can you pull up slide seven for a second Patrick. Is that it? Yeah, I just wanted to point out and and maybe you can comment on Q1 for 2020 was pre COVID. And if we look at that the performance there it's you know it wasn't great pre COVID so I'm wondering if you might be able to speak to some of that. You know the Q1 performance and what we remember about it and that relates a little bit to sustainability planning. I'm actually if I'm looking at this correct correctly. This is the operating margins I mean can you speak to that a bit. You caught me off guard with that I wasn't prepared to go back that far. I am not sure that I can speak to that right now. I was really focused on the year end perspective and everything that's happened since so I apologize I'm not prepared for that. No worries Patrick I just I think it's an important for us to recognize that even before COVID hit the hospitals were in financial you know strain and to understand why pre COVID I think is important because to that you know that speaks to some of the sustainability planning that we're you know going to be continuing to do we are going to get through COVID thank goodness for all the vaccines thank goodness we may all have be vaccinated by April and there may be some pent up demand and we may get back to some new normal. But we have to recognize that there were some some issues prior to COVID with with our hospital system and so I that would be helpful to kind of unpack a little bit of what was happening in Q1. And I guess my my last question and really it was just a surprise to hear and I have to go back and look through some of the narratives and understand which of the hospitals this related to but hearing that travelers was a cost driver. Given that so many hospitals were furloughing staff and volumes were down. I'm surprised to hear that that travelers continue to be a cost driver unless some of that was stemming more maybe that was more Q1 or you know I recognize to that if you're having a labor shortage during COVID. Then you are going to you know be paying a wage premium to get health care workers into your hospital but I would have thought with the furloughing and the reduced volumes that wouldn't have been as much of a concern so I'm trying to understand a little bit more about that. Yeah I think for some of the hospitals I read about it was it wasn't so much like I don't want to sound derogatory but standard care providers it was more in this in the stream of people with more specific provider credentials so they were already in demand but the organization couldn't figure out how to hire someone or couldn't attract a candidate like that and ended up having to find travelers who they were paying hundreds and hundreds of dollars an hour to contract. It wasn't across the system some hospitals noted they were alleviated of the traveling burden. But we did read that several hospitals had had to utilize contracted staff and with the demands of COVID it drove that price up to quite a premium. And we've heard that since so it's not anything that's subsided with the end of this fiscal year it's still happening. Okay thank you Patrick I appreciate it and I appreciate all the work that you all put into this I'm imagining this was many labor hours to pull this all together so thank you. Thank you Jessica I just want to say that anecdotally what I've heard from a number of hospitals is that the cost of travelers has gone up since September 30th. As more and more people are returning to get their their screenings and their their. Elective surgeries that more and more travelers have been brought online so if it's a problem in 2020. It probably will be more of a problem in 2021 and it just. If there's any legislators listening it just reinforces the fact that. Last year was a good start on workforce but there's much more that needs to be done and we have to continue to look at that. Unfortunately like the position that we were in last year. There's so much volatility that's still in place and. I'm hopeful that by the time we get to actual budgets the hearings themselves. That a lot of that volatility will be erased but I think again it's going to be. A tough year. At least at this point in time to really. Pinpoint the type of guidance that for monitors would expect to try to protect them from. The ever escalating costs of health care and I think that. Last year in the budget decision making process we were very careful to err on the side of caution. To create sustainability for for hospitals and I think up to this point that has been achieved. We're in a position to come out of this pandemic. In a place that nobody would have ever thought possible when we were having discussions nine months ago about. What was going to be the effect of the pandemic on our health system in Vermont and so kudos to everybody at the federal and state level that. Rows to the occasion to make sure that our health care system was kept intact. With that being said in addition to tracking Patrick what. You had been tracking for a while with Mike Del Treco and we still need updates on that. I think at some point somebody's got to tell us is there additional money in that $1.9 trillion bill. I realize that bill hasn't passed but once it's passed we need to know. Is there additional funds coming to the hospitals and that's another variable. So there's a lot of variables and it's going to be a rough. Six months really going into the hearings trying to figure this all out and. What we decide here in March for guidance. Is going to be based on the information that we have at that time and we'll do the best job that we can. So with that I'm going to open it up to the public for public comment or questions. Does any member of the public have any comments or questions. Someone's hand just went up and it is. Your shelf ice Eric from the Health Care Advocates office. Thank you chair Mullen I was just curious and this is a perhaps a bit unfair. You've mentioned Patrick mentioned a focus on the year end as opposed to quarterly numbers. Is this curious why. If Patrick could expand upon what was the driver behind. UVMs operating March and being up around 27 million in Q3 and then dropping down to. Minus 600 K in Q4 which seems to be. Different than the rest of the system. It's actually on slide seven. Thank you. Yeah I do not have an explanation for that it's definitely a slingshot. Quarter to quarter for the University of Vermont Medical Center. So I really don't have an answer for you on on that shift. I think Patrick to follow up on what Eric is talking about one of the things that might be helpful is a timeline at UVM. When different events occurred such as the rollout of epic and the costs associated with that the. Ongoing ups and downs at the surgery center at Fannie Allen. Closed open closed again. It would be really helpful to put that all on a timeline including the cyber security breach and everything else because. We're going to need that to dig deeper into. Where UVM really is at moving forward. We know that they've had a very bad year but moving forward where will they be. And another impact of the quarterly changes could be when they booked receipt of some of the funding so I'm sure they'll be able to answer that but if they booked receipt of that and their financials in the third quarter. That may have. And related to some of that big bump. Yeah, there's there's there's most likely some. COVID dollars hitting in Q3. Okay, Mike Del Treco. Good afternoon. Board and members of the public. First of all, thanks for a comprehensive report. Patrick, Lori and Caitlin really nice job. I've been spending a fair amount of time with you and I think we've made great progress and thanks so much for the for the package. Secondly, I appreciate the board's thoughtfulness early in the proceedings quite quite some time ago to wave. The enforcement provision and I think absolutely necessary and I really appreciate that action when it took place. Patrick on one area I wanted to make clear and it was referenced as advances and I know it's Medicare advances. So so in fiscal year 2020 there are about $180 million of Medicare advances and those are the loans that have been referenced and that's probably largely what's driving the cash position and I know you call that out. I just wanted to be very clear that that's why there's money still parked on the balance sheet of the grant money, including CARES Act money from the federal government and state money in aggregate. Our hospitals utilized about 75% of those dollars in their non in their other operating categories. Even with those funds, you can see that our organizations have margins operating margins. Personally, I think that's the biggest thing we need to keep our eye on total margins important, but it includes things like investments and other other restricted funds and things of that nature, which certainly are not part of operations. And certainly we need to keep our eye on margins as we move forward and I think Maureen you called it out. I think Jessica you called it out and Tom called it out really an important part of how we move forward. So those are the three or four items that I wanted to discuss and the final thing not to miss this one, but Jessica as we learn more about loan repayments on the Medicare advance will certainly let you know and Kevin as the new package on roles. We'll certainly have our eye on how much money or if any money will be coming to the state of Vermont. Sometimes it's a surprise. Funds show up in a transfer and and we're the sort of the last to know about it, but as we do as we do become aware of those things we'll we'll work with you you and your team to make sure everybody's a prize. So again, thank you all for a pretty comprehensive package and appreciate the time to speak. Thanks Mike and it's always good to have the surprise with the transfers coming in rather than going out. Other public comment. And Jeff team and. Hi Mr Chairman. Thank you. I just wanted to expand for just a little bit on what Mike said and speak to your your closing question, which was what we do expect from the $1.9 trillion package or whatever ends up materializing. The American Hospital Association is really asking for three main things they're asking for the provider relief fund to be replenished due to the continued kind of uncertainty for hospitals around the country. They're asking that the Medicare advance loans be entirely forgiven, which is a big ask because of the cost and because of the potential impact to the Medicare trust fund. So it's also considered as unlikely, but it is part of the sort of package of requests that hospitals are making for the legislation. And then the final third piece is that hospitals are also asking for a continuation of the suspension of the sequester policy. Which as I understand that the parliamentarian has ruled cannot be done under reconciliation anyway so that would require a separate piece of legislation. But as that package comes together, like Mike said, we'll make sure to provide the board with whatever information we do have my sense is that the provider relief fund will definitely be application based and need based. And we'll learn more about that as the as the legislation comes together. Thanks. Jeff, do you know if any of the Medicare advances were repaid? That's a good question. I don't know that off the top of my head. I don't know if Mike might. They have they have not been repaid. Okay, that's helpful. Thank you. Other public comment. Other public comment. Hearing none. Patrick, Laurie, Caitlin. Great job. A lot of information. Every time you get more information, you have more questions and we know that we've given you some tasks to get back to us on. But we know you're up to the task and it's really encouraging to see you working so closely with Mike Del Treco from VOS to make sure that we get all the information and the right information. So with that, I want to thank you very much and mention that we're going to be seeing probably too much of you this month as next week we transition into the beginning of discussions on guidance in that maybe a month long discussion. So good to see it today and we look forward to seeing you next week and the week after. With that, is there any old business to come before the board? Hearing none. Is there any new business to come before the board? Hearing none. Is there a motion to adjourn? Some of them. Maureen, I'm going to take yours as a second to Jess's motion to adjourn. All those in favor signify by saying aye. Aye. Any opposed signify by saying nay. Have a great rest of the day, everyone.