 The first order of business on the agenda this morning is the Executive Director's Report, Susan Barrett. Just very briefly, I've announced this a couple of times. Folks who probably heard this already, but I'll just announce it again. Next week, we are having Springfield Hospital in. Importantly, though, to announce that we'll be hearing their request for a budget amendment every day as well as their enforcement hearing, and we have a potential vote scheduled that day for both of those items. And the information on the rate increase is on our website, and it is open to public comment. And then on May 29th, we'll be visiting Dan and his team at Gifford Hospital for our traveling board meeting. Our schedule for May will be on our website very soon. Thank you. Thank you. The next item on the agenda are the minutes of Wednesday, April 17th. Is there a motion? Second. It's been moved and seconded to approve the minutes of Wednesday, April 17th. Without any additions, deletions or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Thank you. So at this point, we're going to turn it over to Lori, and we're going to walk through those hospitals that we have already heard on enforcement and begin to make some decisions. So Lori, whenever you're ready. Hi, Lori Perry from the hospital budget team, and we're presenting on enforcement deliberation for fiscal year 2018. You saw this slide before in previous presentations about the enforcement mechanism that was in our guidance for fiscal year 2018. The portion on the bottom we wanted to mention the FY 2020 budget guidance for hospitals with actual fiscal year 2018 projected fiscal year 2019 NPR FPP that is at least 2% below budgeted NPR FPP. For NPR FPP, the GMCB expects NPR FPP and expenses in the fiscal year 2020 budget submission to align with the hospitals actual fiscal year 2018 and projected fiscal year 2019 results. For hospitals, the GMCB would not expect to see NPR FPP more than 5% greater than projected FY 2019 NPR FPP unless there is a clear explanation and documentation describing why a larger increase in NPR FPP is justified. For hospitals with projected FY 2019 NPR FPP that is greater than budgeted, the GMCB would not expect to see FY 2020 NPR FPP greater than 3.5% unless clearly justified. We had enforcement hearings for Cotley, Northwestern, North Country, Gifford and Montescuton. And as Susan mentioned, we will be presenting Springfield next week. Staff recommend no rebases. The Board should consider the following factors. Fiscal year 2020 budget guidance will take into consideration FY 2019 projections. Hospitals historical operating margin, specific causes of variants considered to be short term. And then staff recommend continued month monitoring of hospitals through reporting and some hospitals will be required to provide in-person updates to GMCB staff. The first one for deliberation is Cotley Hospital. And we presented the operating performance for the fiscal year 18 year in budget to actual variants was negative 2.6%. To actual variants was a 1.9%. They are currently fiscal year 2019 as of February. Budget to actual variants is a negative 4.9%. Actual to actual is a 1.8%. The next section is their operating margins for the last few years. And we are expecting enforcement discussion and then staff recommendation is no enforcement, including no rebase. Expectation is hospital will comply with fiscal year 2020 budget guidance. We will have a monitoring discussion on the recommendation and a vote. For Northwestern. I think it might be good to take them one at a time. One at a time. Good. So the recommendation from staff has been no enforcement, wouldn't no rebase. Expectation is compliance with the fiscal year 2020 budget guidance. The only addition to that that I would hope whoever would make a motion would add is that this is a hospital that has already been communicating with us on a monthly basis. So I would hope that we could add that it's put that into an official board of motion that those monthly discussions continue since we know that art will be leaving in shortly over a month. Would someone like to make a motion? I'd like to make a motion for Copley Hospital that we have no, but there's no rebase and that the hospital comes in for monthly updates either in person or by setting any reports. Or by phone. A second question. Yes. Do you think you can come in to meet with staff for board meetings? No, we're basically, what's been happening is that the CEO and sometimes the CFO have a meeting with myself and whoever the head of the hospital budget team is at that time. And that could also occur by phone. And for example, Dan who's in the room has been doing that. And you know, I think, I know I really appreciate our monthly check-ins. So I think that's a good thing. Not at all. Not at all. So, Mr. General Consul, do I open it up for a public comment? Yeah, I think they should proceed as motion seconds for discussion over comment. Okay. Is there board discussion? As I said last, I think it was last week, maybe it was earlier this week. Copley is one of the hospitals that I am concerned about because of the, they have so much turnover in their leadership and because of their historical performance. Because it's great, especially ensuring that we're communicating monthly and keeping an eye on how things are going. It's a good way to go. Anything else from the board? Tom? I share in Robin's observation that I would note that the year 2019 budget is now 6% over the 2018 actuals, which is, I think, a stretch. And if you look at their five-year trends, their NPR growth has been 2.5% and their expense growth has been 4.9%. So this kind of structural separation there. But on the other hand, they have been in transition in terms of before their senior medical staff. And so it's a lot of the variance that can be assigned to those transitions. And I do know that they did add a sort of worker to the emergency room. It seems to be reducing the demand for military services, which is consistent with the all-fare model expectations. So I think the recommend is to do so. I'll just add to what Tom was saying. Tom, I'd also say that through February, their budget to actual variance is down about 5%. And so that would mean when they come in for 2020 budget, they would be expected to be no more than flat with their current budget. Without going through some extended circumstances, which they do have, and they may be able to show us that should their staffing change in orthopedics and orthopedics come back, then they may need more than that. But without showing that the way that the guidance works, they would be only able to come in flat to budget. So that's one reason why I'm not rebasing them. And with that, we expect their expenses to be in line as well. Anything else on the board? If not, at this time I'll open it up to public comments on the complete decision, seeing none. All those in favor of the motion signify by saying aye. Aye. Any opposed? Thank you. So next, Northwestern. Northwestern. Northwestern's budget to actual variance for fiscal year 2018 was negative 2.6%. Actual to actual change was 2.2%. And they are for fiscal year 2019 as of February budget to actual variance is a negative 1.7%. Actual to actual change is 5.6%. And again, we're presenting the operating margins from 2014 through their budget 2019. The enforcement discussion is what we will be having today, of course. The staff recommended no enforcement, including rebase. Expectation is hospital will comply with fiscal year 2020 budget guidance. And we were asking about monitoring discussions, any other recommendations, and then your bill. One of the things that I would suggest on the monitoring discussion is that we heard about their plan to reduce expenses over time. And it might be a good part of anybody's making a motion to include a monthly update. This one I think could even be a writing of the progress on their implementation plan. This is one of the hospitals that over the last five years was tied for the highest growth in expenses. And I think that they correctly set a laser focus on trying to reduce costs. So I applaud them for that. I would hope that motion would include just a monthly update on the progress and how that is going. I would add to that, if we're going to get a monthly update, then have it be more encompassing than just include the implementation plan. But also just the status of where they are against their budget in top line as well. The only reason why I didn't mention that is we're getting monthly reporting, so we'll see that anyways. But not updates. We're not getting forecasts. True. Does anybody who should make a motion? I'll make a motion that for Northwestern, there's no enforcement and no rebase. The expectation would be there would be monthly reports to include updates on their implementation plan for cost savings. As well as updates on the status of their NPR in operating March and each one. It's been moved and seconded. Is there discussion from the board? I would say similar to Coble that there is, the motion is a good motion. And that Northwestern does have some steep hills to climb, I think. If I'm looking at the numbers right, if you look at their 2019 budget relative to their 2019 actual NPR, it's a 9.2% increase. I'm sorry, I missed the number. It's how much? I'm sorry. It's back up. Okay, speak clearly. It's how much of an increase? I missed the number. 9.2. 9.2, I'm sorry. And their original budget expectation was for a 13% increase in their commercial payer. So, but I've been to the hospital twice and met with Jill and her staff and it's a very competent staff. And I'm absolutely certain that the trend that the chair mentioned in terms of the five year trend being at the top can be erected and will exit by disease in the 2020 solid path. Correct. I would just add that they're currently down through February negative 1.7%. And so if they stayed at this rate, then they would not fall into being 2% below. And they would be able to be at 3.5% over a budget. You know, they have a piece of 5% over if they were down more than 2%. So, you know, right now they would be trending to be in compliance with less than 2%. Other board comments or discussion? Seeing none, Jill, would you like to say anything? Thank you. Okay. Yes, Jeff. I just had a quick sort of clarifying question, which is that this is now potentially the second motion where a requirement has been added for a monthly discussion. And while I'm fully in support of those monthly discussions and clearly they're productive for both parties, I just think it might be helpful to get clarification on how long that expectation would last. And if it could be revisited at some point, if the hospital's performance was in a different place based on the board's assessment. So I think that we're, I hate to say this close enough to the next budget season. So I think that in my mind it would be in place to let August presentation. And at that time we would have to assess whether or not it would continue. Very quickly. And just to clarify, I thought this one was in writing this one. Yes, this one was in writing. I thought it was in writing. Okay. Thank you. But you can feel free to call me anytime, Jill. I'd be happy to. Any other discussion? If not, those in favor of the motion signify by saying aye. Aye. Any opposed? Thank you. Next one is North Country. North Country. Their fiscal year 2018 year-end budget to actual variance was a negative 3.4%. Actual to actual percent change was a negative 0.4%. Year-to-date February for fiscal year 2019 budget to actual variance is a negative 2.6%. Actual to actual percent change is 1.5%. And we're presenting their operating margins from 2014 through their budget 2019. Staff recommends no enforcement, including no rebase. Expectation is hospital will comply with fiscal year 2020 budget guidance. We're asking what are your thoughts on monitoring and any other recommendations and then you vote. This is one of the hospitals that we still hadn't received the 2018 Auditon. Is that still the case? We have. You do have it. Okay. We just received it last week. Okay. And again, this is the hospital that's struggling with the change of IT. Is there any motion? I'm sorry. Oh, do they come in monthly? They don't necessarily come in monthly, but they do talk with us monthly. So I'll make a motion that there's no enforcement on North Country, no rebase, and that they continue monthly discussions either via writing film or in person with GMC-based staff. Second. It's been moved and seconded. Is there other board discussions or questions? If not, is there any public comment or discussion? Seeing none, all those in favor of the motion signify by saying aye. Aye. Any opposed? Hey, Gifford. Gifford's fiscal year in 2018 budget to actual variance was a negative 17.9%, actual to actual percent change was a negative 10.1%. Currently for fiscal year 2019 as of February, budget to actual variance is a negative 10%. Actual actual percent change is a negative 1.5%. Again, we're showing you their operating margins from 2014 through the budget of 2019. Staff recommends no enforcement, including rebates. Expectations this hospital will comply with fiscal year 2020 budget guidance. And what is your monitoring discussion? Any other recommendations in your vote? Hey, would anyone like to make a motion? Motion for Gifford Medical Center. No enforcement, including no rebates. Continuation of monthly in-person phone or written reports per the recommended, per guides from GMP staff. It's been moved and seconded. Is there board discussion? Yeah, this hospital certainly looks like it's going to fall within meeting adjustments to their NPR based on only being able to be up 5% from where they're trending. So when they come in for the budget discussions in August, we're going to really want to make sure that we have an update, not only what they will have submitted, which would have probably been through April actuals, but where are they trending for the year? Because right now they're 10% under. So to the extent they're only be allowed to be up 5% above where they're trending. This is one of the hospitals that really falls into that category. And they're only allowed to get 5% without justifying why they would need anything more than that. So I would expect this hospital to end up having a budget to budget in 2020 that will be below their 2019 budget. Tom? I would add to that that Giffords efforts have been aggressive over the past five years where they've had a negative 4.3% trend in NPR and in expenses they've made it 1.9%. So my sympathies and that I think Gifford must feel like a Sisyphus pushing to rock up the hill that they never get to the top. But I think the process that we've set forward is a good one and it's a very steep climb for Gifford. I would make one note that their debt is at 5.2% of NPR. And the system average is 3%. So maybe there's some small opportunity in that corner of their finances but I support the motion. Other comments or questions from the board? Seeing none, we'll open up the public comment. Dan, would you wish to say anything? I think we said it all. Thank you for your understanding. Okay. Does anyone else wish to offer any public comment? Seeing none, all those in favor of the motion signified by saying aye. Aye. Any opposed? Don Stutney. The last one for today, Don Stutney. This for the year 2018 year-end budget to actual variance and then operating performance was 4.4%. The actual percent change was 5.3%. The 2019 year-to-date February budget to budget variance was negative 1.7% to actual percent change is 2.3%. And we're showing their operating margins from 2014 to budget 2019. Staff recommends no enforcement based on their past and current operating performance. We're asking for your monitoring discussion, other recommendations, and your vote. Okay. Any questions for Lori? Lori? Well, I guess just on the monitoring discussion on this one, whether or not we would require them to have monthly updates or not. I don't think they need to, but we've deferred to Kevin to talk about whether he's had discussions with them and would want to continue that. I think really the information that we need to see is already in that monthly reporting because I don't see the need for any additional monitoring at this time. Lori, would you agree with that? I would agree because we ask for all the hospitals to give us any concerns they have in a narrative form every single month. All the hospitals. Would someone who wish to make a motion? Sure. The motion for Maniskutney would be no enforcement and no further action. Second. It's been moved and seconded. Is there board discussion? I'd just like to comment. I mean, they were up 4.4% on their NPR year over year, but I think one of the reasons that we're not looking, or I'm not looking for any enforcement is they've been a hospital that has been performing negatively for operating margin for the past several years, and they are just finally getting to a point in 2018 where they were at 1.9% in operating margin and we're seeing in 2019 that they're running negative to date. So this is a hospital we need to continue to watch as far as their performance for operating margin. And they also have the variable of Dartmouth and how much money Dartmouth might put into the system. So that's another variable we'll be looking to see what happens in 2019. Okay. Anything else on the board? Is there any public comment? If not, all those in favor of the motion signify by saying aye. Aye. Any opposed? Thank you, Laurie. You're welcome. So we just have one more, and that will be next Wednesday morning. Actually, it's next Wednesday at 1 p.m. 1 o'clock. Yes. Here. That's not a fan. The rescheduled one was in the morning, so... Sorry about that. I don't want to confuse anybody. I'm confused enough myself. Is there any old business to come before the board? Is there any new business to come before the board? If not, hopefully everybody will enjoy the rest of this Good Friday and see that build weather this morning because I understand we're in for a little bit of water later. Is there a motion to which or... All those in favor, signify by saying aye. Aye. Any opposed? Thank you, everyone.