 Okay. With that, I'm going to start the meeting. My name is Kevin Mullen, chair of the board. This afternoon, we're going to dispense with a couple things on the agenda and postpone them till tomorrow. So there will be no executive directors report or votes on minutes of meetings. And we're going to get right into the purpose of today's meeting, which was an email letter from Dr. Bromstead on September 23rd, asking for reconsideration for some decisions made on the three network hospitals. And that is the primary purpose of this afternoon's meeting, although I do want to bring up for everyone's consideration, because I see that there's a lot of other hospitals on the line that the board may also entertain today a motion on that is the result of the September 19th memorandum that hospitals receive from HRSA outlining what the guidelines will be for the reimbursement from the federal government. And I know there are a lot of different interpretations of this HRSA guideline, and there hasn't been enough time for clarification yet. But the board may entertain a motion to try to circumvent any possibility of placing a hospital in the position of not feeling comfortable based on those guidelines. So that may also become a discussion today, just so that everyone is aware of that. With that, I am going to turn the meeting over at the beginning to our general counsel to just outline why we're here and what we're considering. So, Mike Barber. Thank you, Mr. Chair. For the record, my name is Mike Barber, general counsel for the board, and I just wanted to give a few introductory comments before you take up the University of Vermont Health Network's request to reconsider the approval of a split commercial rate for the network hospitals and the adjustment of Porter Hospital's FY 2021 budget. And the first thing I wanted to make sure you understood is your authority to reconsider your hospital budget votes at this point. So there are no statutes or rules that specifically address reconsideration of these votes. However, administrative agencies such as the board are generally recognized as having authority to reconsider a determination where the matter is still within the agency's jurisdiction. So there is a Vermont case, Nash versus Warren zoning board of adjustment that is on point. In that case, the Warren zoning board had voted to approve an application for a conditional use permit. However, at a subsequent meeting before a written decision was issued, an interested person presented additional evidence that led the zoning board to reconsider the application and deny it. The Vermont Supreme Court looked at the relevant statutes and concluded that the zoning board's decision was not final until the written decision was issued and the board could reopen the proceedings and reconsider its decision based on the new evidence. So with respect to hospital budgets, the statutes state that the written decision is the final appealable action. Since no written decisions have been issued, hospitals FY 2021 budgets are still within the board's jurisdiction. And you can reconsider those votes either on motion of a hospital or if warranted on your own initiative. There are recognized grounds for reconsidering decisions once they've been issued. However, in general, you have broad authority to examine the correctness of your decisions before they are final, which as I said at this point, they are not. So I just wanted to make sure you understood that authority piece. And before I turn it back over to you, Mr. Chair, I also wanted to say that if at any point in your discussion you would like legal advice on the substantive issues raised by the request, I would suggest that you consider going into executive session for that. Under the open meetings law, you can go into an executive session to discuss confidential attorney client communications made for the purpose of providing professional legal services provided that you've made a finding that premature general public knowledge of the communications would place the board at a substantial disadvantage. You know, we don't do this a lot, but given the potential for an appeal, I think that standard would be met with respect to the issues raised in the request. So that is an option for you to consider. And with that, I'll turn it back over to you, Mr. Chair. Thank you, Mike. With that I'm going to ask if any board members have any specific questions for the general counsel at this time? Hearing none, next I'm going to turn it over to Patrick Rooney. And Patrick has had a rough task that was placed on him. Under the open meeting rules, we cannot deliberate any place other than public on an issue like this. So what was asked was for board members to get questions that they might want to Patrick in anticipation of this meeting. And so it's going to be interesting to see what those questions were and what that information is. So Patrick. Thank you, Mr. Chair. Laurie, if you could bring up the slide deck for us, please. I have to share that praise, Mr. Chair, with our team, Laurie and Kate, they did the lion's share of the work and pulling together the board's questions yesterday in ways that I'm quite honestly astounded by and the rapidity with which they did so. So we have to share that praise across the team and as well as our collaborative work with the legal group over the last couple of days. It certainly has been quite an achievement that they've been able to put this all together and get this team going, as well as Abigail Connolly, who set this meeting up and got all of this information posted. So thank you to all of you for your participation in this. As the chair recognized that with open meeting law, board members are not allowed to meet in public or together outside of a public setting. So we did take each and every one of theirs their questions to get to heart here to put together a slide deck with some supportive data. This is not a presentation format here. It's more of a substantive look at each and every one of those perspectives that the board wanted to see to support the discussion here today. So, board members, because this is in presentation, if you could please, as you work through your discussion, cite the slide number in the lower left-hand corner and Lori will be driving the slide deck and we will very rapidly move through those slides you seem, you deem pertinent to your discussion here today. So with that, Mr. Chair, I turn it back over to you. Thank you. So I take it that your intent is not to walk through all these at this point? No, it is not. It would probably work better to navigate through the discussion and as board members see fit, we would be more than happy to bring up the slides that support their perspectives here. Okay. So with that, Dr. Brum said, if you could tell us who's going to be speaking today and, Joanne, if you could swear them in? I'm going to be providing the bulk of the presentation and comment. Somebody's not on mute. Somebody's not on mute. Somebody's not on mute. Thank you. And I'll serve as MC for our group. For the most part, I think at this point, if you want to swear folks in, you should swear me and Dr. Steve Leffler, President of the UVM Medical Center, Anna Nunin, President of Central Vermont Medical Center, and Jan Bertrand, who's the CFO of Porter Medical Center. And she's standing in for Tom Thompson, our interim president there, who could not be present today. And again, if I could have the board address questions to me, and if they're specific to one of our affiliate organizations, I'll pass them out. If most of our staff are on other questions that are relevant to the finance team or legal, you can swear them in before they give testimony. But I think if you do the four of us upfront, you'll have the bulk of it, Chair Mullen. Thank you, Dr. Brum said. Joanne, if you could swear in the witnesses. Sure. I'd ask everyone to raise their right hands, please. And do you swear the testimony you're about to give will be the truth, the whole truth, and nothing but the truth. So help you God. I do. Thank you. Would you like me to begin now? Yes, that would be great. I also want to recognize that we have several of our hospital CEO colleagues from around the state. And very importantly, members of our boards of trustees at the network level and for each of our affiliates on the line as well. And right up front, I wanted to be clear that the way and thank you, Mr. Barber for laying out the two points that we would like reconsidered. It needs to be known that with the bifurcated decision on our allowed rate increases as CEO, I have to instruct our leadership teams to build plans and budgets going forward only on the part of that rate increase that is going forward. And we certainly can't be building plans going forward on portions of a rate increase that could be rescinded outside of our control. And certainly nobody builds a house and puts the foundation on sand. Hopefully it's on bedrock. And I say that because this is all about having adequate resources to care for our patients and our communities. And this is both in the near term to what I just said. And because the decisions of yesterday and today compounded into the future, we're also talking about the long term health of the state's academic medical center and our two affiliates sent from on and Porter. And when we don't have adequate resources, our people, the people that I'm incredibly proud to serve are very altruistic, they're mission driven, and our people will continue to try and meet the needs of all that come to us for care, despite not having adequate resources. And in that situation, they get tired and frustrated. I'm speaking from experience. I've seen this twice before in my career in Vermont, once at the very formation of Fletcher Allen healthcare in the mid to late 90s. And the second time when the ill conceived Renaissance project ran into difficulties. And many of you may know the traumas that occurred then are people trying to meet the mission get incredibly tired and frustrated without resources. Year over year, we've put hundreds of hours into conversations, good conversations with the Green Mountain care board staff. We've written budget narratives that are incredibly carefully crafted. We've had day long presentations and answered many, many questions from the public, the healthcare advocate and all quarters. And we've gladly submitted answers to follow up questions. And the past reductions in our budgets crafted honestly to meet the needs of the people that are coming to us for care, quite frankly, are incredibly disappointing and frustrating. And this boiled over in 2018 with the Green Mountain care board's decisions relative to the 2019 budget. And we stopped short of asking for formal reconsideration, but we did make our frustrations known. And that's what has led us to the day. It's really difficult to keep a leadership team motivated when year after year we produce honest budgets to do nothing more than to take care of our patients and meet our missions to be told that those budgets are not appropriate. We build those budgets relying on rules that the Green Mountain care board sets and you set those in advance. And every year we expect to have a robust debate. This is Vermont, the town meeting state. We expect to have a robust debate on how to best achieve our mutual missions, which are to meet the triple aim. And in today's environment, the quadruple aim. And we expect those debates to be based on facts, financial sound, financial principles and math. And these all are the core of a healthy regulatory process. We also expect that exchange to take place as part of a process that is fair and predictable. And as I said in the letter I sent to you last week, and I'm definitely not going to reiterate what's in that letter. We don't believe that this year's budget review process met that standard. And we're really asking for you to reconsider your orders in two ways. I'll restate what Mr. Barber said. We ask that you remove the temporary nature of any portion of our commercial rates and grant us a single rate representing the combined amount for each hospital. And second, approve Porter's budget as submitted so we can continue to support the Helen Porter nursing home, which is a core part of the continuum of care for that community. By yet again cutting our necessary rate increases, this has made our hill that we have to climb to sustainability very, very steep, particularly on the back of a year where we're working through a global pandemic. However, granting these two requests, Mr. Barber stated them, I just stated them, will allow us to focus on what's most important to us, taking care of our patients and our people and our communities and meet our mission. So that's what I had to say, Mr. Chair, and I'm happy to answer any questions or farm questions out to any of our three leaders that are sworn in with me. Thank you. Thank you, Dr. Bromstead. So at this point, I'm going to turn it over to board questions. I'm going to go in alphabetical order and call on different board members because it's too hard to follow the raising hand at times. So with that, I'm going to start with board member Holmes, Jessica. I actually don't have any questions at this time, but I may as other board members ask questions. Okay, thank you. Come back to me. Okay. So next will be board member Launge, Robin. I was curious if Dr. Bromstead could or someone on his team could speak to the HRSA guidance and whether they're making, they have a rationale related to that request in connection with their, the bifurcated rate request for restoration. Now I'm right out of the starting blocks violating what I said and I'd ask our general counsel to answer that. Thank you, board member Launge. Just to warn in. So Chair Mullen, just to be certain, I raised my hand and took the oath when Joanne administered it earlier and in planning for this eventuality. So I think I'm good. Okay. Thank you, Eric. You bet. And thank you, board member Launge. I understand that Jeff Thiemann from VAAS is going to be addressing the HRSA guidance. VAAS, I think, appropriately has been taking the lead on that issue for all of Vermont's hospitals. And at risk of previewing it, at risk of, you know, spoiling the surprise, I think what you'll hear from him is that all hospitals, including those as part of the UVM Health Network, are concerned about the potential effect of the HRSA guidance. And we do believe that that provides yet another reason supporting our request that our rate not be bifurcated in the way that it currently is. Thank you, Eric. Other questions, Robin? Well, I was looking for a little bit more legal analysis, but I can wait for Jeff if that's what you want to do, Kevin. I will follow your lead, Robin, whichever you prefer. I don't care. I was just looking to have a little bit more discussion about that. But how about we wait for Jeff? Okay. Do you have other questions, not related to this? I don't at this moment. No. Okay, we're going to turn to Board Member Pelham. Tom? Thank you. I would like to make a request of Patrick to walk through slides one through 15, if he could. I, you know, part of the context for me here is the guidelines in the budget process at three and a half percent, which is a number I embrace, especially from a perspective of affordability. It is a, as I understand it, and I've actually recalculated it at one point, it is looking at a 15 or 20-year period from the mid-90s up to 2016 in terms of the gross state product of the state of Vermont. So it's kind of based in underlying economic concerns. And it's the number that was embedded in the all-payer model agreement between us and the federal government. I was happy to see that when we went through the QHP rate review process, that the average of both MVP and Blue Cross Blue Shield combined was below three and a half percent. And so, you know, I'm new as a Board Member trying to struggle between some of the concerns that Dr. Brumsted has raised, as well as rates that are affordable to Vermonters. And at this point, I don't think they are affordable. So there is a remedial action that's necessary. But I think that slides one through 15 do provide some context for the issues that we're going to be discussing today. And I'd like Patrick to go through them and point out the network hospital statistics as you go through them. So pointing out UVM Porter and Central Vermont. Thank you, Mr. Chair. Thank you, Tom. Yes, we will proceed through slides one through 15. On slide two is a familiar look that we produce year over year showing the result of the Board's decision and that patient revenue annual percentage increases. You will see on the far right, although it can be considered temporary at this time, the NPR increase for the system is 2.7 percent moving into budget year 2021, following years of higher rates dating back through 2014. Here we have the requested or submitted and approved NPR FPP figures for budget year and fiscal year 2021. In the middle column, you will note the differences in those figures from approved to submitted and also the approved change percentage and the approved change percentage post adjustments. So you will see that 2.68 figure in the bottom right hand corner rounded up comes to the 2.7 percent you saw in the previous slide. We also have a caveat at the bottom around the University of Vermont Medical Center that does show that just given the size of the medical center on an annual basis that the approved growth would be about 0.4 percent without the substantial revenues being considered from the medical center. Of note is the difference here in the NPR in the middle column and in red showing that the board cut budgets from submitted to approved by about 17.5 million dollars. So here we have the percentage of the 2020 budgets to submitted the variance in the system totals. So we have about 89.7 million dollars in growth from the 2020 budget to the 2021 budgets. And then on the far right hand column, we have the percentages of that growth throughout the system. So it goes from as low as negative 22.6 percent with Rutland to 85.7 percent. And again of the center column, the budget to budget dollar variance, that is the percentage of that variance. So of course, again with the medical center being the size that it is, it will of course take the lion's share of the variance just being the size of the organization. Here we have the variance between the approved budgets, FY 20 and FY 21. FY 22, 21 approved as it currently stands today, a very similar look. And with some of the decisions that were reached, the medical centers variance went from 85 percent up to just shy 94 percent. And Rutland's came down to 28 percent with the decisions that were reached a couple of weeks ago. And Patrick, if I can just intervene one half second, just to know about the scale in terms of NPR of the UVM Medical Center to all the rest of the hospitals. And it's about a 50-50 split in terms of going back four or five years and looking at that ratio that the medical center as a percent of total NPR across all 14 hospitals is about 50 percent with the remaining 13 being the balancing 50 percent. That's correct. That needle doesn't move a whole lot on a year to year basis. Okay, so slide six again, looking at the a few different data points here. This is based on the NPR commercial pair increase and decrease. So not considering Medicare and Medicaid in the equation. Again, as has been stated previously here, the medical center will obviously take the lion's share of the variance totals here from budget to submitted budget. And here's another familiar look that we produce every year. This always indicates what was submitted and approved. Of course, this year it's a little more complicated here with the COVID component that's been discussed throughout and the fact that there was an imposition of COVID rates as discussed earlier for some of the hospitals. The result being the FY 21 approved at 5.1 percent and COVID consisting of 0.5 percent. Here's another component to this. The COVID rates that were approved by the board and the equivalent and the equivalent of that across the system just shy $20 million and the dollar value impact on each of the hospitals who either requested and were approved for it or it was imposed upon by the board. This is done off of the dollar values that were submitted by each individual hospital, understanding that that is different for each hospital. So you can see it's as low as $277,000 per quarter all the way up to $9.5 million This is a historical look at operating margins. You will note that we left fiscal year 20 out of it, either from a budget perspective or projection perspective. There's still financial activity yet to come. We did not feel be pertinent to include 2020 in it for obvious reasons. So historical look at actual audited financial statement operating margins for each of the 14 hospitals and then system totals at the end. Slide 10 please Lord. Similar look but in margin percentage over the last five years of audited financial statements with an average on the right since slide 10. Coming out to a five-year average of 2.6 percent across the hospitals. Obviously this shows some of the financial duress that some of our state's hospitals have been in over the past couple of years. Slide 11 please. Thank you. This shows the requested margin for fiscal year 21 and the operating margin based on approval. I will caveat that this does not consider that the commensurate reductions and operating expenses that the board also orders when they reduce NPR or reduce rate. So you will see some hospitals here where it appears that they are in the negative. This is before any commensurate reduction. So moving forward when final budgets are approved and submitted by the hospitals those numbers will change. So don't take it for any more than it is. We did this simply to show the impact as it stands today on the hospital system based on the approvals by the board of fiscal year 2021 budgets. And these figures are subject to change for the operating margin view. Slide 12 please Lord. So as I stated before this is a this is an operating margin percentage look of the previous slide the same caveat applies. It is more to add perspective to today's discussion than anything else. Again those red numbers will change when hospitals go back and perform gap closure between what they submitted and what the board approved for them with the commensurate reductions and operating expenses. Slide 13. Thank you Lori. And we provide the same look for total margins as well. After all non-operating income is considered in that equation the same caveat applies. There is still work to do on the operating expense side to align the budgets approved by the board with what the operations need to be for the coming year. And on slide 14 we provided a total margin percentage in line with the previous three slides with these applying caveat that we've discussed already. And slide 15. This is an update of the CRF awards. We put out requests in our monthly financial documents to the hospitals that if they could put a dollar amount of anticipated funding on the state relief funds that they please do so. The hospitals you see in the left hand column here were able to do that. Most others cited that they were not. And then on the right hand side we have the awards relief funds as discussed by Secretary Smith on the 18th presentation to the to the board. And at that time Porters was not known to us but that figure has since come in so you can see the differential there and what was supplied versus what was realized. And with that I will turn it back over to the board. If you could go back to, I tried to write these down as you went by them, if you could go back to slide four please. It was four I want to look at for a minute here. So if you look at this slide what this says is that in the budget process for 2021 we had 89.7 million dollar in requested NPR increases. Correct? That is correct. And if you look right above that at the University of Vermont Medical Center their request was seventy six point eight million dollars which was eighty five percent eighty five point seven percent of the total. That is correct. Next slide please. So here is what we did flexibly for the board. We approved increases of seventy two plus million dollars of that sixty seven point five million was for the University of Vermont Medical Center and I'm not eating in Porter and Central Vermont and one logic we probably could but I'm just focused on the biggest one. So that sixty seven point five million dollars was ninety three point six percent of all the NPR increases that we improved. Correct? That is correct. Before you answer that Patrick I just want to interject at some point Tom I'm assuming you're going to tie this into a question for Dr. Brumsted. Yes I will maybe not as we go through this slide show but I farther down the road I definitely will. I only have two more slides if you could go to slide nine. Well Patrick maybe you may want to repeat that because the court reporter probably didn't get both of us talking at the same time. Oh of course yes board member Pelham statement is correct regarding the ninety three point six percent proportion of the budget to approved budget variance. Slide nine. So this profiles operating margin over a five-year period and the in the number in the lower right hand corner the three hundred and twenty nine million dollars is the total collective operating margin over that five-year period for the thirteen hospitals. Correct? Correct. And two hundred ninety five point seven million of that accruing to the University of Vermont Medical Center. Correct? That is correct. And you don't have the math there but if you looked at the amount accruing to the University of Vermont Medical Center over that five-year period as the numerator and all Vermont hospital community hospitals amount at three hundred and twenty nine plus million as the denominator that would come to eighty nine point nine percent of all the operating margin across the entire system for five years. Correct? Well I haven't done that math but I would say it is the majority of the total of three hundred and twenty nine million dollars accumulated over the last five years. And if you can go to slide fifteen please. Maybe it's not yes this one. So down at the bottom we see that the CRF award as of nine eighteen twenty for the University of Vermont Medical Center is thirty one point nine million dollars. Correct? Correct. Now did we factor that at all into our budget review process or we were aware of the of a number which was like twelve point nine nine but did we somehow factor in that thirty one point nine million dollars into the budget process for the UBM Medical Center? We did not apply any of those relief funds coming from the state given the unknown to what they could actually be once the state made the decision so no we did not for any of the hospitals. Okay thank you and I'll ask my other questions later. Okay I'm going to move to board member Yusuf or Maureen. Uh sure let me get off mute. Um so you know first I guess. Excuse me Maureen at some point uh Chair Mullen um and not right now I've you've got a fluke your meeting I have to respond to um member Pelham's um uh uh soliloquy there because it was just fraught with uh incredible misstatements misinterpretations and errors so I'll come back to that at some point. Well actually Dr. Brum said I'm going to give you the opportunity now I was hoping that um member Pelham would phrase it something in order of a question to you to give you that opportunity but you may do so at this time. Okay in in all of that I you know in the flashing uh numbers um maybe Mr. Rooney can go back to the slide that shows the margins over five years um yeah I guess that's the one when you um look at um uh 15 and 16 for the UBM Medical Center those numbers are very close to what um we predicted uh in the CLN for the Miller Building that we would need to make sure that uh we did not pass along the costs of that uh building uh to rate pairs and we stuck with that and then as you look at I'm sure even Mr. Pelham will agree that uh 75.6 million is um uh over twice as much as 31 million and you know that 31 million is less it's right around uh under a three percent margin um academic medical centers um the uh that 3.1 percent margin um in uh the uh 2.2 percent margin in uh academic medical centers puts it uh in the lowest decile of academic medical centers the message there is if you want an academic medical center in this state it needs to be funded the numbers are large because as is accurately pointed out um the academic medical center needs half of the tax another point that I'd like to make that has consistently caused confusion is the conflating of the 3.5 percent in all-pair model with what many years ago was pulled out as an NPR cap of 3.5 percent yes they're the same number but in the all-pair model at 3.5 percent is the collective result of the PMPM the per capita trend that's applied the CMS component was supposed to be 20 basis points less than the PMPM trend for Medicare Advantage and um Medicaid is what Medicaid is and we were to solve for what was required of commercial payers that's very different than at the beginning of this process assuming that medical inflation was going to be 3.5 percent and that should somehow guide the NPR growth we showed very clearly and anybody that follows healthcare finance knows that 3.5 percent is nowhere near real medical inflation um it because of the growth in pharmaceutical costs um and what we've been struggling with with um uh uh staffing costs in rural America um we're blowing through that 3.5 percent year after year and the chronic underfunding led as we clearly said in our budget presentation to an inordinately large increase request in uh 21 it's to be able to help us to catch up to the un chronic underfunding of the state's academic medical center and um I would refer you back to uh slide 15 in our budget presentation that just shows the deterioration of margin and um you can't run an academic medical center without a 4 percent margin even a 4 percent margin uh puts us in the lowest quartile so I'll stop there sorry I'm getting a little exercised thank you now we're going to move to member useful Maureen um thanks um Patrick if you could go to slide 18 uh sorry 17 um no okay the one the one that has the historical five year for operating margin in and um that's down further the one that has the three year three year the hospitals and historical data for five years just um uvm cvmc and porter goes past uh so that yeah there we go okay sorry 19 um you know first I want to say we know this is a budget right and and you know as we know everything there are assumptions throughout the whole budget and I'm sure that every year um you as we do do the best that you can for the information that you have and what we have right now though is the benefit to look at the past performance and see what's actually transpired and you specifically in your letter called out what the board has done over the past several years and what that has done to your financial um position and I want to look at the last four years of actuals because that's what we have is is actuals for uvm and focus on the fact that for the last four years you've exceeded your npr every year you've exceeded your budget uh for 2016 and million 156 to million 126 2017 a million 211 to a million 172 2018 1254 to 1209 2019 1273 1254 but more importantly you've also exceeded your operating margins for those three years um with them with 30 30 million dollars over in 2016 in 2017 another 20 million dollars in 2018 although you were higher on top line you did fall short by four million dollars on your operating margins meaning your expenses were outrunning your revenue which is a problem that um I see that the medical center has and we can talk about your 21 budget on that as well and then in 2019 again you overran the top line by 19 million dollars and your bottom line fell short for it by eight million dollars but cumulatively over that time period you were still up 36 million dollars so I beg to differ on saying that um that you have been significantly harmed by the past four years of decisions and the four-year actuals you've beaten your numbers every year on the top line most years you do on the margins but other years you don't and that's because your expenses run out of hand so um just want to get a little bit of understanding on you know I just really want to be on the record so that it's clear because some of the things that have been written do not represent what I see as the facts and you talked about fraught numbers and things like that these are the facts these are the financial figures these are the numbers you represented and you exceed them every year so we do have that hindsight when we look at the budget process um so I just I just want you to respond to how do we look at the fact that you exceed every year top line you're not if you also exceed your expenses beyond that on the years that you haven't produced a higher operating margin and cumulatively you're up um up well over in the four years and even if we trend it in where 20 would have been you still would be up I'm still tracking with uh our ultimate margin and that our rate increases um have been inadequate to cover those expenses um and create the margin irrespective of what the MDR result is and I understand that we have a basic uh disagreement on whether we can control those expenses or not I would tell you based on experience that the vast majority of our expense and we laid this out in the in our budget presentation is related to pharmaceutical cost growth the only way to control that cost growth is through things that we would not do which is withholding specialty drugs and very expensive medications and labor costs and we have very recent um examples of what happens when you try and manage labor costs within the rate increases that you've given us and you know if you want to deconstruct this uh more uh member use of her um I'd ask uh Todd Keating or Mark Stanislaus but the basic rule that or the basic result that we're seeing is expenses are outgrowing what we've been allowed to put into our rate increases to cover inflation well that is very apparent in your 21 budget when we look at that because your 21 budget has a top line increase of 77 million dollars and half of that 38 million dollars of the 70 million 77 million dollars is the eight percent commercial request that you asked and your expenses are up 125 million so yes it's it's apparent that your expenses are far outrunning um and that's a major issue when when you kind of put that in perspective that on a 38 million dollar utilization increase if you will because your top line is up 77 million half of that is is rate of half of the 77 so on a 38 million dollar expense you have 125 million dollar 38 dollar revenue you have 125 million dollar expense so you know when we get into if we get into further discussion if we open up um discussing about your request um you know to put into perspective a two percent reduction in your commercial rate was worth nine million dollars and that's on a billion five expense budget nine million dollars on an expense budget that's growing 125 million dollars on a 38 million dollar top-line revenue yeah that's that's very much out of line and um part of the reason you know we're talking about this but you know another option maybe you could discuss is you know in your budget you talk about no Medicaid increase um very minor minor Medicare increase and therefore you have to to make the math work push all of this expense or onto the commercial rate payer that eight percent and what's happening with that is that's pricing commercial users commercial patients out of the market so the commercial patients we already hear many of them don't come for services because they can't afford it so yes we need to have healthcare accessible we need to make sure that you have the services um at the hospital but there's also a balance between what the commercial consumer has to pay and will pay and adding another eight percent which was the request that you had on to that just prices many of them out of the market so the question is why aren't you as the largest user of healthcare services in the state working with trying to get more from the state just accepting that you get zero and then pushing it all to the commercial payer um well um a lot in uh those comments um we've all over years talked about the cost shift and that actually is one place that I believe the Green Mountain Care Board and we are the same I will point out that the despite the sub inflation um rate increases that you've allowed those have not translated into reduced premiums for rate payers in Vermont not once and if you look at what we requested because we've been underfunded in 21 we made this very clear if you look at that and average it over the prior five years we're still um under four percent for our commercial rate increases and look at what's happened to the commercial premium increases over that same time period they're decoupled right now and we've had that conversation as well but um you know look at it over five years you're you're all throwing out numbers about trends um and what's happening over time very appropriate our commercial rate increases even with what is a big jump are below four percent and we are very sanguine about that in our presentation and in our um uh and in our budget narrative that those are uncomfortable big jumps for us for all three hospitals but um you know that is the result of underfunding we have to catch up you know what happens with uh negative compounding in trends you as eventually need to either uh catch up or you end up where we are with vastly deteriorating margins um below what's going to allow us to generate or have access to capital yeah I would say it still didn't really answer the question about why you are not pushing for higher Medicaid rates but I do want to now is not necessarily the time to go through through how the insurance reimbursements work but we have brought this up every time the network shows a chart about what they believe is decoupling of the insurance rates and what you charge and that is not in fact true and we should review that because basically the insurance blue cross will shield if you want it's pretty simple they pay out what the claims they receive and then they have about a seven and a half percent on admin fee so so that that's basically what happens they they pay out the claims and they've lost money for the past several years and within their component and within their rate there's much more than just the hospital rate but I can tell you that the hospital component is coupled into the blue cross blue shield and MVP's rates and other insurance rates and in fact what we've approved here is higher than what they have in their budgets which if their utilization and everything else were correct that could cause an issue but we should we keep saying we should review that at a later time because they do use the rates from the hospital budgets and there are other things such as pharmaceuticals as you said and other costs you know I'm not trying to support you the way but the math there is is pretty simple they do lose money and we can show that so I think that would be a good thing for another meeting but just want to make sure that you know we get also on the record that there this is not a decoupling and yes a whatever increase you have certainly can be a higher increase on a commercial rate based on federal issues federal taxes and sometimes it's lower too so it certainly was lower than eight percent next year which is the commercial rate you requested so you know that that might show how it's not you know one in the same but um I'm also pretty active and thanks um uh Chair Mullen if I might um ask um Rick Vincent CFO at the academic medical center to uh respond I'm not sure uh Rick if you raised your right hand or not when we were sworn in Joanne if you could swear Rick in okay would you raise your right hand please do you just want to testimony we're about to give will be the truth the whole truth and nothing but the truth to help you God I do thank you I guess the point I just wanted to make when we're looking at the the margin the operating margins here which is what we tried to point out in our presentation is what's embedded in there and what we tried to decouple is the impact of our 340b programs on the operating margin and when you pull that out of there it's very it becomes much clearer the fact that the commercial rates have not kept up with uh with expenses and I think that's the that's the one thing that's lost when we look at these numbers at this level here that we tried we tried very hard to kind of show uh why you know the the impact is essentially embedded within our budgets that when you take that 340b related uh business out of our out of our numbers we essentially started to lose money last year okay um Dr. Brumstead uh I don't have a lot of questions I think that the direct stands for itself throughout the whole budget process I do have one though because um I was troubled by the narrative that seems to be coming out of one of the parties to this appeal which is Porter and um are you aware that um even after the reduction and even after um what you've aligned out as an anticipated transfer that it's still close to a 2% operating margin for that hospital um uh Jen Bertrand do you want to uh respond to that yes this is the perfect slide can you hear me okay I can yes perfect so I do want to speak to that a little bit and correlate this to what's necessary in terms of support as well as funding for capital needs um so yes although the margin does reflect 2% from the operating standpoint that 1.9 million that you see there significantly actually under funds what's available for capital and I'm not sure if you're familiar with the survive sustain and thrive model uh but the appropriate reinvestment to sustain is 120 of depreciation and to thrive is 140 of depreciation and with these two numbers that you see here whether we take the operating margin dollars or the total margin dollars there it does not cover at the 100 percent of our capital request and budget for 2021 and so the majority of that goes to those capital needs inclusive of other things that we've spoken of obviously in terms of population health and whatnot but I didn't want to point that out because operate or excuse me our capital budget that we've requested is 2.8 million dollars with Helen Porter included um so we're already going to be digging into saving so to speak in order to fund the capital needs of this organization and just one other point um when we ran the recalculation of our current age of plan we're almost two uh 15 years at this point as well so Jen um Dr. Bromstead made a case why an academic medical center needs to receive a higher margin but Porter is not an academic medical center and if you take a look at the operating margins for your peers around the state most people recognize this as a very trying year and the submissions and the approvals were significantly lower than anything that Porter put in in fact Porter asked for the largest uh in the entire state what do you say to that are they just all budgeting incorrectly well I certainly wouldn't say that each organization's going to budget to the needs of their um respective hospital's needs I think for our particular needs and what we need to fund Helen Porter that's why the hospital's operating margin does look so high and again when we bring that operating margin into context with Helen Porter and that support of Helen Porter it does bring that operating margin down to um as submitted two and a half percent um but where it stands currently at two percent um and and we've talked about the the need of keeping Helen Porter in the community and what that delivers in terms of a reduced total cost of care and I think that's important in this and there's a lot of organizations in our hospital network in Vermont that funds services um many services within our communities and supports those services through subsidies and whether that is um services such as palliative care which are housed within our hospital budget submission or things like Helen Porter or even uh you know day's cash on hand that's supported by the parent corporation and provided to some of the hospitals that are reporting I think it's important to look at the breadth of services that we are there that are out there and one of ours is obviously Helen Porter and that support of Helen Porter. I hope that answers your question Chairman. Thank you Jen. I'm going to open it back up to uh board members if they have any follow-up questions. Kevin this is Robin I have a follow-up uh related to the Porter that's on topic um hey Jen um thanks for joining us uh are you just Helen Porter except Medicaid? Yes actually the payer makes for Helen Porter Medicaid right now is about 70%. Thank you and have you contacted the division of rate setting about the the Medicaid rate for Helen Porter? We're constantly in communication in terms of our relationship um through our our cost report preparing consultants I will throw that copy out out there but we do try to communicate with them and have the rates adjusted dependent on their certain factors that go into that rate. There has been improvements to the rates over the last uh I will say year it began in July of last year however to put some things in context the total expense per day for Helen Porter is around $410 per day to care for the patients there. The Medicaid reimbursement rate even with that increase is approximately $295 so you can see it's still quite a bit upside down in terms of 3% but there have been strides in the last year. Thank you um are you familiar with Medicaid's ability to provide extraordinary relief when a nursing home is in trouble? Yes. Yes. I would assume because of the subsidy Helen Porter has not been eligible for that Medicaid extraordinarily extraordinary relief. We have not tapped into that um funding with the exception of this year due to COVID we did begin that process. Okay thank you. As a follow-up to Robin's line of questions Jen are you familiar that Helen Porter according to the published rates on the uh department's uh website has the fourth highest reimbursement rate in the state? Oh that's interesting uh no I was not aware of that candidly. Again though I will point out that that could be also with the way they determine the rate and knowing that Helen Porter is a five star nursing home and so when they calculate that rate there's expense that drives that that rate of reimbursement. Okay other board members hearing none at this point in time I'm going to turn it over to the health care advocate for questions of the witnesses. Mike Fisher. Thank you Mr. Chair um I want to be honest I have more statement um than a question though I would be happy to uh ask Dr. Brumsted to respond if he has any response to it. Proceed. Thank you. Um so first off I think uh the HCA stands by our August 31st comments submitted to the board about the hospital budget process. There's no reason for me to repeat the details of those comments but I also think it's important um for some of the concepts to be said out loud in this form um whether measured by unemployment, business contraction, lost income or the costs of basic necessities, Vermonters are facing unprecedented unprecedented financial hardship. Simply put Vermonters just can't afford increases in the cost of care. This was true before the COVID pandemic um but during the COVID pandemic it's true in an even more acute way. I hear the frustration expressed by Dr. Brumsted and by UVMMC. I guess I want to express the same level of passion and frustration on the part of Vermonters who need care or who are afraid that what will happen to them if they need care and they can't afford to meet their basic needs. I'm not commenting here about the specifics of the UVMMC budget proposal uh as to whether it's needed or appropriate. We can't possibly evaluate the level of details that would be necessary of their budget or their business practices. I'm simply wanting to express in as strong a way as possible uh that the impact of big rate increases of commercial rate increases as has been said by other by members of the board um is that it prices people out of the ability to get care. We all know that the health care marketplace doesn't function like any other marketplace. Even before the third party payer dynamic I can't decide if I want to get the care I need like I can decide if I need a new lawnmower. Consumers don't have a choice. I know it's complicated and I know I hear here very clearly the cost drivers of drugs and paying for staff that are outside of the control of UVM and of every other hospital. But simply put we have to continue to put as much downward pressure on the rise in the rate of growth of the cost of health care. And just to say it one last time because I just think it's really very important the bottom line for the consumer advocate is that Vermonters can't afford it. The impact of big rate increases is more and more people are priced out of the ability to get the care they need. Thank you. Dr. Brown said you have anything to in response? My only response to Mr. Fisher's comments that by and large I agree with is that it's also a time of unprecedented dependence on access to care. We are in the midst of a global pandemic. It's not over. I will say this has been a wide-ranging conversation and I would say that we all collectively have and in different ways with different opinions put our stock in the all-payer model to try and wind our way through this incredible time escalating health care costs and needs. I'm still an absolute believer in a model where we move to the providers being accountable for the quality and the cost of services. I would say that the cost of those services need to be covered because the only way to solve the equation if the costs aren't covered is to restrict access and that just doesn't work for any of us. And Chair Mullen if I might again this has been a wide-ranging conversation. I apologize that I got a little bit exercised and heated but I would like to have you come back to our very specific two requests and we can debate about taking the academic medical center from eight to six is a problem or not but I'm just telling you that from my uh perch as CEO in the decisions that I need to make the bifurcation of the allowed increase into a piece that is uh potentially uh can be rescinded um is presents a great difficulty we just can't plan about around that and definitely uh those that uh judge our financial health the bond rating agencies having been with them the last 10 years and knowing the analysts that are on our accounts I can guarantee you that they other two that haven't downgraded us uh will if um uh we don't have uh stability in uh what our uh rate increases on so I'll leave it there Chair Mullen thank you thank you Dr. Brumson and I will remind the board that um as uh council barber laid out there are two um requests in the motion that is currently before us that are asking for reconsideration and that is to um not have the rates be bifurcated and uh specific uh ask when it comes to poorer medical center's rates so um is there further questions from the board if not I'm going to open it up to public comment and I'm going to start with Jeff Teeman since uh he was offered by Dr. Brum said as someone who wished to uh make a public comment thank you Chair Mullen um I think it was actually Eric Miller um who who offered that um but I'm going to make sort of a two-part public comment the first relating to the question that came up from Robin about the HRSA guidance um and then a more broad public comment if that's okay Mr. Chair that is fine okay so with regard to the HRSA guidance I don't have a detailed or formal legal analysis of that but it is with certainty it's blurry um so much so that the American hospital association has asked for clarification on several components around reporting timing um and how relief funds received will be reviewed um I think from an association standpoint we're concerned that um a state government board that labels a separate commercial rate um as a COVID-19 rate could be perceived by the federal government as a form of new assistance and potentially therefore clawed back um so we would request or or ask the board to consider applying one rate to clarify that this is a hospital budget process um and not not a COVID related relief process um I think in general the requirements um in the HRSA guidance are complicated and they're still being reviewed and the AHA is actually seeking clarification so it just seems like a regulatory risk space that we should avoid right now um and it's our view that your decisions um today should not add to the complexity that already exists here and I think we know that there's plenty um more broadly I just want to offer a comment in support of the network's request for this reconsideration when this budget process began my plea to the board was to make sure our entire system of hospitals is strong to make sure that Vermont's high rankings for quality and cost and access continue at their current rates and most urgently as Dr. Brumsted pointed out to make sure we can continue to have the resources and where with all we need to manage the pandemic as you know very well our academic medical center is a major resource for our healthcare community and the entire state not just during the pandemic but always board member Holmes said it well during deliberations on UVMMC's budget they train the next generation of doctors while also resourcing our entire state and patients all over Vermont in numerous other ways just one current example is the crucial role they play in helping us procure PPE and testing supplies um every day for the past several days and I check every single morning Vermont is the only green state on the COVID act now warning map should there be a surge and there is always that possibility we need this resource and our entire hospital community to be strong and ready for that reason it just makes solid sense to me that we would not threaten our capacity or our ability to treat patients and manage this public health crisis in any way including by cutting hospital budgets without a clear or compelling rationale so given the information that has been presented today and shared by Dr. Grumsted and his team I urge you to to protect our shared interest in serving Vermonters with our healthcare system and doing so effectively and efficiently and to everyone's point as affordably as possible and we're doing that work too so with that in mind I would encourage you to reconsider these budget decisions because I think it would be really unfortunate for any of us to have to come back here in a few months or a year and wish that we had managed this differently thanks just to be clear Jeff isn't it necessary if we're going to solve this problem that was created by this memo that came out a weekend ago from HRSA that it really should be for every single hospital in the state of Vermont that was given a replicated rate uh yes Mr. Chair that would certainly be our view and for the reasons that Dr. Grumsted articulated around around certainty and sort of administrative and logistical confusion thank you Jeff other members of the public I see a hand up from Claudio Fort Claudio can you hear me we can yeah thank you Chair Mullen and members of the Green Mountain Care Board I'm Claudio Fort president and CEO of Rutland Regional Medical Center Rutland Regional is a 144 bed independent non-profit full service community hospital and the second largest hospital in Vermont I share the concerns expressed by Dr. Brumsted and his colleagues about the Green Mountain Care Board's commercial rate decisions for four of the five previous fiscal years Rutland Regional Medical Center's operating margin performance has been significantly lower than budget for the five-year period from fiscal 2015 through fiscal 2019 Rutland Regional averaged less than a 1.75% operating margin and for each of the previous two years we generated less than one half of 1% of net operating income for our current fiscal year Rutland Regional took significant and painful pressures measures to reduce our operating expenses due to our historic financial difficulties and the long-term changes in capacity and volumes that we predict will be the new normal in the post COVID world over this past summer we've permanently laid off 45 of our colleagues and implemented other difficult cost reduction measures to reduce our operating expenses by almost 13 million dollars the intent of these reductions was to minimize the impact to clinical staff and front line workers therefore most of these cuts came from administrative and support positions despite these financial challenges Rutland Regional has submitted budgets in full compliance with the budget guidance directives of the board despite these financial challenges over the five-year period from fiscal 2016 through fiscal 2020 Rutland Regional's overall charge increase averaged just 1.8 per year the third lowest average of all the hospitals in Vermont we have been sensitive to the impact of hospital rate increases on our patients our local businesses our schools and the municipal and the municipal entities that provide health insurance to their employers and despite these financial challenges we have committed to advance our health care payment and delivering reform efforts to support the goals of the Vermont all-payer model by assuming additional financial risk through agreeing to enter into the Medicare program under the one-care accountable care organization. Rutland Regional submitted a budget request that included a 6 percent overall charge increase on september 16th the board voted to approve our requested six percent rate increase however this was uh quote separated as a four percent standard increase and a two percent covid rate increase we feel that the six percent rate increase is what we need to legitimately operate the hospital over the coming year irrespective of what happens with covid for this reason we did not designate or request any of this rate increase as covid related if we suffer another shutdown of elected procedures or a surge of critically ill acute covid patients all bets are off a two percent rate increase will not mitigate this impact we're further concerned that there has been no definition of what a covid rate increase means this new ambiguous provision introduces much more uncertainty that may result in significant consequences to our hospital and the patients we serve one of these ramifications is that by characterizing part of the rate increase is covid related this may be considered by the federal government as covid relief funds that will result in the federal government clawing back some of these federal relief funds that Rutland Regional has received another potential consequence is that Rutland Regional we believe we've exhausted our ability to reduce expenses and not impact clinical quality further expense reductions that Rutland Regional will likely have to come through the form of elimination of certain programs and services over the past several years we have seen hospitals throughout our region and our state take measures such as closing intensive care units and eliminating critically important but costly services like obstetrics well this may appear to be beneficial by allowing the affected hospitals to reduce their net patient revenues they only shift these costs to other hospitals since these patients ultimately do get admitted to other icu's and these babies do get delivered somewhere so the end result is some hospitals look good while others take on additional volumes of services that increase their net patient revenues but require disproportionately greater expenses to be added to safely provide this additional care and some of this care has and may continue to leave the state thereby exporting Vermont health care dollars which don't go seen but ultimately result in higher costs for Vermonters I'd also like to state that there are many many more factors that influence the total cost of health care and the cost increases to our patients than simply hospital rate increases utilization plan benefit design patient out-of-pocket cost sharing percentages post-acute care utilization the health care labor market drug cost increases availability of primary care the cost shift state and federal regulatory mandates the malpractice environment the effectiveness of care coordination the availability of mental health services are just a few of the numerous drivers of the cost of care I believe that the almost singular focus on net patient revenue and the reliance on hospital rates as the primary tool to adjust net patient revenue has exhausted its utility and is beginning to impact the effective and efficient operation of our hospitals listen we don't want to be arguing balls and strikes with our regulator I believe we can work together to develop a broader and more comprehensive understanding of these cost drivers and to develop a more cost-effective way to direct and incentivize hospitals to address these in the meantime we respectfully request your reconsideration of the bifurcated rate decision for wetland regional and to approve our six percent rate increase as requested I want to thank you for your consideration and opportunity to address you thank you claudia all other members of the public can I make a comment kevin you can ham um state your name is alerted my name is hamilton davis um and I write about health care and health care reform um my my my question is i'm just looking at this and i've i've seen you know i've been watching these kind of hearings since 1980 and the uh and what what sounds like significantly a standoff one of the questions is that the one of the questions is that I have that I still don't understand is if the if the board let's say call it it's 50 50 whether the whether the green mount care board now votes um to um votes to change make the change that's been requested I think the claudia's uh statement was powerful but it's still 50 50 uh based on marines because uh marines position he answered the question of kevin that I would hope you would uh mr mullin I hope you would ask uh dr brumstead if the decision if the board decides to stay with the current budget what will your response be so ham it's a somewhat confusing question because dr brumstead hasn't asked to um have a reconsideration on the rate for uvm barlinton only for porter he's just asking that the bifurcation of the rates um be eliminated well I I don't know how to I don't know that I don't know really how to reframe my question but I think the question is obviously present implicitly if the um the what what brumstead has said in several several different ways okay is that he believes that his or his organization the medical center hospital of mainly okay uh is is is progressively getting less able to deal to do the things that it thinks that ought to do it ought to do if the if the so my question is given the given that fact okay what will he do if he does if he's not happy with whatever decision you make I think that's perfectly fair question well ham you know it's this is public comment we don't uh allow the public to interrogate the uh witnesses um and again I'll just reiterate that dr brumstead did not in his letter ask to have the rate increased for uvm barlinton is there other members of the public in in in ham we want you to be able to have a Thanksgiving and a Christmas celebration well the governor wants to too he was on my side you know Kevin for those who were not watching uh ham asked the governor a question during the the press conference today and uh you could see the passion in ham's uh question that he really would like to see his family at the holidays thanks Kevin other members of the public if not uh at this time does any board member wish to make any particular motion and I will restate the fact that um there are there was one letter but there were three different motions that were made um during the budget process and I believe that um each of those motions would have to be considered separately and because of that um I would have to disqualify myself from the ability to make any motion on porter as I did not vote in the majority and member power to disqualify itself from making any motion um as it relates to uvm as he was not a member of the majority in that vote but with that being said once a motion is made um all will be entitled to vote do I have that correct counselor barber yes thank you and Kevin I just wanted to make another comment if that's okay go ahead Maureen um something I've prepared but partially related to what what ham said um and you know I haven't given away what I'm going to to do at the end I just wanted to really kind of set the stage for um talking about the letter that we received um and discussing a few of the things in there before we move forward and then you know I kind of need to just put that out there because we did get a letter that was I would say on the border being relatively accusatory to the board of us not doing our job and not using the benchmarks and things like that so I just want to kind of go through a little bit of that first specifically what the letter said was on an annual basis the board establishes benchmarks for any indicators for use in developing and preparing the upcoming budget Maureen yes Maureen this is Joanne the board reporter and that's too fast please could you slow down and start again sure thank you on an annual basis the board establishes benchmarks for any indicators for use in developing and preparing the upcoming fiscal year budget hospitals then build their budgets and manage their operations with those guidelines and benchmarks in mind the board is required to approve or adjust the hospital budgets by reference to the guidelines and benchmarks established in advance this year's budget process did not comply I'm reading from the letter with the GMC's own rules it adjusted our budgets based on guidelines and benchmarks that it never articulated prior to its deliberations I specifically want to talk about UVM and CVMC respectfully as UVM states the board can impose restrictions on various indicators for example rate increases yet the board shows only to provide guidance on NPR I believe this gives the board flexibility to approve rate increases based on specific hospital circumstances and by no means restricts the ability to adjust this request yet we did set one metric we set three and a half percent over prior year for NPR and when we review the three network hospitals in the letter from UVM it states the board did not abide by the benchmarks and guidelines that we set it seems in a way it was to our benefit that we did not had we abided by that UVMC requested 5.7 percent in order to reduce UVMC's to the 3.5 percent benchmark that they were supposed to be moving towards that would be a reduction from their 8 percent commercial rate to 1.2 percent we ended up approving a 4 percent commercial rate with a 2 percent additional rate because of the circumstances that were in due to the pandemic actually in the past four five years their average rate is three and a half percent so the four percent was kind of a maybe ceiling of what we were looking at for almost all of the hospitals excluding Northwestern if we did and then again I think I mentioned this before but to put into context their request was 77 million dollar increase where the 5.7 percent and of that 38 million was the rate increase alone and when we looked at their expenses their expenses went up by 125 million so so there's definitely one of the things I've pushed year over year is cost savings and metrics and we hear that we are working on them and that you have them in there but they're not keeping up with the pace of the expense growth on CVMC their request was 8.7 percent and in order to reduce to a three and a half percent benchmark using the only lever we really have right now which is commercial rate they'd have to have a negative commercial rate in order to meet that so respectfully I just want to say we did use the benchmarks that we set the network didn't necessarily use the benchmarks that we set and we're in unprecedented time so I understand that there may be need to be accommodations made which we did do and I am open to the discussion that we're going to talk about now but I just want to make sure because there's been a lot of press about what this board has done to the network hospitals and that we didn't use the process and in fact we did use the process and we we did use the one benchmark that we set it may mean in the future that you're asking for us to make more benchmarks to have more benchmarks out there so that we can can be measuring against that and that's something quite frankly there has been some resistance to because we didn't want to just get locked in necessarily to rate but maybe that's what we do need to do in the future so I just wanted to make sure I felt it was important because I felt the letter that we received was unfair and as far as some of the statements it made about the board and our process and being untethered and other things so just want to make sure that I'm on the record of saying I don't believe that was true we do our best as we're going through this as well and balancing not just the hospital requests but what it means for consumers who are using the services and the affordability accessibility as well so before we move forward I just wanted to make sure we got some input on that as well because what's being written is not supporting what actually happened in the process Kevin this is Robin I'm happy to make motions but before we do that I wanted to also just make a statement about the HRSA guidance because I that way if folks had a reaction or wanted to comment I was hoping that we'd be able to allow for that is that okay it is all right so I did review the HRSA guidance that was received and I don't disagree with Jeff's characterization of they're needing to be additional information and clarification from HRSA in terms of how they're going to react to it and certainly it can be quite difficult to understand how a federal agency is going to react to something that occurs at the state level so but with that said I did just want to clarify that what we are approving is a maximum change in charge and a max or a maximum commercial effective rate it is not the actual reimbursement rate that reimbursement rate is calculated or negotiated between the commercial insurer and the hospital individually so and in addition while I can certainly see why there was some confusion because of the guidance related to the temporary rate increase and I and I agree that perhaps characterizing it as a COVID rate increase would make sense not to do that but to because really it's a temporary we characterize it in our hearing and our discussion as a temporary rate increase I do think that in written orders those factors can be clarified to be clear that this is a maximum that it is not based on actual expenses related to COVID and while some of the hospitals made projections to tie their rate their temporary rate to potential expenses expected in 2021 related to COVID we did not necessarily use that justification in approving the rate so I think when we were talking about the temporary rate the way we were looking at it quite frankly is that it provides us a way to ensure additional hospital sustainability in a very unprecedented time which quite frankly is what the hospitals asked for if we were to pursue our rate increases as we normally would I think hospitals would be looking at getting the standard rate that we approved so providing for some additional commercial rate to protect the hospital in an unprecedented time certainly makes sense to me I'm not necessarily and we can get into the discussion about you know whether it should be bifurcated or not in reality the way it would work in the commercial contract is that it would be a rate that was agreed to for the year but I just wanted to clarify that so that we head on the record that the temporary rate increase would not related to the types of expenses or calculations that are included in the HRSA guidance at least in my review of that guidance thank you Robin your comments are are similar to some that I had as well in that I think that the guidance although well intended from HRSA can be interpreted in a number of different ways and I would submit that it could be interpreted that even if it was called a COVID rate that it still could be argued that it's not a reason for a clawback but because of the fact that I would be diametrically opposed to trying to place any possible clawback on the backs of just a small subset of Vermonters which is the commercial market I would be in favor and as you know the chair doesn't make motions usually I'm not prohibited from it but I'm not at this point going to make a motion but my preference would be to take any conversation off the table and eliminate even the conversation of a bifurcated rate and have a single rate and that would be for all hospitals in the state of Vermont that receive those decisions and it's simply based on the simple fact that we would never want to subject a small subset of Vermont which is commercial ratepayers to putting the bill and that that's where my position lies but that's just one board member well I'll jump in here since I haven't said very much Maureen did you want to go you know okay I'm not sure the process here Kevin do we need to have a motion to reconsider first uh if we do I would certainly support one I think we have to keep an open mind if we've missed something or made a decision that has unforeseen consequences we need to reconsider our decision so first of all I would support a motion to reconsider just to have uh the debate but secondly at least with regard to the bifurcated rate I would support rolling the bifurcated rates into one year long rate one to protect federal dollars two to reduce uncertainty and three to give hospitals the confidence to make investments throughout the full year knowing that they will have that rate for the full year I think we can think about and we should talk about what we do at year end and how we address that but at the very least I would support rolling the bifurcated rates into one year long rate and I think as part of that motion it might be very important to also remove the enforcement section of this year's guidance which refers to that and go back to you know the rules that are in place for the Green Mountain Care Board and we could call a hospital in at any time if they were you know taking off like a rocket ship and blowing their NPR and just going way off the the playing field of the budget so so maybe before we have more discussion I should make a motion related specifically to the reconsideration because before we substantively discuss the grant the grounds for and what we are reconsidering first we have to agree that we would reconsider at all so does that make sense for me to proceed with Kevin yes and I'll ask counselor barber is it better to address the two specific requests from the network separately from the broader requests of all hospitals or could it could that one be rolled into one motion I'm not sure that there's a legal answer to your question if they could all be rolled into one motion if it's going to apply across the board to all hospitals the same but I think maybe the the wiser thing to do would be to address the requests that's before you from the network on those two issues and maybe separate those out and then based on the discussion and what you end up doing consider whether there's an extension to other hospitals that would be appropriate so now knowing how wise Robin is I'll turn it back to her for what she wishes to make for a motion okay so the first motion would be to so I would move that the board reconsider it's September 16th 2020 vote to establish the but the budget of the uvm medical center cvmc and order second as I understand the motion and both the the maker and the seconder as I understand it had voted in the majority on all three of those motions so I think that your motion is proper to to reconsider each but then under a reconsideration I think you're gonna have to focus to specific yeah savings that were made yes but we can't do that until we agree to reconsider I didn't discuss this with council barber before yeah okay yeah are there questions from other board members yes I'm just wondering how uh the focus on the three network hospitals um relates to non-network hospitals that had uh a COVID related rate increase so a lot that'll have to be a separate motion later on in the meeting but it does take the question of councillor barber who did advise Robin that this was a legal motion but also advised me that people who were not in the majority um could not um make the motion um is it okay to do all three at once Mike I'm sorry could you repeat the question is it okay to do all three network hospitals in one motion to reconsider I don't think it's improper okay yeah good okay favor ma'am you're off mute ma'am you can't do this this is a legal proceeding if you could mute yourself it would be greatly appreciated is there any further discussion from the board if not all those in favor signify by saying I any opposed signify by saying nay let the record show is unanimous decision to reconsider with that um would someone wish to make a motion about reconsidering a specific motion yes so uh I am actually gonna start um with quarter because I think that's a different question um uh I think hold on so um let me just back up so I think now that we've moved to reconsider the budgets that puts us back in the position of uh discussing each of those budgets anew so it says though we never voted um so it would be helpful for me if we could go to thank you the quarter lies um so and could you go forward please to the slide uh related to the decision one more thank you um so uh what I'm gonna propose as my as a motion related to port of medical center is that um we approve the request of a 2.7 percent npr with a commercial effective rate of four percent um subject to uh let me leave it there for now and then come back to the enforcement question I'll second that it's been moved and seconded to um approve port of medical center's budget with a 2.7 percent um change in npr fpp and a four percent change in commercial effective rate did I summarize that correctly robin yes with all the standard budget conditions yes thank you sorry I forgot that part um and if I might I can speak to why I moved for that you may okay so um as I think I said during the porter hearing like the the issue around support of uh the specific helen porter nursing home was really not my issue um I think you know we typically allow for hospitals to manage to their budgets um and certainly I think sir I was I was uh supportive of the idea that given that it's a 2.7 percent npr request request I am willing to um to maintain that that is under the guidance that we had set um and in terms of the commercial effective rate I think my intent in adjusting that is that uh I do want to reduce the uncertainty related to the HRSA guidance although I I don't think it this actually triggers it but I do want to support the reduction of the uncertainty um and um I do think that during this unprecedented time I understand why hospitals are assuming uh more volatility and utilization and relying more heavily than in the past on their commercial rate requests which I think you can see easily from the chart showing that the commercial rate requests this year were twice what they typically have been in the past you don't have to move Laurie it's okay um because I was talking about generally um with that said I do think um we also have to discuss when we get to the discussion discussion portion um how whether and how uh to review the commercial the very high commercial requests this year because in a normal year I would not have voted you support more than 3% from this hospital okay other board members further discussion discussion um yeah I'm gonna throw out a potential concept and hang on there fellas but um so I understand the need to look at one rate this year with with some of the things that have come in recently which which what has already been discussed so potentially eliminating the bifurcated rate whether it's on this hospitals and other hospitals but I also support what Robin just said as far as kind of a normal rate um these some of these rates at 6% which we'll be looking out in the future would be higher but then I think that need to be that we I would have supported for a commercial rate so to we've also um it appeared to me from the letter from UVM band almost asked for giving out more benchmarks so that they have other benchmarks to to measure against um so one way to do that would be to incorporate a concept that would be in next year's budget guidance but that would be looking at a two-year change in charge rate and potentially having the guidance on it on a two-year change in charge so I'm just throwing out hypothetical here but in that example many of the hospitals were well under 4% for the rates that they requested and received this year and they don't necessarily have the benefit now of coming back and getting this COVID rate and non bifurcated rate if they didn't ask for it um and next year again I'm just throwing out hypothetical if 4% was we're going to look for an average of 4% each year then they could have 4% this year and 4% next year um on a hospital that had six it would be six this year two next year that would be our guidance for example if we if we you know accepted this path I think it then gives the board the flexibility it gives the hospitals the assurance that they're getting a rate this year it gives the board flexibility during the process next year to review requests that may differ from that just as we have done NPR as a game example yeah whoever has music playing at least mute yourself it's probably someone at a hospital it's like usa so this is 4475010 okay can you still hear me we can hear you now thank you so so the concept I think would would kind of give the assurances that the hospitals want this year um and I understand why they why they need that going forward but it would give us the flexibility next year to come up with a rate if we so desire to do it that way um but I wanted to give the heads up for that you know at this point and then just as I was saying you know when hospitals come in um we do consider what's going on with the hospital that's why we differ from the three and a half percent rates you know barring what may be written about it sometimes we do make those considerations so so next year when things come in we would start with that position um and then if there were variances from that um we would discuss it and and at that point I think also to just ground ourselves again the reason that we wanted to put in this incremental rate wasn't to punish the hospitals because we were taking it away it was really trying to be what we thought would be helpful because of all the uncertainty because there were incremental costs that specific hospitals have specifically lined out that are just related to what's going on with COVID because patients aren't coming back to the hospitals and and we're seeing you know 90 to 95 percent utilization we all hope that returns back in 2022 so you know just grounding ourselves on why did we even do this that that's why we did this right so at the end of this year or in the budget process we're all going to know a heck of a lot more we're all going to either be saying you know wow we're through this hospitals are back moving along as they had been in the past or unfortunately we're in a worse predicament than we thought we didn't get enough federal funds people didn't come back you know and and we'll have to make those accommodations at that time so just wanted to put that out there because I think it gives some flexibility for what the intent was for this and um we certainly will have time to to think about that um versus just going with saying okay it's you know forget what everything we had set out to do and we'll just approve all these as an ongoing measure um so I just wanted to put that out for conversation other board discussion on the motion before us well maybe I'll be in the dress go ahead Tom so I mean I I like what marine has said I um you know the record will show that when it came to vote on Porter that I explicitly excluded um any impact on Helen Porter um and and explicitly said that's something that we have to deal with next year what I liked about the COVID rate though is it is it was a way to revisit um budgets relative to potentially one time and expenditures that would roll out from COVID into 2021 but not continue on and so um thinking about rate payers every every dollar counts or penny counts um it might be good to revisit that um you know in next year's budget process but I I can support the combining this into a single rate especially since it has exact not doing it as anxiety to the hospital budget process you know at at the at the local level given this federal guidance and you know the accounting for it etc etc but um you know I do whether it's uh and you'll think that some of this was was not meant to be base building and that we shouldn't just assume now that that the combination of the 3% and 1% um is necessarily base building other board discussion yeah I guess so I would certainly support rolling um this bifurcated rate for Porter into a year long rate as I said before I support that for all the hospitals for the reasons I said I do think as Maureen and others have said I think we need to make clear that we originally intended these supplementary rates to serve the need for as Voss calls them recovery budgets that was our intent um if we do roll the both rates into one which I as I said I support I think we should put more thought into our 2022 guidance around commercial rates I think Maureen has one idea there may be other ideas um out there I would hate to lock us into any particular one idea now but I like Maureen's concept of thinking about what are benchmarks that we want to give more guidance um more transparency to our process that was something that we heard from hospitals this year so perhaps we generate some benchmarks that are tied for example to medical inflation tied to recent history as Maureen has mentioned tied to commercial to Medicare ratios uh tied to 2021 performance so I think some guardrails would generate some more transparency in our process and I do think in the 2022 budget process we should plan to explicitly ask for the first nine months of 2021 budget performance to be more explicit in how we set um or determine what commercial rate decisions might be for 2022 so I guess I would say let's think about what our budget guidance looks like and allow ourselves some time to think about what we want might want that to to to be um but I think some of Maureen's ideas are good and we may have even better ideas as we as we get closer to the budget guidance but I do support rolling this rate into one I actually have to make some comment though on the Porter hospital budget because of some recent media reports I do feel it's important to address them and I want to make it clear that I don't believe there was any intent to impede support for Helen Porter nursing home in our budget decision nor do I think our budget decision prevents the full subsidization of Helen Porter nursing home even with the small commercial rate reduction that was ordered by the Porter hospital can still make the full $2 million distribution to Helen Porter and be left with almost $2 million in operating margin and $2.5 million in total margin and that assumes they make no expense cuts uh furthermore even with the board's budget reduction and with full subsidization of Helen Porter Porter hospital still generates a higher operating margin on a percentage basis than almost every other hospital in Vermont and I also just think it's important to note that the $486,000 cut that the board made to a $90 million budget was completely offset by the receipt of approximately $500,000 more in CRF funds than Porter hospital was expecting so I just want to say to say that Green Mountain Care Board is putting Helen Porter at risk in its budget order I find completely untrue and I also just think for the public's benefit it's important to know that Helen Porter nursing home is a legally a separate entity from Porter hospital the Green Mountain Care Board doesn't regulate Helen Porter we don't see the underlying finances of Helen Porter we don't know pay or mix although we learned it today 70% Medicaid I think that's important we don't set any reimbursement rates for Helen Porter the department of aging and living independent living overseas nursing homes and Diva sets those Medicaid rates so if Helen Porter nursing home is losing millions each year it could be poor expense management it also could be poor reimbursement it could be both we don't know we don't we don't regulate either Diva to Robin's point Diva has processes by which Medicaid reimbursements can be increased if the entity is struggling and it sounds like the entity is struggling if it's losing millions each year and I strongly encourage Porter hospital to all pass with Diva to ensure the financial sustainability of Helen Porter I absolutely agree it's a treasured asset in the community and a path to sustainability should be found I just want to repeat though then the Porter hospital budget decision the board did not eliminate the partial or even the full subsidization of Helen Porter nursing home and like I said the budget left Porter hospital with a higher operating margin in percentage terms than almost any other hospital we did limit Porter hospital's ability to raise prices to individuals and businesses who have private health insurance and those who pay out of pocket for their health care services we reduced the price requested price increase from 5.75 to 4 and I just want to note that that 4% rate increase exceeds what we learned in this hospital budget process the estimate by most top most hospitals of medical inflation including the network itself in their own presentation they had estimates of of medical inflation of between 2.2 and 3% so that 4% exceeds medical inflation and certainly exceeds what most individuals can expect in salary growth this year so when we're looking at hospital requests we have to consider affordability and we have to balance that with you know the needs of the hospitals and in this state where we have many many people in our state have lost jobs in reduced hours expect flat or even reduced salaries and businesses desperately trying to keep employees on their payroll while their own businesses are suffering revenue shortfalls we have to consider both of those things so what I think is is an interesting path forward put forth by Robin is if basically effectively we support reinstating quarters NPR to 2.7 but keeping the effective commercial rate at 4% what that might allow quarter hospital to do is to reach out to Medicaid and to the extent that Medicaid reimbursements are not fully covering the cost of delivering care to Medicaid patients whether it's in Helen Porter or whether it's in the hospital itself I would encourage border hospital to seek those higher reimbursements from Diva for both entities that actually would be consistent with the all payer model right which holds that the state is harmless for total cost of care increases that stem from Medicaid rate increases we are held harmful we are held responsible for total cost of care increases that stem from commercial rate increases but we're actually held harmless if they stem from Medicaid rate increases that was to reduce the cost shift so the all payer model actually provides us a framework so that we don't need to use commercial rate all the time increases in commercial rate to solve for expense growth so in other words my final point here is if quarter can successfully seek Medicaid reimbursement rates that are higher and in so doing stay under the 3.5% growth cap that would be consistent with both our guidance and the all payer model and it wouldn't unfairly burden commercial rate pairs so I in some would definitely support the motion at hand and I just wanted to clarify I think what I think the board's position was on Helen thank you other this is Robin sorry there's some go ahead and claud de champ I believe that there's a buzzing sound coming from your think if you could be put on mute please ah great um I wonder if before we move to a vote we talk a little bit more about um about the Maureen's idea of the guidance or your idea of um on the enforcement because I do think for me it's less of an issue with Porter but more of an issue with um some of the other hospitals related to the temporary rate increase I think as folks have as Maureen and others have articulated um and quite frankly as Dr. Brumsted articulated the issue for me there is that it is compounding over time and it just does not feel fair to commercial rate pairs that uh that addition that this higher rate uh due to uncertainty would then be compounded indefinitely into their commercial premiums so um I'm not sure the best way to go about that but I think it is important to make sure the hospitals have notice that we may go back and look at rates next year or you know who knows if it'll be next year it is hard I think to be certain about it I would personally not revisit it prior to a year because I do think what certainty we can provide is important but obviously if we're still in a pandemic next year let's hope not but if we are um we may not want to revisit it sorry I'm going to be a Debbie Downer I'm just like I would like to assume that we won't be in a pandemic but we don't know and so that in and of itself makes it hard to be certain so I guess what I'm trying to say is like I think it's important that we are clear whether or not we might revisit some portion of the approved commercial rate in the future and I'd rather be clear now that that's a possibility than wait until we issue guidance in March because I don't want to be accused next year of a bait and switch. Okay do you wish to amend your motion or is this in preparation for a future motion? I wanted to I thought it well I can do it either way but I wanted to talk more with I think we need to have an idea of whether other folks are interested in that because I'm obviously just one. Yeah and Robin let me um um I'll do one of my math examples just just so we we have you know what would happen in a given case just just so we can talk about it and you know as the public knows we can't do this before so we haven't done you know we haven't all talked about whether we didn't want to do this but take a hundred dollar charge and assume there's a six percent increase this year you get 106 right again just doing math assume for next year we're going to do a combined rate of of eight and you did two percent on the 106 you end up with a rate of 108. Now I want to do the example a little bit differently which is if we had given that hospital the four percent each year it still works out to the same 108 you know or like it's it's marginally different meaning if we said okay we we're we're giving you the six percent rate only four percent is going to carry for the year and then the next year you gave them another four percent in that argument that we still come up to the same place so I just wanted to give you the math on that so the point of that would be then if they get the permanent rate this and that example it was six and if we wanted to consider a two-year look and we would have plenty of time to to review what that would be and how we want to look at it um then then we would have that ability to make the next year's rate um would would form out by math right so if you had a three percent this year and again we said it was eight over two years maybe next year you get to be five if you had a six percent this year next year you get to be two um so it you know works out that they would would be in the same place although higher one year than another year so I don't know if that helps or not but I just want to do the math part of it if we if you actually said okay at the end of this year you have to reset and take away that you know two percent and then work from there the compounding still works pretty similarly that it won't make that much of a difference but my concept was really just trying to be creative in this situation that we're in right now where I think we want to give at least for the current year everyone would have the assurance that they have that rate for the whole year and that we've hopefully eliminated the issues that we potentially could have by having a bifurcated rate or maybe it would have you know qualified as additional funding for covid and under the federal scheme so I think we've set that we haven't really finalized as Jess brought up there might be a variety of different things that we can look at that we've talked about before right the whole Medicaid to commercial reimbursement where do all the hospitals set you know different you know and that's that's where one of part of our process is difficult because we set these rates across the board for everybody yet each hospital is different and so we've tried to incorporate that into our process and at times that gets looked at like we're not using the benchmarks but but I think we are we're trying to factor in what's happened what's the financial health of the hospitals you know what are their other issues that they're facing you know what's their payer mix a lot of different things you know so that we can be flexible there but that's how that part would work and again it was you know we're not I guess determining that now but it does make me more comfortable approving one rate with the understanding that I'm at least going to want to bring up something like this in the future when we look at next year and that we've now already started talking about that you know with the hospitals yeah I guess I I feel like I wouldn't want to put anything in set anything in stone because I think we don't have crystal balls and we can see what's happened in the last eight months that nobody could have predicted we have no idea what's going to happen in the next next eight months and I also think to Maureen's point every hospital is going to be in unique situation when we revisit their budget next year and we have no idea what that situation is is going to be so I wouldn't want to stipulate anything in this motion about how we're going to treat commercial rates next year other than to say I think the board should have a conversation maybe in the next few weeks about or you know certainly as we're moving into thinking about 2022 but what kinds of things we might be looking at when we consider commercial rate and I think we will always have the latitude to adjust commercial rates for the 2022 budget looking at 2021's experience and looking at a whole list of factors that are unique to each hospital so I don't think we are losing anything we can always look and adjust but I think if we box ourselves in with this is what we're going to do next year I don't want to do that because I don't have a crystal ball and I'm afraid that would be you know problematic I'd rather give ourselves the full flexibility to look at all of the factors that are facing that hospital and make a decision then but I do agree it would be helpful I think to the hospitals for them to understand what are the factors that we are looking at you know this is the first year we started asking questions about medical inflation and what is your medical inflation I think we can ask more explicit questions next year and have them calculate it rather than on the fly in a budget hearing in advance I think we should be looking at a little more closely at those commercial to Medicare ratios cost reports deliver information about charge markups that would be helpful to look at I think there's more work that we could do to understand prices and have a more informed decision making and have the hospital understand what we are looking at but I would put it in the guidance versus something now in emotion so let me remind the board that the motion before us is to approve Porter Medical Center's budget with a 2.7 percent NPR FPP and a 4 percent commercial effective rate along with the standard budget conditions is there further discussion consular barber do I need to open this specific motion up to public comment or not yes to hearing no more discussion from the board is there any member of the public that wishes to offer comment on this particular motion only hearing none going back to the board is there any further discussion hearing none a general console barber if you could call the roll member Holmes yes member use for yes member Pellum yes member lunge yes Mr. Chair no okay moving on let the record show that that was a four to one vote moving on would someone wish to make a motion on either central Vermont or UVM Burlington sure Laurie can you go to the CVMC decision page okay I am going to move that we approve the central Vermont Medical Center NPR FPP at 7.3 percent with a wait no let me back up I move that we approve the central Vermont Medical Center's budget with an NPR FPP 8.3 percent with an approved commercial effective rate of 7 percent and the standard budget conditions it's been moved and seconded to approve central Vermont Medical Center's budget with a 8.3 percent NPR FPP and a 7 percent effective commercial rate with the standard budget conditions and commensurate reductions to expenses is that was that part of that motion Robin yes sorry okay discussion from the board if not I'll open it up to public comment is there any public comment on the specific motion before us which is for central Vermont Medical Center hearing none I'll go back to the board for any discussion hearing none the motion before us is to approve central Vermont Medical Center with an NPR FPP of 8.3 percent a commercial effective rate of 7 percent commensurate reductions and expenses and subject to the standard budget conditions any further discussion hearing none all those in favor signify by saying aye aye any opposed signify by saying nay let the record show that it was unanimous decision moving on does somebody from the board wish to make a motion concerning University of Vermont Medical Center I will move to approve the UVM Medical Center budget with an NPR FPP of 5 percent and an effective commercial rate of 6 percent with commensurate reductions to expenses and standard budget conditions is there a second second it's been moved and seconded to approve the University of Vermont Medical Center's budget with a NPR FPP of 5 percent a commercial effective rate of 6 percent commensurate reduction to expenses and subject to the standard budget conditions is there a discussion hearing none I'm going to open it up for public comment on the specific motion concerning the University of Vermont Medical Center is there any public comment on this motion if not Council Barber could you please call the roll member Pelham yes member Holmes yes member lunge yes member Eastford yes Mr. Chair yes okay I think now I am going to move I'm going to try to do this all as one motion which may be crazy but let me try I am going to move that we reconsider the hospitals who we approved a temporary rate increase reconsider the budgets of the hospitals we approved a temporary rate increase which include nvrh Brattleboro Memorial Hospital Mount Nascotney NMC Copley R and RRMC and that we approve those budgets with the same NPR increases as we approved prior and that we approve a total uh commercial charge or rate increase as one unbifurcated rate I'll second that well before you second that would you consider excuse me would you consider amending the motion to not talk about NPR but just to reconsider the hospital budgets that received a temporary piece and a standard piece to be one one piece so that we're not reconsidering anything other than that treatment uh Mike other portions of their budget orders would be in order and fine with me if Mike thinks that works I mean I think the legal question is whether we can partially reconsider the budget and I'm not a parliamentarian like I I I don't see why you couldn't limit it like that if all the board members are in favor of that limitation um but it's not something that I've looked into I guess so I yeah I think it sounds like it's okay to me um based on the case law that you had talked about previously so I can let me reframe let me withdraw the motion and reframe it before you do that could I also point out one thing just to make sure that there is not an error rather than specifically naming them could you just um frame it in the form that hospitals that received a temporary and a standard piece I I think you're right I just don't want on the spur of the moment leave somebody out here yep no that's fine I I got the list from the budget team and Mike okay anticipating that we might do this because I didn't want to do it on the fly but I'm I'm happy to do it that way so Kevin I worry a little bit that it's kind of a a doubling up for the the network hospitals because we've already dealt with them so um those would need to be separated out we wouldn't want to have a revote on them in this motion would we no I think the motion would be for other than the three network hospitals okay let me try again thank you for your patience I move that we reconsider the uh with okay let me start over with the exception of the uem network hospitals discussed today I move we reconsider the hospital budgets for those for whom we approved a bifurcated rate and replace the bifurcated rate with a single rate okay and uh I know you don't wish that you don't relish the role of parliamentarian council barber but um can this be done in one motion or does it have to be done in two first to reconsider and then to vote yeah I think it's reconsider and then vote based on my research so far yep great okay let me it's like a motion chart you got the motion right because you did say to reconsider okay so good so your your motion is accurate I did not hear a second second okay the motion before us is to reconsider those hospitals other than the three hospitals that are part of the uvm network that received a temporary as well as a standard rate increase to treat their change in charge as one rate is there discussion from the board does anyone wish to make public comment on this particular motion hearing none is there any further comment from any board member if not the motion before you is to reconsider those hospitals that are not part of the uvm network where that received a temporary rate increase in addition to the standard increase to have it be one change in charge is there any further discussion if not all those in favor signify by saying aye aye aye those opposed signify by saying nay let the record show that it was unanimous decision Robin your follow-up motion okay so and then I move that we approve we approve the budgets of the let me back up I move that we approve budgets or hospitals why don't you want to move that you amend the budgets okay I move that we amend the budgets of the hospitals that we had previously approved a bifurcated rate to set a standard rate in the amounts that had been previously approved in total is there a second second is there board discussion and we probably need to say that that does not apply to the uvm hospitals just to be clear correct hearing no board discussion is there any member of the public who wishes to comment on the motion before us is there any further board discussion hearing none all those in favor of the motion please signify by saying aye aye those opposed signify by saying nay let the record show that it was unanimous decision of the board is there any further business to come before the board chair mullin if I might yes dr brumsted I just like to thank the board for your willingness to reconsider I understand that this was certainly not usual in custom areas I set up front and experiences back to the 90s this is the first time I've been involved in any reconsideration and so I we really appreciate that flexibility and I'd also like to speak directly to member usifer and colleague claudio forts comments and make it clear as it has been in the past that despite my getting exercised today we will be all in in collaborating with the board and the board staff moving forward to make the process improve the process as we go forward so thank you very much and on that note there is a the hospital budget debrief meeting at the regular board meeting on october 7th jeff teamon has accepted for the hospitals and I believe mike fisher has accepted for the health care advocate but we'll be listening to anybody that has comments to make on the hospital budget debrief at the october 7th meeting I just want to remind the board that there has not been a motion today I'm not suggesting there needs to be one but I just want to remind you that you have not changed this year's enforcement policy and that policy to to remind people was only to have enforcement if for the two years 20 and 21 the npr was exceeded so if you wish to have the ability to call somebody in mid-year which are under the standard rules of the green mountain care board it might be important to make that motion so this is robin I'll just chime in I personally think that the mid-year adjustments are while not impossible are tough especially with the level of uncertainty so just personally I wouldn't I'm not I don't need to have the flexibility to call people in mid-year I would however want to be clear as was discussed earlier by both Maureen and Jess and I that historical performance and projections for 21 would be considered in 22 and I think that we can clarify that in the guidance as was proposed earlier by Maureen and Jess moving forward so that would be my take on it but obviously I'm open to other people's perspectives on that I mean Kevin I know you say sometimes the chairman shouldn't make a motion but you certainly can you know I think it may give us flexibility I think is what you're trying to do it just it doesn't mean we'll pull anybody in for enforcement right it's just saying it gives us flexibility to review mid-year right that is correct it's part of our standard rule that gives us the ability at any time to call someone in and I would just hate to have given up that opportunity given the enforcement that was approved under different circumstances months ago and so like robin I don't like mid-year adjustments but I could I could foresee a scenario where one could possibly be necessary obviously nobody would like to go through that process and I think it would be a worst-case scenario but I hate to tie our hands and take away our our ability to do so wait so do you want to make a motion as the chair I hate to make motions but I will make a motion hopefully we'll get a second I hate to be be out there but well first you ought to hear the motion because all you do is discuss it doesn't mean we vote for it right I would move to rescind the enforcement policies as previously voted on by the Green Mountain Care Board and refer back to the rules that are in place for the possibility of enforcement I'll second it board discussion I can support that I mean it's an unknown either way but it's just nice to have the option as I say to have the tool in the toolbox other board discussions you know I can also support that as well I think it it gives flexibility and I think when you actually read some of the things about enforcement I mean it can go both ways right you can you know the hospital was really not making their numbers there could be adjustments made to rates to help or increase you know help get there versus the other side as well so I think it just gives us flexibility so I can support that as well can I ask a clarifying question Kevin this is Michael go ahead Mike would it be to rescind this and replace it with something else because one of the things that the guidance typically does is kind of defines what the board is going to consider substantial deviation from the budget and kind of what they're going to look at and so having no performance kind of enforcement policy leaves that undefined and maybe so I'm just wondering is is there going to be something that's going to take its place and when would that be kind of discussed I think that it would it would be wrong to create enforcement on the fly and I don't want anything that would be create the ability for a willy-nilly enforcement action and I think it would take much more time to consider but I think we have time before we would even consider bringing someone in for enforcement action to have that discussion and and allow the stakeholders to participate as well so at this point I'm really looking just to rescind the enforcement action that has already been passed okay thank you thank you is there further board discussion I might have some additional comments but I would be interested in hearing the public comment first yeah we always go back to the board after public comments anything else from the board before we go to public comment if not does any member of the public wish to comment on the motion hearing none further discussion from the board I guess I would say yeah somebody's trying to speak I'm not sure I'm not sure um 3730185 were you trying to offer public comment apparently not so go ahead member Holmes I just wanted to say I mean I I agree with both of you who I think said that mid-year adjustments are tough and so I would just say that if we are going to do if we are going to rescind this you know enforcement action I would really want to be very very clear on what those parameters are that would bring you know a hospital in and I agree with Maureen it could be either up or down I think people often think that it's punitive in the sense of oh they're gonna you know if the hospital is running too hot they're going to cut the rate mid-year which I know is transactionally difficult for insurance companies and hospitals and all that the flip side though is if a hospital is really struggling um it's it's possible to have you know a mid-year adjustment that might raise the rate so it is symmetrical in both directions but I would like to have a deeper conversation about what would constitute or trigger that um you know reconsideration in the middle of the year so I guess that means that we're gonna have future conversation maybe it's on October 7th I don't know that may be the beginning I don't think that it will be the end other board members so I this is Robin I think um my hesitation is not because of the additional flexibility or concern about um using that flexibility my concern is with modifying the guidance after approving the budgets um I mean the reason why we included in the guidance is so that when people are submitting their budgets that they understand the rules of the game for enforcement up front and so I'm not really comfortable changing it um at this point so I would just start the budget orders have not got out hospitals ask for reconsideration on specific requests and I think it would be much worse if we after written budget orders change the enforcement policy than before um and that's why I see the need for the motion today got it thank you for that explanation any further discussion if not all those in favor of the motion signify by saying aye aye aye those opposed signify by saying nay let the record show that it was unanimous decision is there anything further to come before the board um I just want so I think the other question I wanted to just check in on is I do think um that the original extension of time provided for uh the written orders to go out two weeks after decisions were made um and I just wanted to check with Mike Barber on the record to see if his interpretation of that is that it would also apply to the uh changes we made to the budgets today or whether we needed to further extend the time because I don't think it's realistic to think the staff should be able to yeah accommodate those changes completely Robin and this would be my interpretation and Mike can tell me if I'm wrong but I would think that um the only hospitals that would be subject to the previous date would be those hospitals that received one rate and had no reconsideration at today's meeting and that based on the previous vote um the it would be a two week time period for the written decision for all those decisions that were made today those particular entities would the realization that um knowing Mike and his team they're going to do them as as rapidly as they can without making mistakes in that it's it's not going to be dragged out but that that would be my interpretation of what's happening but Mike I really should be asking the lawyer yeah so it's the board's interpretation or issue to interpret but I think that is supported um once you move to or once you reconsider uh a decision you've made you kind of go back to before immediately before that decision was made so I like for the hospitals that you didn't reconsider uh Friday I think was the the deadline we're planning to meet that um and for the hospitals that you did reconsider uh I think the final decision uh votes for today so um two weeks from today obviously we can get those out sooner because we've been working on them so um that's all I have to say so with that do you feel the need for emotion I do not I just wanted to make sure it was clear both to us and to the stakeholders okay very good clarity is always good okay is there any other business to come before the board hearing none is there a motion to adjourn so moved second it's been moved and seconded to adjourn all those in favor signify by saying I I those opposed signify by saying nay the meeting is adjourned have a great rest of the day everyone