 We will resume. Dr. Ethan, I'll turn it to you for any closing remarks the UVM folks may have. I think we're going to go back to the hospital presidents and have them have the closing remarks. We're going to start with Steve, I believe. Thanks, Steve. Thank you, Chair Foster, Green Mountain Care Board, and all the public comments today. This is a critically important discussion for the state of Vermont, and I appreciate all the dialogue today. Everyone trying to do their best to get it right. As Vermont's level 1 trauma center, answer center, children's hospital and academic medical center. The medical center plays a crucial role in the health of our community, both locally and across the state of Vermont. We take that role seriously and we're very proud of it in recent years, building a budget that allows us to live around that mission has become increasingly difficult. We've tried to navigate a very difficult economy and extremely tight labor market. Our 24 budget, our 24 budget would result in a margin of 3%. Money that would be used to reinvest in our future and our staff equipment and facilities and most importantly, to better serve the patients who need us. Last year in 2022, we lost nearly $23 million. That is unsustainable through tremendous hard work by the 8,000 employees at the medical center in 23. We're going to meet our margin target. That's a first step in regaining financial strength so it can be strong going forward to meet the needs of our patients. We're working very hard at the medical center to do our part in reducing labor expenses where possible. Growing our own workforce and making changes to improve patient access and revenue at the same time. Complicated, difficult, but important work. At the end of all this, our budget discussion, if you come back to a simple reality, as a nonprofit hospital, we cannot be prepared for the next pandemic. Support our aging population and address challenges to access now budgets, budgets that allow us to cover the expenses of providing essential health care services to all of our monitors who need us. The budget we submitted reflects what we believe we need to care to meet the care needs of the population that we serve. On behalf of the 8,000 employees, the medical center, I look forward to continuing our conversation with you about how we can ensure ensure a healthy future for all of our monitors. Thank you. And. Oh, and just just to be clear, this is me chair foster, I apologize, but I forgot. This is only University of Vermont medical centers. And so each of the presidents from the other partner organizations will have their closings after their. Sessions. So that's all we have for today for this until we go into executive session. Great. Our logistics. We'll need to adjust a little. Director Lindberg, are you here? It's a lot of boxes. Yeah, there you are. Okay. Do you want to go straight to Porter now? Yeah. Yeah. Great. Let me just share. Alright, so we'll have some themes. I think we've covered quite a bit of some of the material in our conversations already, but there are a few things unique to Porter that I'd like to cover. So 1 is, you know, of all hospitals, Porter showed, you know, the highest growth in NPR and the highest growth in operating expenses. It seems like the 2 things that are driving that are. A favorable cost report and it looks like there's some significant increases in outpatient services at Porter. So do I have that right? That and there is a little bit of a unique piece to Porter, Sarah, in terms of when we broke down the increase in NPR for those 2, for that 2 year period, they did have, we had 3 different buckets. We had the volume. Component, we had the rate increases from Medicare, Medicaid and commercial. And then we had this other category that represented pay or mix, bad debt and charity shifts from 22 to 24. And for Porter, there was a significant amount of bad debt, meaning we wrote off a significant amount of claims from our epic transition. So when you look at that bad debt level back in 2022, compared to the 2024, it actually looks like a revenue increase just because there's there's less, less right off of revenue. So I would just highlight that that one kind of uniqueness related to Porter. Okay, that's helpful. And we see Porter, one of the very few hospitals where that NPR line is above the operating expense line. So I'm seeing some, you know, pretty strong financial recovery at Porter. Do you know why the cost report was so favorable for Porter last year or any guesses about that? So, since they're a critical access hospital, they, Porter gets, gets rate inflation, if you will, on their Medicare patients. So, when you think about the, you know, the high use of contract labor and the salary adjustments that we've needed to make, that then worked into the cost report settlement because that's how we get the rates for the critical access hospitals. So that's really what drove that increase there and related to the cost report. Okay. Would you highlight anything unique about the employment cost per FTE at Porter versus what we already have discussed? I don't think there's anything unique there. Okay. And then this one, I think, I'm sorry, I keep looking at the wrong screen when I'm trying to drive. So we do see this, you know, large increase in utilization. Again, that's just an adjusted discharge. And if I'm reading the numbers right, it seems like a lot of that is driven by shifting and seeing more outpatient care revenue. And so that adjusted discharge gets pulled way up. And I did notice in one of your responses that I'm just curious if any of that change to revenue is being driven by the sharing of orthopedic services at Porter? I'll let Scott, I think Scott's back online. Scott Comomo, the CFO of the Board Medical Center, I think he can validate that, but I do think that's correct. I can comment on it. I can comment on it, Rick, if Scott is not online. Okay. And you're correct, Rick, there's orthopedic activity involved there. Part of the outpatient utilization drive is also our radiology and lab. Absolutely. But you've got it, Sarah. Okay. All right. And then for migration, it was actually, I had never really looked at it this way. So I was surprised to see at how much care is being imported or in migrating to the Porter service area. And then the only thing that stood out here that I wanted to make sure I touched on was I was a little bit surprised to see such a substantial bump in the Medicare expenditures in calendar year 21 and didn't know if you had noticed that on your balance sheet or, you know, if you could have any insight about what was a driving that kind of spike. I know you only saw half of those funds in the HSA, not necessarily at Porter, but just curious if you had a bump in Medicare utilization that was notable. Nothing is coming to mind right now, certainly on the revenue side again, going to going back to the impact of the contract labor that would show up. But in terms of utilization, I can't think of anything specifically that would have drove up a higher proportion of Medicare there, unless Scott and Tom have any thoughts. I have noticed the trend as well. I can't put my finger on exactly the driver. You know, if I had, again, without good, good, good afternoon, folks, is Tom Thompson, the president, CEO of Porter, appreciate your work. First time I get to chime in today. If I had to surmise at this, I'd also say there might be a little shift of commercial patients from our market. So that might also contribute a little bit to that data point. Okay. Yeah. And the only other thing that came to mind is, I think that is when the cyber attack might have affected some of the ability for services to be provided at the medical center. I just didn't know if that also might be contributing to that spike. I couldn't contribute it for sure. We did a lot of diagnostics at that point from the medical center's patients. Yes. Okay. Thank you. And then as far as the cost report goes, among the peer group, Porter stands out as quite large for a critical access hospital in this peer group. Again, I think that's likely picking on some of that shift to the outpatient revenue. And then we see quite a relatively low acuity of 1.2, talked quite a bit about your initiatives related to CMI. Anything additional? You want to highlight specific to Porter? No, nothing there. Okay. And do I have it right that increasing the CMI for Medicare would not necessarily affect reimbursement there since it's the cost report? Correct. CMI increases for critical access hospitals really don't have a material impact. But if the severity is increasing, you know, other pairs might, even if it's the same rate, they don't get a rate increase. If the coding shows a higher severity, they still might, the reimbursement might go up commiserate with services that were provided. For other payers, there will be a small impacts. But again, most of the CMI impacts are with Medicare patients. Yeah. Okay. And then we see as you were alluding to that the ratio of admin to clinical salaries quite low here, probably due to the fact that a lot of those are flowing through UVMMC's cost report. Anything to flesh that out? You know, that's the connection that can be made there in terms of the shared service FTEs and costs that are brought to bear across the network are quite small at the Porter Medical Center. And for cash available for operations, we see you're right at the median. I was just curious, you know, if you've talked a lot about how you really consider yourself a network, and I just didn't know if you had specific benchmarks for the amount of cash on hand or margins that is at each hospital level, or if you really monitor more of that network-wide. So the margins we do establish targets for all the partners. Cash, we view that as a, we monitor that from a network perspective. Each partner still does have individual days cash on hand balances that you, as you can see here in the, in the data. But that isn't, we don't have specific targets for days cash on hand for the individual partners that we target as a network in totality. Okay. And are you mostly looking at the EBITDA operating margin for those hospital level targets? Exactly. Okay. Great. Thank you. And then, yeah, profitability, I think is another place where, you know, there's a lot of, there's a lot of I think is another place where you're very close to the median. That's right. You're actually exactly at the median, which is why I can't get you to pop up on there. And then we do see that the cost per adjusted discharge is just above the median at 12,000. So despite a potentially deflated CMI that is already within the range. As far as cost coverage goes, so very, I think, again, this might be some of that care pattern goofiness that maybe led to different services often see bigger dips when we have smaller numbers. So I don't think, you know, I think that's why that looks as dramatic as it does. And I note that, you know, among critical access hospitals for commercial that that Porter is showing, you know, combined the lowest cost coverage at 130% of the Medicare allowable cost. And, you know, among the lower for Medicaid, we see that, you know, the cost coverage on inpatient is actually below the Medicare allowable cost at Porter. And for outpatient, it is have 150 in my head and so there it is. So again, seeing that value being the lowest among the critical access hospitals. And then finally for Rand, this is back 2018 to 2020, but we see very near the median back then for that time period for inpatient care and a bit below the median on the outpatient side. And so again, this is taking all those commercial payments, dividing by a standardized unit of service to try to get a sense of how much things cost on a unit basis. So yeah, so that was kind of the material that I thought was important to highlight for Porter specifically. So Chair Foster, happy to turn it back to you for board questions. Great. We can just go, I guess, in the same order if that's helpful. I don't know if Ms. Member Lunge, you have any questions, but go ahead if you do. Sure, thanks. So I just want to confirm that Porter intends to participate in all the ACO programs with one care for 2024. That is correct. Thank you. Could you speak to how you are integrating E-Consults into the hospital at Porter? Yes, so the, hi. So our E-Consults are a network-wide initiative. So it's really open to all hospitals across the network. But I was curious about what specifically was happening at Porter. In terms of what? I'm not sure I'm following. So how has Porter's providers been using the E-Consult feature? Are they using it more or less than other network hospitals? How is that rollout going? And I'm just looking for a little more detail about Porter. I'll just note that I would say that your narrative was somewhat light for Porter in terms of detail on what's actually going on with this hospital. Thank you, Robin. So the way we rolled out E-Consults was in a staged fashion. So we did start with UVM Medical Center. So if we looked at the total volume of E-Consults, UVM Medical Center is higher for that reason. And then in this fiscal year, we've rolled it out to the rest of the network hospitals. And while the volumes are smaller at the other hospitals, they're mostly proportional to the size of the hospitals. Okay. So on page 30 of the narrative where you've outlined the travelers costs, I'm wondering if you could speak to why the dollar amount for travelers is greater at Porter than at the other two network hospitals? I had thought I had read something in the narrative that you were centrally procuring. So could you speak to that, please? Yeah, we have centralized that process, but it does take time for that centralized rate card to look the same across the whole network. So contracts are renewed on typically a 13-week period, and so if we have a consistent rate card as a network, it'll take time before those contract renewals actually are impacted by that rate card. So for a Porter, it means that they're still, they haven't had enough contracts come up for renewal, where they start to get down closer to the 105 that we have for the other organizations, but they will eventually get there. Thanks. Turning to the PHSO, I was noticing in your responses submitted this week. I'm just going to pull those up on my other screen. You included and I appreciated two tables outlining the FTEs assigned to each by hospital. So this is table page three and four tables one and two, and I noticed that you included that for Porter, there are additionally about an FTE of support for the community health team that's not part of the PHSO. Could you speak to that? And is that a Porter employee, someone else in the HSA? Yeah, are you referring to the table two at the bottom? Yes. So those are not network non-PHSO employees. So those are, when we speak specifically about the work that the PHSO has done to streamline blueprint funding, these are funds that are outside the system. So we just wanted to make sure we delineated that to make sure that it was clear. Thank you. That's helpful. So could you just explain that a little bit though, because I thought as the fiscal intermediary that all of the CHT funds flow through the hospital? So they may flow through, but they would flow to an organization that then that uses those funds to fund their own FTEs. Okay, I understand. Thank you. That's helpful clarification. And then in the narrative, also in response to these questions, when I asked about the PMPM blueprint and one care payments and how those flow through to primary care, the answer was that those flow directly to the practice. Could you speak to how that works at Porter? How does that practice experience that funds flow? Like did they see it directly? How is it included in their practice level budget? So I can speak to it at a high level and then someone who has more specificity may want to add, but so from a high level perspective, all of those funds flow directly back to the practices, whether it's Porter or any other practice. So they're not coming through the PHSO, they're not coming through a central mediary, they flow directly back to the practices. So how each individual practice then uses them are not under the purview of population health. Does that answer your question? And I can go a little bit further, Robin, to in terms of the actual allocation of the PMPM, internally we do it the same way as the money in terms of how the money comes into us, it's based on attribution. So internally we do the same thing. We allocate the dollars when they come into the health network, they go back out to the primary care practices and shows up as a revenue item for them based on their attribution. Great. And I was hoping that someone from Porter could answer this next question, which is for your FTEs that are assigned to your PHSO. Can you speak to how those folks get connected with local resources and understand the local environment if they're not physically located in your area? They are physically located in our areas. They're attached to our practices from the PHSO. Okay. Thanks. And then I just have a couple more. So I noticed in your narrative that you are, and I think actually you talked about this last year that you've started to replicate CVMC's workforce programs at Porter. I wonder if we could get an update on how that's going and where things stand. Yes, I can start. I'd be glad to start. This is Tom. So slowly, slow, but sure. I mean, we've been most invested in a partnership with Panaford Career Center in Middlebury with an LNA training program that provide where we provide funding for folks that we interview and hire to work both in the hospital and at Helen Porter, our skilled nursing facility, they work at a level while they go to school and train and we support that training too. So that's been our most successful effort right now at grooming our own LNAs. We've been recently working more and more. We also worked with the Vermont State College System to then fund those folks, some folks transitioning to LPN programs. And that's the next step we took with that. And that's at a smaller scale but growing. And we expect to expand significantly in the coming year with the overall workforce initiative of the network. So we'll get to the full point where CVMC started years ago with LPN, or excuse me, LNA to LPN, to RN, and then beyond. Great. Thank you. Just one moment. I just need to switch to another list here. So switching gears a little bit now. I wonder if you could let us give us a better understanding of what's going on with Helen Porter nursing home. What were the fiscal year 22 losses in fiscal year 22? And what are the projected losses in fiscal year 23? I'll let Scott answer that. I don't have the FY22 number handy, but I know that in the current year we're projecting a five to six million dollar loss. Okay. And do you have a sense of are there, I guess the way to ask this question is, are there ways that you could potentially improve the profitability of Helen Porter? And have you looked at independent nursing homes that turn a profit to see if there are things you can learn from them? Well, so this is Tom. So I'm a little confused because this is a little bit of, I appreciate that this comes under our global financial statement, but it's non-hospital entity. I will tell you what we've done. We've worked extensively on all elements of the revenue stream at Helen Porter and the whole financial statement from the revenue side and the expense side to optimize operations. We're also engaged in that effort as a network right now to lever our collective resources to optimize financial performance, including the government payers. A challenge for Helen Porter is that we have maintained full capacity the entire time through the pandemic beyond and largely with agency staffing. So we have at any time 30 to 40 or approximately 30 agency staff in a skilled nursing facility where we're receiving 70% Medicaid payment. So I mean, we are a lot of that loss has to do with the fact that we've maintained or chosen to maintain our same capacity with very high level labor costs. So we are looking to optimize every lever on financial status for Helen Porter. We also are working on a network wide initiative to quantify the value add for our acute care settings of how we accept patients into the skilled nursing setting to lower the total cost of care, which is why our spectrum of care at Porter is so valuable. So we're working on that avenue to help also. A couple of other things maybe I would add is that we did apply both Helen Porter and Woodridge did apply for increased Medicaid rates to help with the significant cost inflation that they too have experienced. CBMC actually did get their rate request approved. We anticipate Helen Porter should be any day now, which will help improve the finances. Tom said we're actually in the process of looking to manage our post acute facilities as a single service line, if you will, looking to optimize them from a leadership perspective, operations, revenue capture. We've submitted an RFP looking for a partner to partner with our leadership team to look for those opportunities across all of our post acute facilities. Thank you. And the reason why I'm asking about it is because the losses at the nursing home do have an impact on your bottom line, right? When we roll everything up as a network, yes, the nursing homes that we do impact our overall network bottom line. Okay. And it used to be that it would impact Porter's bottom line. Is that no longer how you're doing it financially? We still look at Porter Medical Center. We combine the two, but that's just historical. In reality, we're looking at the overall network margin when we're looking at those post acute facilities because we have some in New York state as well. Okay. In looking at your profit and loss, it looked like, and you've spoken a little bit about the, Sarah mentioned the increase in outpatient revenue and decrease in projected inpatient. Is that shift related to just general service line changes? Could you speak a little bit more to that as to what is causing the shift of outpatient, inpatient to outpatient? Is that the ortho and the radiology that folks just mentioned? Yeah, that's the majority of it. I don't know if there's any other services that are shifting to outpatient Tom and Scott? Outpatient Lab is also contributing heavily to that. Okay. Thank you. And then lastly, under your operating expenses, it looked like there is a 30% increase in other operating expense between fiscal year budget and fiscal year 23 budget and fiscal year 24. Could you just explain what that's related to? Other expenses? That's not sure. Yeah, I'm not sure what you're looking at Robin. Is this a narrative? It's in the, I think it's in the PNL. I don't have to in front of me. I'm afraid. It's okay. We'll get back to you with what drove that increase. Sure, of course. And then I guess I did have one other question that I found. So in relationship to the increase from the favorable Medicare cost report, how is that reflected in your commercial rate increase ask for Porter? If you look at our narrative, so we do have a grid like we've done for all the other hospitals for the rate increase. You're just flipping to it now. So we do the calculation the same way that we do for UVM Medical Center and for CBMC. So you see it right there in terms of the Medicare rate increase that we're anticipating. The 640,000 is what we're anticipating there in terms of a rate increase. We also have the Medicare ACO rate increase, which is really a share savings estimate at this point. But the same math that's done for other two hospitals is done for Porter. And that's really what drives the rate for our critical access hospital to be lower than it is that are the two hospitals. Thanks. And then I guess the only other question I have is when looking at Porter's operating expense increases compared to other critical access hospitals, it seems quite high. And so I'm wondering if you could just kind of talk me through that. Because quite frankly, when Porter joined the network, part of I think what folks were saying and I think hoping was that being part of the larger organization would achieve economies of scale and would help with expense growth cost containment. But seeing those numbers compared to other critical accesses now, that doesn't seem to be the case at least this year. So if you could just respond to that, I'd appreciate your thoughts. I think a component of that just this year, it could be our shared service allocation that changed for Porter, which would be different than other critical access hospitals that are not part of a network. Certainly when you look at the core expenses and the financial performance of Porter, cash balance, the performance has increased since they joined the network. But in terms of that expense, that may be what's behind that number. But we'll definitely, as I said, look into that expense number and get back to you. Looks like Tom wants to comment as well. Yeah, I will add that we have also made, in prior years, Porter had quite honestly, artificially limited some expenditures that needed to be made. And I'd say that laid largely with staffing investment. So as an organization, we have made a commitment to staffing investment, both in terms of people and in terms of pay. In the union environment specifically, just to mark one, we have one union, it's the Registered Nursing Union. And we've provided for contracts that were in excess of 30% in the last three-year period of time. And are similarly working, looking at the other speakers who have talked today in the public comment, we've also, similar to our other partner organizations, been focusing on bringing all of our employees up to a market rate. In Porter's case, we had a longer way to go on that than our other partner organizations and making up for lost time in that area. So that has been a key area of focus for us as an employer and organization. Thank you. Those are my questions. Just a couple kind of similar along the last one that Member Lunge asked. For the administrative cost, you had a correction for the shared services that were all going to UVM Medical Center. Is there a correction that can be done for the apportionment that should be going to Porter? Absolutely, yep. Have you done that? We didn't do it for the response that we sent back, but we can send that in follow-up. Yeah, okay. If you could do that for Porter and CBMC just so that you're not normalizing for one and the others are artificially low, that'd be good. If you know this buzz, my brothers are born at Porter and the family goes to Porter a lot, a nice hospital. But one of the things that was sort of in the town back in the day when you're affiliated with UVM was people were really concerned that it would become more expensive. Is there a way to look at or compare whether or not Porter's expenses have grown faster as compared to Peers since the affiliation? If we have access to the critical access hospital data there, we might be able to do that type of comparison, but not something we have today. Yeah, it's reading some of these old Digger articles and one of them, let's see if we can get the data on this one. I'll read you the quote from the former CEO, quote, any new affiliations must bring greater value to people in the community and the network and will be scrutinized through that lens. Expansion will not hurt consumers. What consumers can expect is that we will always have the affordability of health care at the forefront of all of our strategies. We clearly get that affordability potentially can be a barrier to access to care. And that concept of the affiliations not harming consumers, I was wondering how we as a state should look at that and evaluate whether or not this affiliation between UVM and Porter's driving up some of these costs or if it's saving them to Member Lunge's question. Yeah, like I said, we can take a look at that. There's not something that we're prepared to do today. So I think in the future, Owen, I think what we need to do better is be able to come back to you and say here's the value that Porter is getting as a result of the affiliation. Here are the clinical exchanges that are going on. Here's how the patients are benefiting. It wasn't the way that we've prepared for today that I can recall, but I hear that that's important and you're bringing back these quotes in the past that I think have cited that. And I think we believe that we're doing that, but let's bring that back to you. And if there's a way to do it quickly, I'll do it quickly, but it isn't something that we've prepared, I think, for these budgets. Yeah. And Chair Foster, I had to sit in my closing comments, but I think one of the biggest advantages is the access to resources that none of us could possibly have on our own. I mean, that's in my career, a pretty long career in health systems, that's always been the advantage of the small organization received. But I'd also say it's been the ability to really help us with a high value strategy as an organization. So at Porter, it's given us more access to clinically appropriate services and access to clinically appropriate services scale to our organization. The ability to bring those in in a financially sustainable way and capitalize them. We have done a ton of it yet because capital has been very light because of where we're at, but I think it's been the ability for us to help get a lot of strength behind a high value strategy at a local community level. Yeah, that'd be great. It might not be something we've prepared or discussed prior to this hearing, but from the policy perspective of what we do, we hear people criticize and say, these affiliations and this consolidation is driving price and it's driving costs. And I just would love to have a fair honest conversation pro and con on that, because I think it is something policymakers think about quite a bit. And if there's increased costs that are coming from the affiliation, we should see if there's a way to remove them. And if there's increased savings that are really materializing to assist in the supportability challenge, we should definitely be highlighting them and recognizing them and informing ourselves. Increased access and increased quality, right? Yeah, yeah. My brother asked, was complaining that they don't have all these services that they want at Porter. And I said, well, do you want to pay more for insurance? Because that's what it's going to take. And that leads me to my next question, which is you guys all know we're doing Act 167 work. It's underway in earnest. And one of the things that's happening is, are there infrastructure overhead or service lines that can be safely limited or removed? And I guess my question is, if there's a recommendation from the consultant on that that says that that's a cost saving opportunity for Porter, is Porter and UVM going to be open-minded to that kind of recommendation? Absolutely. Yes. Great. I don't have anything else, but it's nice to see you, Mr. Thompson. And thanks for letting me ask you all questions on this. Thank you, sir. Good seeing you. Thank you. Hi, I just have a few questions. Sarah, is there where you could put up exhibit nine? Yep, it'll just take a minute. Thanks. Yeah, I think my general comment too is similar to member Lunge. There's a little light on the submission compared to most of the other hospitals. We're getting a lot of its network, but trying to find Porter specific stuff. And there is a little light, but I think, you know, largely adequate. It's just hard to pull it out the way we organize our information. So I'm a little confused by a few of the components of this exhibit, which is in the Net Patient Service Revu FPP lower box. The All Other, which you explained for FY24 in the letter that made up of Employee Self- Insurance Plan, Small Non-Commercial, Non-Contracted Commercial, Public Agency, Workers' Comps, Self-Pay Other. It's an exhibit nine. It's a really big number in 21. But in 22, it's about half. Then 23 is the foot you provided us the breakdown. But then the commercial, so is that similar for 21? Is that a similar makeup of those elements to the All Other category there? We're going to have to go back and take a look at that because we do make movements from time to time in terms of where insurance lines roll up in these roll-up categories. Just looking at this list here, nothing comes to mind in terms of what would have been a significant change there, but we can definitely give you that same breakdown for 21 that we've given you here for the 24 budget. So part of why I asked that question. Go ahead. I was just going to just, I had forgotten to ask that I was surprised to see the self-pay revenue equal at CVMC Importer. I'm just curious if that's typical to have such a high proportion of self-pay at Porter. Self-pay is a combination of two things. One is those that are covered by insurance and they have their co-pays and those that are truly uninsured. So the fact that those two are near each other means that the commercial amount of business at both organizations has to be fairly similar because there's not a lot of self-pay in the other in Medicare and Medicaid. Okay, thank you. Thank you, Board Member Merman. Yeah, thanks. If you go back to that exhibit though, the reason why I asked is initially when I was looking through the various hospital submissions, I noticed there was a 100% increase in commercial revenue from 21 to 24 at Porter, which seemed striking to me. I was trying to understand that, but if you actually combine the commercial and all other, while it's still a strong increase, it goes from 46 million to 63 million. It's definitely, you know, it's more, I don't know, is that 50 to 50, 50%-ish or something. So do you have any reflections looking at this? Do you think the commercial business at Porter is just skyrocketed from 21 to 24? No, again, this has to be a mapping change between those time periods. And so we'll get you the change that happened between 21 and 24. Yeah, there was a billing system conversion going on during that time. And I'm sure that that classification, as Rick mentioned, is part of it. Okay, that would be really helpful because I think that would probably change some of the assumptions in the exhibit 10 as well, which I think would be helpful to clarify. So the other thing I just wanted to point out, and I don't know if it's really relevant for this discussion, but I think it's kind of how we're capturing data. I mentioned it to you, Sarah, on the tool, if you could pull up the tool for a second under the utilization tab. Just being in the ED business and kind of knowing what other departments roughly have for volume, the ED volumes looked pretty high to me with a remarkably low admission rate but my understanding actually talking with Sarah, I think as you figured out that that might be including some of the urgent care patients are slipped into that. Was that what you said? That's correct. We discovered that there is a revenue code that Porter is using in the hospital discharge data that we're not seeing from other hospitals that looks to be affiliated with urgent care. Yes, I just want to kind of flag that if you were to look through this and say, wow, those ED visit volumes look off for us, we're overcounting them in our system, which would make you look like you'd have a relative, I'm sure very few people are getting admitted from urgent care, if any, so your proportional admission rate would look higher. That's just one thing I was noticing on the data. That's all I have for now. Thanks. If I could follow up on a couple of points that all three of my colleagues have had questions about and that's where is the savings or where is the improvement in quality communication care coordination or outcomes following the consolidation. And Chair Foster asked if we could find that data. There are publicly available sources and I hope we all get a chance to look at those. The Healthcare Cost Institute, the Healthcare Pricing Project from Yale, and the RAND studies on pricing transparency. All of those have looked at what's happened as hospital systems have consolidated. If we don't like reading studies, we can google the effects of healthcare consolidation on pricing and quality. What the evidence shows, unexpectedly, we expected better care coordination, better quality, better communication, and lower prices when this trend started 20 years ago, but we've not seen those things. It's been disappointing from a policy perspective. Across the country, and these data sets include Vermont, but across the country, consolidation has not improved quality, access, affordability, communication, outcomes, it's raised prices. And the revenue that's come from the prices shows up in infrastructure projects, administrative layers, growth in those layers, and higher executive compensation. When I joined the board a year and a half ago, I wanted to find whether those things were happening in Vermont or not. They appear to be happening in Vermont. So if you have data from within that shows savings after consolidation, savings from the shared service organizations, improved access at organizations after consolidation, we would like to see them because they're not available in public data sources. That you're telling us that things are better, but we're not seeing that in the data that you provide us. And that is contrary to what the rest of the country is reporting. And Rosh, do you have anything else? Okay, great. I'll turn to the healthcare advocate. Thank you, Mr. Chair. Mike Pishor here. Just because nobody else is focused on it, let me just spend a moment looking at the numbers. Make sure I'm right here. I think on Porter's profit and loss statement, you're showing projected 14 million excess revenue. Basically, you're 23. Yeah. And quite a large NPR, 28.4 increase. So there's a lot of utilization increase. Is that, am I reading that right? Utilization increase, but also a fairly significant increase in Medicare revenue from updated cost report settlements. So catching up on the fact that 21-22 had saw significant increases in contract labor and other expense growth, that you're now seeing the adjustment for that cost report settlement in those numbers as well. And that boils down to, I mean, your request is a 6.86 commercial rate increase. Is that also right? So that the 6.8 commercial rate increase is impacted by the Medicare rate increase that we think we will get in 24. The cost report settlement that you're seeing in the 23 data is specific to 23. Okay. Thank you. A couple of comments. Okay. And I'll turn it back to you, Mr. Thompson, for any closing remarks you may have. Oh, I'm sorry. We do have a public comment. Mary, how are you? Hi. I'm thinking I'm having some internet issues because you're moving a little slow. So I hope that you can hear what I'm saying. I'm a nurse at Porter Medical Center. I work on the Birthing Center. I've been there 27 years. So I've been here before affiliation and plan to be there for a few more years for sure. I'm also the treasurer of the Porter Federation of Nurses and Health Care Professionals, which is our nurses union, and just a note that we are in negotiations for our fourth contract as we speak. We have some sessions coming up in September. We had some questions regarding a comment on narrative on page 20. It listed 3.9 labor expense inflation factor for PNC. This is considerably lower than the labor expense inflation factors projected for UVMC and CVMC and lower than the 5.2 bureau of labor statistics projects for 24. And you're asking for the 28% increase. And we just want to find out what accounts are that wide discrepancy on that. I can continue on with my questions or you can answer, but I'm not sure how you would like to address that. I just have a few questions. Yeah. I don't have a problem if you have questions, if that's okay with the Porter folks. Okay. I'll just continue. Maybe I can get a written response on some of these questions. And what, with the budget that you've presented for PNC, what is the total amount of percentage that will go to management and what will go to traveler salaries? Another question we had as a union group. And actually a bunch of you have already spoken or asked this question regarding the benefits of our affiliation and the cost savings and the cons of that affiliation. We too would like to know that information. One thing that might be unique to our hospital is our administration has a dyad system for how they're running the upper management. And we wanted to know if there was, if you had any information on the effectiveness of this dyad structure and the cost savings on that or expenditures on that. And I think everybody else kind of talked about the other things, like I said, for the affiliation, the savings and the pros and cons of that. Thank you very much. Great. Thanks for your questions. Mr. Vince, if you'd like, you can just send that into the board and we'll post it with your materials, because I think they're relevant to the to the budget decisions, some of the questions. So we can do that. I don't see any others. So I'll turn it back to you, Mr. Thompson, for any closing remarks you may have on the Porter budget. All right. Chair Foster, thank you for that. Thank you, Mary, for hanging in there and getting your questions out there. It's good hearing from you. So during this long day, I looked at my originally planned remarks and wanted to go on and change them all, you know, right? So it's been a very informative day and there's been a lot of good, a lot of discussion. I'll try though to stick with where I originally was going to start, because I think things, things still hold very true for us. So in preparing these remarks, I looked at the Greenmont Care Board's mission, which is a focus around accessibility, affordability and quality. And so that is being extremely aligned with Porter's strategic plan. You know, in our organization, we have a nice complementary of the spectrum of care, ambulatory care, acute care, skilled nursing care. We also have a strong focus on collaboration with agencies of similar mission in our community. So we know very much that we're not in this, we'd have to end all be all of everything in our community. And so actively seek out, we actually refer to this intentional collaborations, partners that help us fulfill our mission. So that that permeates everything we do. I've, this is the fourth Greenmont Care Board hearing that I've been privileged to serve as president of Porter. And each year in that in my history and even preceding my history, we've always been pretty well complemented by this by the board for the responsibility of our budgets. And, you know, this year is no different. The thing I'd like to add though is I've been a CEO for 35 years, and this organization, the EVM Health Network, puts more rigor into the budget prep process than any organization I've ever been privileged to serve in. So we are very focused on being well benchmarked and providing the data that we believe will help you serve your role as regulators. I will also add though, it is really critical, you know, that that this budgets for our organization and our network be approved as presented to really help bring to life that that that stabilize and sustain focus that we both agree is really important for the healthcare system in Vermont. You know, at Porter, like all of our partner organizations across the state, we've had a lot of profound challenges. The patient demand has been really challenging to manage effectively. And that's one of the best benefits of our health network is the ability for us to move patient care across our different settings as effectively as we can with the resources available to us. We also have talked a lot about the workforce shortage. I think the thing I want to point out here is the fact that Porter has always maintained capacity in all its care settings despite the high cost of agency staffing, which we've been blessed by, but also it's been a huge expense for us. You know, as I look at the 24 budget, we need a budget that we have submitted to to help us address these realities that we're facing so that we can help us recruit higher retain key professionals and support staff throughout our organization, to help us continue to invest in the pipeline programming span upon growing our own staffing, which is a huge part of our future and to address some of the new areas that we've not gone into before, but need to things like housing in our community to help support the recruitment and retention of staff. The budget we've submitted also will combine with the philanthropy efforts that were really focused on our community, help us maintain the level of resources and our balance sheet to bring needed investment to aging facilities. Right now, our Helen Porter rehabilitation and nursing is one of those areas of focus. We're basically rehabbing a 30-year-old facility to serve some of our community's most vulnerable adults, as well as the mission it serves to help take some of that capacity out of our acute care settings and lower total cost of care. The next thing on that rise in share foster, you know, our organization, you know, that big priority on our hospital campuses, our emergency department, and that is the next area of focus in our master facility plan to help replace that facility. We believe this, we believe we've put forth a very responsible budget along with our organization. We believe it's very important investment in our ability to provide exceptional care for our community, and we've looked forward to fulfilling any unanswered questions you might have about that budget. So thank you for your time today. Thank you. Thank you, Mr. Thompson, into the to the Porter team. We'll take a break. So I'll turn it over to Director Lynn Burke. Thank you very much. So turning our attention to Central Vermont Medical Center. Notably, this facility showed the lowest amount of growth among the network hospitals for operating expense. Would you please comment on what's different about the expense profile for CVMC versus particularly UVM MC? So a big piece of that is obviously tied to the, I think you'll see as well that the revenue growth is lower for CVMC. So the expense growth certainly flows with the amount of volume that we've seen change through that period of time. Up until recently as well, in terms of the proportion of the expense base that was in contract labor for CVMC, it was certainly lower than the UVM medical center and proportionally lower than the Porter Medical Center. So those two things are the major items that drive that for CVMC. And again, I think we've got the CFO, Kimpat node on and Anna if they want to add any additional comments. Rick, I think you covered it. Okay. Any insight about why some of the efforts to minimize contractual staff has been more successful at CVMC versus some of the other locations? So I'm happy to speak to that. Rick, if that's okay with you. So I think we've mentioned in the past and even earlier in today's conversation that CVMC has a number of workforce pipeline programs that we launched in 2018. And those have had successful impacts on our need for traveler to cover our patient care needs both at Woodridge, our nursing home and in our acute care setting. However, I would say we are still utilizing travelers as Rick alluded to. But I think that's a big piece of why the costs are less potentially is those programs have been successful in bringing staff on board in different roles from LNA to LPN, LPN to RN and now RN to BSN. And we also are obviously taking advantage of the network programs that exist in the surgical tech arena, respiratory therapy and the like. Did that answer your question? Yeah, yeah. Thank you very much. Sure. I also noticed that the kind of the distance between the operating expense and revenue growth is the greatest for CVMC as compared to other hospitals. Any insight about why that pattern might be true? Yeah, we've definitely been struggling certainly financially at CVMC for a little bit. Revenues have not kept pace with expenses. Part of that is again that the volume growth has not been as great at CVMC as it has been in the other two remote hospitals. So the capacity that we have in certain services, so OB, the operating room, other services with that capacity at a certain place, the volume really hasn't always been there to fill that gap. And OR volumes have started to pick up in the last few months due to the periop team that we have centrally within the network. But there's still some work to do to ensure we've got strong volumes in all of our services at CVMC. I think you're on mute, Sarah. Thank you. It had to happen. So I was going to say this clearly shows that the financial struggles appear more acute for CVMC as compared to Porter or UVMC. I was curious, it does look like a little bit more ambitious margin recovery at CVMC from 23 to 24. So going from that negative three up to the positive two, I was just wondering how you came up with that kind of benchmark for this budget. So a piece of that certainly is the work that we're doing in terms of volumes to push where we know we have some access opportunities to get more patients in. Anna can probably speak to some of the efforts we have to to use some of the capacity at CVMC, particularly in the OR, where we don't necessarily have all the capacity that we need at the UVM Medical Center. So we've started to, we have been all along, but certainly a more concerted effort to try to move some volume to CVMC. So that all factored into why we're anticipating a larger margin in FY24. In addition to what Rick mentioned, the other areas that we're focused on is in our ancillary support areas. So respiratory interventions, radiologic interventions are examples of that. So we're bringing more volume down to address the access issues that we're experiencing across the network where we have the potential. We'll bring those patients here to Center Vermont for those procedures and tests. And is the the volume we're kind of trying to help CVMC pick up? Is most that coming from, you know, Vermont? Or is any of the New York stuff coming down that way? You know, I would pretty much be all just Vermont patients that would be that would be moving towards CVMC in terms of doing those services there. Okay, thank you. And then it did look that of the three facilities, the kind of cost per FTE is the closest to just the cost alone index for CVMC. So just any reflections about why that trajectory looks a little bit different? Again, a piece of that is the lower utilization as a total proportion of the staff costs of contract labor that has driven that down. Another is, I believe, just the staffing mix in terms of the type of staff that we have at CVMC. Kim and Anna, I don't know if you have any other thoughts. No, again, Rick, I think you've covered up. All right. And as you've already noted, not seeing quite the same change in utilization, particularly from 21 to 22, but did notice an even more significant drop in recovery during the pandemic there. Any anything that you want to note about CVMC during that difficult time? Yeah, again, the volumes definitely are not as robust at CVMC during the even before the pre-bent pandemic period, which you see there before the 2019, not the same level of growth that we've seen in our other Vermont partners, but we're working towards using the capacity that we do have there at CVMC to meet the access challenges that we have. Just to add to Rick's comment, I think that's part of the power of the network, is to work in that way as a collective to make sure we're meeting the needs of our patients across the network and across the state by opening up availability here at CVMC. We have the capacity, so having patients come down here is an advantage for them and obviously supports us as well. Thank you. So as far as migration, not seeing a ton of in-migration sounds like that might start to change as you're able to kind of redirect some care and also seeing this common drop from calendar year 21 to 22. When I see that, I immediately am thinking about Medicare Advantage and I just wondered if that patient population is, you're feeling that more acutely at Central Vermont than some of your other facilities. Not that I'm aware of that we've seen a higher penetration of MA plans there, but if anybody else has any thoughts there, I know Kelly, if you've seen any data that says that CVMC would be unique in terms of the penetration, but I haven't seen anything. I'm not aware. Okay. And then this one's probably the weirdest comparator group in Vermont since we only have two hospitals that fit in this categorization, but we do see Central Vermont being below the median in this comparator group in terms of size. And then I think we already talked about kind of getting this adjusted, but we do see that despite, that is at that upper 75th percentile for the admin to clinical salaries. So it'll be good to kind of get that adjustment for all the facilities. CMI, anything to add about Central Vermont specifically? No, nothing more than what we've already shared earlier. Yeah. And then this one was notable to see, I was surprised to see that this among the peer group was at the 75th percentile when it looked like your cash, these cash on hand available were so low. Any idea about what might be different about those data sources? This is mid-sized or mid-sized rural hospitals across the country? Yep. I mean, what that tells me is obviously there's a lot of mid-sized rural hospitals that are struggling. If at that cash level, the CBMC is at the higher end of the benchmark. Yeah. Okay. And then profitability actually more favorable than peer groups and during this time period might be related to the cash position we just discussed. And then we see that 12,000 per adjusted discharge, which you think might partially be measuring deflated or under reported CMI. As far as cost coverage, this is a place where we do see some atypical reimbursement rates for inpatient among commercial payers and a pretty significant decline in that cost coverage in recent years. If we just look at inpatient PPS hospitals, we see that your payment or the typical coverage of the Medicare allowable cost is the second lowest after Northwest. In the outpatient side, we see that CBMC actually has the lowest cost coverage at 185 percent of the Medicare allowable cost. So I think just evidence that the reimbursements at CBMC haven't necessarily kept up with some of other hospitals. And finally, Rand is showing the right between the 25th and 50th percentile for inpatient and just above the median on outpatient through 2020. Anything specific to note about either of those indicators? No, nothing to add, sir. All right. That's what I had. Over to you, chair. Thank you. Ms. Lunge, do you have any questions? Sure do. So first again, just wanted to confirm that CBMC will be participating in all three ACO programs in 2024. We will. Okay. Thank you. So on the blueprint for health information, I noted in your recent response that in Barrie, the QI facilitators have external responsibility outside of the network. And I wonder if you could just talk a little bit about that and how that came about and why Barrie is different there. Sure. So we take our community partnerships very seriously and that bleeds over into this effort as well. So we're supporting our FQHC Plainfield and another practice that's a private holistic practice in our community. So we are providing QI facilitation to those two practices in our community. Great. And is that historically been the case, Anna? We've shifted from time to time depending on how engaged they were in those programs, but that's something that we're embracing and very happy to support them in those efforts. Great. Some of my questions have been answered. So that's good. So on exhibit 11 for CBMC, I was noting if we look at the travelers line from 21 to 24. In 21, the travelers were quite low, which I seem to recall was related to the workforce pipeline programs, although I could be misremembering. I wonder if you can just speak to that growth and whether you are expecting that your new normal is in the 70-ish range or whether you're expecting to get back to your lower levels. Like I can start if you want, Anna, then you can chime in. So one of the things, so what's unique about CBMC is actually the nursing home is in these numbers. So unlike the corner budget that we just reviewed, the nursing home is a separate tax ID number. So the data for CBMC does include nursing homes. And we've made a conscious decision as a network to help with inpatient throughput to staff the nursing homes as much as we can. So the increase here certainly is purposeful. We're trying to keep as many beds open in our nursing homes to help create the space we need for more acute patients in our hospitals. So that's part of the reason why you're seeing a bit of an uptick here. Anna, anything else to add? Yeah, no, you've really covered it, Rick. The intention of opening up more long-term care beds to help with the flow from the acute care settings here and at UVM specifically to the long-term care setting is why we've increased our staffing there and unfortunately had to increase it using traveler costs primarily in the LNA space despite the fact that since we've launched our programs we've had 82 graduates from our LNA program, still not enough. Very challenging to recruit individuals into the long-term care spaces, I'm sure you're aware. Thank you. And just one moment I'm looking for. My notes are not as good as I wish they would be, but thank you for that. That's very helpful. I had noted in your narrative that you included that there are significant travelers through the nursing home and that makes sense in terms of keeping those beds open. So in the narrative there is a discussion of, actually never mind we discussed that. In the narrative there was some discussion about the length of stay being reduced and I know you spoke a little bit to some of the initiatives that you have at CVMC to increase the OR volume, excuse me, but could you speak to that just a little in a little bit more depth? There was a little tiny bit in the narrative but again CVMC like porters a little bit light and hard to pull the data out. I literally did a word search in the narrative. So if you could just talk a little bit about that that would be terrific. So just like EVMMC we launched an initiative for progressive patient rounds at CVMC and that's a multi-disciplinary team coming together and looking at all of our patients that are in the acute care setting identifying what barriers they may have to discharge and we actually do that on the first day of admission. So that's an evidence based best practice. It's something that other organizations had done. We had it a little more informally but we formalized it in the fiscal year and intend to continue that plan going forward. So that's really been very helpful for us and part of that interdisciplinary team are also our social workers case managers who are looking at what supports individuals need in the community to be successful in transferring into the community or returning home. So I would say that's probably been the biggest push for us that's seen nice results and reducing our length of stay observed to expected and we do use a vizient benchmark for that for us. So we're close to one which is where we want to be. That's the benchmark and I'm really grateful to the team that comes together every day to look at those patients and see what we can do to get them back where they need to be which is in the home and in their community. Great thank you so much. And then turning to your profit and loss statement which is also report one in looking at your projected NPR and FPP compared to budget. Your budget for fiscal year 23 was just around 269 million and the projected is looking at 253 million which my recollection is historically that has been a pattern for CVMC and is coming in under budget for revenue. I'm just wondering if you can speak to the realism of reaching 290 almost 292 million this year. I mean I'm sorry in the 22 in the 24 budget because of course as we've discussed in prior years setting the expenses at a particular level with the revenue coming in sort of creates continues to create the challenges with the operating margin. So I'm wondering if you can just speak to that and why you think 290 too is achievable. So some of it is definitely what we mentioned earlier in terms of using some of the capacity at CVMC to meet the access challenges that we have across the network. We feel like we're going to be able to do that to a larger degree this year than we have in the past in part because we have as part of our margin improvement initiatives that started last year created a centralized PERIOP team. So they are essentially managing the capacity for all our ORs throughout the network. They look to maximize both the physical capacity and they're reviewing the backlog of cases that need to be cared for. So that's one component. I think there are some other initiatives some other volume related initiatives that Kim and Anna can probably speak to. Yeah. The other area in addition to the focus on PERIOP services as I mentioned is opening up more capacity on weekends for radiologic studies here again reducing the wait time that may exist in other organizations bringing them here and getting those evaluation studies done. So I would say that's the other big lever. We also have in the procedural area in the endoscopy suite another provider coming on board and who is a private provider that we're opening up capacity for so that we can meet that community need as well. But again, want to just reinforce the power of the network in the regard of the PERIOP piece. We had been trying to do that work but when we come together as a network to really look at it centrally and say where does the capacity exist who has the need and can we match the need with the capacity. I'm feeling really good about the fact that the early results are we're able to do that and utilize the assets we have here in the PERIOP space to fill that need for our patients that may be in Shipman County or other counties. Thank you. I think that's it from me, Chair Foster. All right, thanks. Are there any hospitals that you try to emulate or that you admire? In general, Chair Foster? Yeah, when I was a lawyer in Burlington there was a lawyer out in the western district of Virginia and I thought he was just amazing. His name is Randy Ramsire and I tried to start working with him and learning from him and try to be like him. Is there any hospitals that you try to be like? So I'm pretty data-driven so the hospitals that we try to emulate are the ones that are the strongest performers in the Vizient data set and that's a data set that looks at quality measures and takes all top performers and we have a way to access what they're doing from the standpoint of best practice so we have a comparator group in that data set that are community hospitals of like size so we look at those hospitals and say how are they achieving outcomes in one area or another and we have open discussion with them about how they're doing that and looking to accelerate our improvement here locally so I would say we try to emulate those top performers in the community space. It's a little bit more challenging to find community rural hospitals that are associated in that database but we found some and those conversations are going which is great so again we're trying to emulate top performers in the quality arena. We focus on quality we'll get the cost out as well. Who are those hospitals? There's a number of them on the west coast as well as in the Midwest. Sorry what are their names? I want to look at their data. It's unfortunately it's not open to the public because it's a very discrete data sharing that we do so most of the hospitals in the community data set are part of academic systems around the country so there are shows associated with them but it's not an open data set unfortunately. Okay I'm just trying to get what hospitals do you emulate but not where they are in the data set or what their data is but what are the names of the ones that you're trying to shoot for to strive for? Yeah they're the hospitals that are associated with the top academic centers in the country so those include Mayo, Cedar Sinai, NYU Langone as an example so the community hospitals within those data sets. And then you're in communication with them trying to learn from them? Correct they have a number of collaboratives that are available in different quality domains and so we work with those individuals on those collaboratives. And then in the 2018 workforce pipeline initiative why did you start doing it in 2018? What triggered you to think that that was something that should be pursued? I'm sorry that was with the workforce pipeline? Yeah yes so we've known for years that there's been in particular a nursing shortage at a national level that's not news to us it certainly was accelerated with the pandemic without doubt and the resignation the great resignation that we've heard about so we were well aware of the impacts of that shortage at a national level so with that in mind we started having conversations here locally we actually engaged with then Congressman Welch to have a conversation across the state with the talent pipeline program that's a statewide program and brought other constituents in to say how are we going to address this here? So we had planned to launch our program we did launch the program kept it going during the pandemic and unfortunately the workforce issues have only accelerated in part because of the pandemic but also because of the an aging workforce and healthcare I think the average age for a nurse right now is 55 that's pretty striking considering that we have an aging demographic and more patients that are going to need our services with fewer care providers to deliver that service. So that was really the the emphasis I'm a nurse by background so I have a particular interest in that area but it's something I've been watching for some time. I got a Vermont nurse around the corner for me right now who's 43 so she's helping the demographic. In terms so like when we speak of you know the benchmarks and within range that can mean I guess I think it means 25th the 75th or some things it's like okay your median are you satisfied with being you know within range or around the median or if you hear something is at median is that something you think you can can work on improving and if so what are the things that you think you can achieve? Yeah so obviously we always strive to improve our performance I always like to look at top docile performance if possible that's usually a stretch to be honest but I think the stretch is what we the people that we serve deserve so not uncommonly we're looking at those high performers it within the dataset that I mentioned earlier and identifying how they're achieving that level of performance so you know my my goal here within this organization is to achieve that level of performance as compared to other community hospitals. We're not there yet to be honest we're working on it but we've certainly with some attention improved our length this day we're going to continue to look at that we've improved our mortality observed to expected so we're now below the benchmark there which is wonderful that's good news and there's other areas that we have to continue to focus on but yes we're always looking to strive to be a best performer to the degree we we can possibly do that and you know sometimes these hearings focus on what you're not doing well but I think that's just because everyone's trying to improve things so we're sort of take for granted all the good stuff because we're trying to find ways to improve things would that just be aware of that that's sort of an unfortunate part of this although there is some celebration of good performance of course as well but what are the things as you look at your hospital's performance that you think are the what are the worst parts of the performance that you're seeing the things that you think need to be improved the most well obviously our margin you know it's no it's no loss on this group that that's been a struggle for CVMC we have an interesting pair mix here we have a very aging demographic most of our acute care patients are medical patients they're not surgical patients and so bringing some of that surgical volume at CVMC will make a huge difference for us it doesn't take much of that surgical volume to to see some improvement and again that's care that people need it's care that they are required to have and just bringing it down here will help us significantly so I would say that's an area obviously a focus for us any any others as it relates to finance or the quality domain just performance when you're looking at those you know the mayows the cedars that you're trying to reach for yeah and you're looking at your data where is the area where you think you can improve the most I think there's still some opportunity in some of the quality measures as I mentioned there's two quality measures that we are doing well in length of stay now and mortality but there's a few other areas where we have some opportunity for improvement that are very clinically driven and we've again got partnerships across the network to focus on those as well as working with our colleagues around the country and then what about the admin costs I know that there can be some disagreement on the admin cost but I think it said it were on 75th percentile and potentially if that data is normalized the shared services that might even move up is that a number that you think you can shoot to improve or is there is it good where it is in your opinion well I think if we're still looking at that data a little bit more I don't know Rick if you want to talk about what's driving a little bit of that push for us of being on the higher end yeah so again the the data and the tool is a combination of the general and administrative salaries so we definitely want to do some more digging on that general piece so the impact that all the non-clinical staff have on that that ratio we just haven't had the time to really do some some digging there but to answer your question about the shared service shared administrative services because I did make a comment and we shared the data that when you look at those benchmarks we're at the median and we're clear that that's not that's not good enough we we definitely think that there's opportunities to to improve there a big piece of that will be standardizing on all of our systems across the network so that you can capture some of those economies of scale so right now we're not all the same payroll system we're not all in the same HR system we're getting there we're close the other area that's really starting to show some promise in terms of administrative shared services is technology so artificial intelligence robotic process automation those technologies are certainly going to have an impact on our cost structure going forward it will reduce some of the some of the the personnel needs that we have in certain areas so we absolutely can do better in those in those areas than just being satisfied at being at the at the median okay well thank you both and miss newton nice to have your responses i appreciate that and i'll turn it to member walsh no questions great um healthcare advocate do you have any questions for cvmc the healthcare advocate has no questions for cvmc today right and is there any public comment okay uh uh sorry uh there miss miss stickney do you have a healthy stickney i don't know um i'm um raising my hand as chair of the uvm network board and i'm excuse me wanted to get a few comments on the record before we go into executive session relative to executive compensation and i don't know anna were you going to make some closing comments before i was but i can do it after you ask your make your comments ali that's fine okay well um as the a governor's oversight board of the um uvm health network uh i wanted to make sure that for public comment it was clear that we have a board of directors that is carefully monitoring our executive compensation at the at the executive level um and we are a board made up of volunteers from throughout the network um we have an obligation to our communities to provide the best possible care in the most accessible way to all who need it and we also as a board have an obligation to make sure we're attracting the best talent we can to uh lead this network that we care so much about so we'll talk more about data specifics in the executive session but for the record i want to make it clear that we indeed are very data driven and we work from very clear philosophy and it's interesting that we all just we're talking a minute ago about uh about the median and the reality is that for executive compensation we are very clear that for salaries we are we set it at the median 50 50th percentile and that's the that's the um that's the goal we're going for and that's the data that we monitor and that we monitor on a regular basis so the board is uh takes its responsibilities very seriously use the lawn mowers outside um takes and we we compare ourselves regularly we have a very rich database that is brought forward to the board and so we have a deep we have a deep set of data by which the board can make its decisions um and feel like it's doing a fair and adequate job so uh it's important to us as a full board to make sure that that's publicly publicly stated so thank you for the time thank you for commenting um and miss newton please go ahead if you have a closing remarks for the board thank you so much so again i just want to reinforce that cvmc we're keenly aware that our budget impacts the lives of the communities we care so deeply for uh this summer is devastating flooding underscored the indispensable role played by cvmc and other health care institutions in our communities particularly in the time of crisis i'm proud of our staff for their response to the recent flooding emergency and i'm proud of the work we do every single day to provide high quality high touch care to those we have the privilege to serve however the flood is not just one it's just one of numerous challenges we've faced in the past years like all health care providers we've navigated the COVID-19 pandemic taking every necessary step to respond to the crisis that was a global issue and to protect our community's health and well-being meanwhile we continue to grapple with the effects of inflation staffing challenges as well as reimbursement rate cuts for medicare and private insurers last year every hospital in the state including ours operated at a loss this despite numerous efforts defined efficiencies in our operations this is not a path to a strong and resilient health care system for our state as a non-for-profit cvmc exists to provide health care to our community we have strong partnerships central remont with other health care providers and human service providers as i mentioned cvmc serves as a convener for our accountable community for health we are also the convener for something called the central remont prevention coalition which is focused on supporting our community members with challenges of substance use we need a positive margin to keep pace with changing needs of our patients support improvements to our aging facilities that are desperately in need and to invest in technology that our patients expect the budget we put together for the next fiscal year is a reflection of cvmc's commitment to provide the best possible care to those we serve maintain readiness to respond to future crises and continue serving our community for generations to come we must be able to cover expenses those expenses are a reflection of the care we continue to provide in the midst of these ongoing challenges and we've mentioned before the cost of increased pharmaceuticals supplies and then the nationwide staffing shortage this despite we're still having that staffing shortage despite all the numerous and i think innovative workforce pipeline program cvmc is invested in since 2018 i really appreciate your consideration of these challenges and their impact on cvmc and on our network our patients and our community and i want to reinforce that the budget we submitted for fy 2024 is what we need to continue to serve our central remont community thank you again for your time i know it's been a long day for everyone but i appreciate your attention um thank you very much um i have a couple quick questions um relating to the request for a executive session um so i want to i want to ask about the contracting with um shern's companies and get into some of the details of those contracts uh is it your position at the health network porter and cvmc that discussing that in the public uh would be uh disadvantageous it is chair foster inappropriate sorry yeah we shouldn't do that publicly okay and it would place you think um the hospitals at a substantial disadvantage with respect to contract negotiations with insurers yes i'm sorry mr maryl i i don't believe you're sworn is that right or are you i am not sworn but i don't think this is testimony per se uh chair foster this is i understand is discussion determine whether or not the upcoming discussion meets the legal standard for uh being taken in private session is that right uh it's factual assertion so if there's a witness who can swear to that that would be helpful i think i'll ask rick perhaps then to answer those questions instead thank you yes yes okay um we also understand that there are some potential contingency plans uh should there be cuts and would you find uh is that your position and testimony that public discussion of those plans would place uh the uvm hospitals at a substantial disadvantage yeah i don't i don't know if it's that it's places us at a disadvantage chair foster but i think it's inappropriate for us to publicly share the possible contingency plans because i think there could be a lot of anxiety and trepidation based on that and the way that we would actually get to those contingency plans would involve a uh conversation with the entire network with our board our community before we'd actually have to be able to deliver on those so i think to share it in executive session to say here are the things that we're looking at um if our if our budgets aren't aren't able to be realized is i think is a more appropriate place to do that okay um well so the standard is that it has to um yeah go ahead russ i don't mean to jump in i had two things um and sorry my voice um first was i i think we've had some back and forth and analysis regarding the confidentiality of the of these potential contingency plans and i'm happy to um be a circle back off offline here we need to um could discuss that further the other one is a little bit more of a practical issue which is um there are i believe only three board members on the call right now um an executive session requires an affirmative vote of two-thirds of the board uh so we need to get dave um back into the meeting which may take us a few minutes so perhaps it makes the most sense to simply rejoin this meeting at six fifteen uh take the motion then and and then switch over to the executive session link if that's acceptable i i think that sounds like a reasonable approach so why don't we do that we'll adjourn till six fifteen and we'll get member merman back um and before we adjourn we were discussing uh whether or not we'd go to executive session um understanding that uvm health network views the cost reduction plans as confidential and insensitive for several reasons so i'm going to ask a question around that um uvm health network could some witness confirm your position that a reason for confidentiality is that the materials in the cost reduction contingency plans is that the information gives uvm health network hospitals a competitive advantage yes the information or use it great okay so i will move that the board go into a confidential session under 18 vsa 94 uh 57 a which allows the board to examine and discuss confidential information outside of public hearing or meeting notwithstanding the open meeting law in order to examine the hospital's cost reduction contingency plans and discuss negotiations between the hospitals and commercial insurers the cost reduction contingency plans have been described as containing competitively sensitive financial information that our legal council advised could be treated confidentially is there a second i will second but i note that russ has his hand up today just mccracken i'm sorry a technical maybe a technical amendment you might consider it's 94 57 b as in boy 94 57 b let the record reflect the correction for mr mccracken and all those in favor of the motion please say aye hi hi um the motion carries unanimously i'll call back to order uh our meeting um is there any old business or new business to come before the board all right hearing none i just wanted to thank our staff in cassidy uh and uvm of course and the healthcare advocate very long day and i apologize for running so long but it's a very important discussion so thanks a lot to the staff in cassidy and uvm for doing it and mr krischer of course and other board members um with that i will move to adjourn this hearing second all those in favor hi hi all right hi we're adjourned have a nice night