 Okay, so the first item on the agenda is the approval of the general advisory committee charter. Is there a motion? Christine, I thought you did a very good job at the last meeting concerning this and so I would move to recommend a staff recommendation that we accept the charter. And is there any discussion? All those in favor signify by saying aye. Aye. All right. Okay, with that we'll invite the team from Central Vermont Medical Center down front. Welcome Anna, welcome Mark. Whenever the two of you are ready, take it away. Thank you very much. I'm sorry, do you want to pose for me? Yes. Would you please raise your right hand, please? Do you swear the testimony you're about to give shall be the truth, the foretruth, and there'll be less than truth, so help is on you. Thank you. Good morning Chairman Mullen, members of the Great Mountain Care Board. I want to thank you for the opportunity to present this morning. With me today is Mark Stanislaus, VP for Finance from the Network, and I'm Anna Newton, the President and CEO of Central Vermont Medical Center. Today we're going to go through the revised FY19 budget projections and we're going to describe the restatement of our FY20 budget. Mark will go through the details of that and then I will follow up with the position transfer. Discussion, so that will turn it over to Mark. Thank you. This is a very high level panel presentation, so if there's any conversations or any details, we can follow up with it with you from there. But just as a summarization, CBMC submitted a 2019 projection of a little bit over $600,000 back in the beginning of July. That was based upon year-to-date March actual financial state or financial performance. And we'll go through that detail what we've tried to spread to you following up. But since March, their margin has turned in an opposite direction. They had about a $200,000 plus margin year-to-date through March annualized. That is approximately about a $4 million loss now. We believe a lot of that trend is going to continue through the 2020 budget. So this is going to necessitate not only a change of the 2019 projection, but also the 2019 budget. And then, excuse me, with the 2020 budget. So you'll have to apologize. This time of year, while my mind is confused exactly which year we're in and which year we're working towards. And I was looking at a trail map and I went with my wife, and I'm going to digress over the weekend when we were four wheeling. And I looked at the map and I said, huh, this is the wrong year. It says 2019. So that tells you where my mind is. So I apologize. So it's all 2020. But so the factors that have changed in 2019 since March for CBSE is their collections have gone backwards by approximately $3.3 million. And this is the itemization that two primary drivers of that is the traditional Medicare and the all-payer model for Vermont Medicaid, excuse me. And also their expense trend has increased by $1.5 million. There's $500,000 in additional with traveler or agencies fees or the premium salary expense that many of the hospitals have been talking about. And there's been a $1 million increase to the employee health benefit cost from a financial statement perspective. We don't believe the $1 million is a true increase. We believe part of that was just not included in their year-to-day actual through March and just a quick summarization. Well, Blue Cross and Blue Shield is their administrator of their benefit plan. And because of the system conversion with Blue Cross and Blue Shield and they were slow to adjudicate some of the claims for January, February, and March. So that full trend was not captured through March and now all of that is caught up. And I think you heard that or from Blue Cross and Blue Shield based upon their conversion. So if there's no questions there I can walk into the financial spreadsheet and I'm gonna look at the bigger cell version. But the columns are labeled A through M and the rows are labeled one through 11. So just for a quick summarization, column F is the 2019 projection that was submitted in July with a margin of approximately $678,000. The revised 2019 projection that we're talking about today is in column E and that's showing a loss of approximately $4 million. And the difference between those two amounts are in column G. So that is a bottom line in principle approximately $4.7 million. So just to compare them, so the total NPR plus FPP is on backwards by approximately $2.8 million. Other revenue has increased slightly for a total change of $2.8 million so we can combine them and the expenses increased by about $1.5 million. And that's how they got to the $4.7 million loss. And we believe that trend is going to continue into FY 20. So I will pause there or I will look towards the board to see if you want to pause there or do you want to transition into the FY 20 budget? Does anybody need a pause to ask some questions at this point or let's get going? No, I would pause for a second. I mean, the changes have been pretty dramatic from when you came in here. Even at that point you had an annualized of the 336. And you were still, to see that much sway is a little uncomfortable in a two month period. And both on top line, on expenses. I mean, what type of controls do you have to be preventing this from happening in the future? I mean, last year you lost $8 million and obviously that was significantly off where your budget was. So this has been a trend that's been going on for a couple of years. And just want to talk about what controls you have and checks and balances both on the top side and the expenses to prevent such a significant shift occurring again in 2020. Okay, also from a margin perspective that is a considerable impact. But when you take a look at the shift in the collection rate, which is, so basically with a revised collection rate it's 49.5%. And the projection was 50.6% if you look on road two. Now, that's only a difference of a little bit over 1%, but it's very meaningful when you talk about these total numbers. So while that's a significant change, well from a 1% difference, I think you need to break it down or we need to break it down into the two driving factors, okay? On the traditional side of Medicare, there was a little blip at the beginning of the year that there was some double payment for the fee for service and the all payer model. So some of that needed to be backed out. So there was some noise factor on that side of the equation. And then as far as the impact CBNC on the all payer model specifically in Medicaid and given with their Medicaid population, on the Medicaid side, there was the same issue. And one care remat is actually revisiting their fixed perspective payment model and how they pay each month to help stabilize that for each one of the entities. But to put the change in perspective morning on those two items is on the traditional Medicaid from year to date March through year to date, what July, there was a decrease in collections by approximately 3%. And the Vermont Medicaid, although a much smaller number in total, that percent variation was 6.8%. So all we can do is continue to monitor those. And the way a lot of this accounting works is it is on a reserve accounting model. Is it's based upon your prior month's actual that you apply to your current business on what's gonna be when you're collected? And there was a blip in that. So it was significant from a bottom line perspective, but from an NPR perspective, it was only an impact of about 1.5% if you look at it in total. So our concerns are exactly the same. The margins are very small. In this case, CMMC has a negative margin. It is an improvement over the prior year. So obviously any change has its impacts. So I can't explain it exactly, to be honest with you. All I can say is that it seems like a fair trend and we're gonna need to continue to monitor it too. That's probably not the best reassuring answer. It's not the best reassuring answer to myself either, candidly. But we have a very complicated payment system. We're in the middle of change and there's a certain aspect of it that we're all getting familiar to the process as we're going through it too. This is going forward, making sure the expenses are tracking. We know you work at low margins. So when you lose top line and then you have higher expenses and then you show a significant loss, I mean, it's tough to make changes in your expense space if in fact you don't get the top line numbers as we move now into 2020 as well. I agree. There's a clear relationship there. So we believe this trend is gonna carry into the 2020 budget. Well, so we carry that approximate $4 million shift when you go forward. Before we talk about this, that projection is under the 2% 2% below FY 2019 will budget. So because of that, it shifts. So CBMC's review into a different review process for the Green Mountain Care Board, as you are aware. So it puts the revenue cap at 5% over the 2019 well projected. So that projected is approximately 2.2% lower than the 2019 budget. And basically, part of this is because of the timing of the crunch that we were all under 2% to be candid. So what we did is we reduced whether revenue line by approximately $4 million in the 2020 budget. The expenses just carry forward. And the other thing I should say about 2019 too is by carrying this forward in 2019, there were some questions about did CBMC budget the appropriate amount of bad debt and charity. So in carrying this projection forward, there is a realignment. So the charity and the free care are in line with the current trends. As compared to the previous projection, there was a little optimism in those two categories. So on the 2020 budget, the proposal is a net NPR plus FPP of $218 million. There would be no change to the expense space. And basically, how does that compare to the revenue cap? Well, 5% over the 2019 projection puts it at approximately $217 million. We'll probably need to take the time to validate these numbers with your staff too. So we know that. So if they're a little off one way or another, but they should definitely be in the fair range to speak about this. And then if you think about CBMC's $3.1 million worth of physician transfers, which Anna is going to talk about next, and you add it to that 219, that would put it in the 220 category. So currently right now, CBMC is a little under a million dollars or a little over a million dollars over that 5% cap. And then we still have the physician transfers to talk to approximately 3.1 million. So we'll sort of summarize, CBMC's 2019 projection would go from approximately $600,000 gain to a $4 million loss. And their next year budget would go from about a $4 million gain to a break even. And so we know we from the aggregate, we know we from Anna from the CBMC perspective, from the health network perspective too, we are not completely comfortable from a performance perspective with a break even budget, but we truly feel that this is a more reasonable we know budget for CBMC in 2020. And especially as we think of the change that CBMC is gonna have over the next couple years as it relates to some of the discussions on the inpatient mental health's height. And we also will believe presenting a budget any lower than this isn't fiscally the right thing to do either. CBMC needs to get to a positive margin. They've made progress in 2019 compared to 2018 and they still have more work to do. So this is all about creating a responsible budget for CBMC and this reflects about a 2% change from the original budget. If you just look at the simple math on a $4 million adjustment on 200 plus million. So that's about what the change is or from the budget or projected in July. And I'll pause there and see if Ann has anything to add and then we can tackle any questions. Any questions related to the revision of 2019 or 2020? So I'm just trying to follow the detail here and sort out what might be one time issues and what are ongoing issues. And so let me just ask going forward is it your experience now that all the issues with Blue Cross Blue Shield are back on track and that's not something that will be or will not be something that will roll into 2020? That should not be something that rolls into 2020 after we capture the change there. And keep in mind that when we say issues this is a normal transition when anyone goes through a conversion they delay claims to make sure it was right or Blue Cross and Blue Shield they were running parallel systems and then we want to be clear that this was just the processing of saving obscene's own health plan expenses. So we believe that's as clean as it can be in 2020 as long as there isn't a change in healthcare spend for the employees. And I'll pause. Next in terms of a one time the traditional Medicare the double payment with Medicare is that because I think in looking at what some other hospitals have told us that's still an outstanding issue that things have not yet been fully resolved with Medicare and people kind of circling around what the number will be but is this something that you think you've captured and will not roll into 2020? Well we feel that we've captured the best that we can knowing what we know today and there are still conversations with Medicare. A lot of those conversations now kind of carry over to the settlement of the all payer versus well the traditional Medicare and hopefully there's no double processing by Medicare in January 2020 and it would make it easier on all of the hospitals and the all payer model too. So I can tell you whether we're productively working through it all together with Medicare and the folks over at OneCare, you know Vermont but we feel that well the cleanup in the adjudication system for the fee for service has caught up meaning everything has been reversed on the fee for service. So you know this is the best estimate that we have at this time. And finally I'm just looking at your the right paper here in front of me. Your FFP rate and you know central of Vermont has done a good job in terms of participating in the all payer model. Your percentage of net present revenues is well above the system wide average. But in this situation I'm just wondering if there's a bit of a problem with that. Your projection in your projection for 2019 was at $37 million, $37.7 million in FFP. And that looks like that's dropping by about 1.7 million. And then rolling out into 2020 your projection was $50 million significant increase. And I'm just wondering how aggressive you've been in approaching the rollout into 2020 of an FURF FFP projection. So CBMC is hit disproportionately by the all payer model from a percent of business from the other hospitals and that is one of the reasons why we believe the collection rate has gone backwards in the 2019 because if CBMC sees more services that are attributed to the enrollees, let's just use Medicaid as an example only. That is one of the reasons why their collection rate actually went down in 2019, that they saw more people so their gross revenue went up and their fixed payments were estimated to be the same. So it is just the math of where you're dividing the two from a simple collection perspective. That's why it's less in FY 2019. In FY 20, as the budget is here, that amount was actually lowered by about about two and a half million dollars, give or take. Yes, often the projection of that one care provided to the hospitals only because when we talked about this with a senior leadership team over at CBMC that we thought that was the appropriate thing to do because of this relationship issue. And this is just gonna be another one of those things that we're gonna have to continue to monitor. But that change felt like it is the right thing to do. Well, so that's why it was made in the 2020 budget. Keep in mind that we're talking about small percentages on big numbers, but they're very meaningful when it filters down to the bottom line. But those are some of our same concerns too, Tom. I know this hospital has a difficult payer mix and you've talked a little bit about the old payer model. But given the new forecast and where you've been in 2018, where you've been in 2019 running at a significant loss and you're keeping your expense low now the same for what you've given us before for your 2020 budget and what your forecast is. And I'm hoping that maybe that's conservative and that you're gonna look aggressively whether it's efficiencies or cost savings because you've talked about how you wanna be at about a two to three percent operating margin. And I think that's where you need to be. And if this hospital didn't have the backing and support of the network, it would be a real challenge to say that this is a sustainable forecast losing 8 million in 2018 losing another chunk of change in 19 running at a break even in 20. And I would have hoped that A would be getting more synergies from the network. And I know in 20 you do have some one time epic charges that are running through and things like that. But I think really understanding where are you going forward? What's it gonna look like next year? I mean, what are your goals and how are you gonna get there? Because this is becoming a pattern, right? It continues to happen. Whether it's, I agree with you, it's small on top line a couple percent change, but when you're working with a low margin and then you have issues with expenses, it becomes significant at the bottom line. So I can all speak to that. So to your point, we've cut the loss from last year and a half to break even for next year seems like the right direction to be moving in. But I think it's important for the Green Mountain Care Board to know that we have a number of initiatives that are looking at operational efficiencies. The challenge with those initiatives is it does take some time to actualize those improvements. I'm pretty confident that with those margin improvement initiatives, we will achieve not only break even, but move forward in a way that gets us closer to that margin. So the intent is that we will continue to operationalize those efficiencies, both across our Woodridge nursing home, the 27 practices that we had in the acute care setting. But it does take time. No, it does take time, but at some point if you're operating a hospital that has a lower NPR, to continue to expect you can have higher expenses than that and not really react really quickly. I mean, we don't want, you're not gonna run into a Springfield situation, right? But all of a sudden Springfield is able to find some, deeper cuts because they have to. And they've got to get those things out of the system. And it's just trying to say, are you really pushing everything that you can? And I appreciate the improvement from 18 to 19, but 19's not done yet. And you just saw significant changes from what you gave us a month ago to now. So I'm not really confident that you're only gonna end up at negative five million. But I hope that you do. I'm not saying just, we've had significant changes from where your budget is to where you came in July 1st to where you're coming in now. So hopefully when everything nets out, at the end of 19, you'll only be 4.8 million loss. But it wouldn't be a surprise if you were higher. Okay, there's definitely more work to do candidly. Okay, and the more work to do is on two sides. I guess I could say that I'm wearing my health network hat right now. But we know CVMC, they need to take a deep dive internally. And I think from the health network, we've been very candid that a key component of the performance for the Vermont hospitals within the health network is going to be this horizontal integration. And because these hospitals, in my opinion, and I'm speaking for all of the hospital systems, that there's a challenge every day to keep up with inflation of how can they keep their expense base in line with the payer inflation and the cost shift. So those savings, the hospitals can only dig so deep before it really changes the type of services that they have to provide. And there are scope and scale that needs to come from the health network on that horizontal integration for us to keep pace with all of this payer reform. And John can talk to that afterwards, but I think part of that responsibility is on the health network to navigate those integrations in our healthcare delivery system. And a big step forward there is going to be epic. So, I mean, I'll pause there and John might wanna speak to that later. But, you know, that is really twofold. Anna has a big responsibility for CBMC to make sure that the funding is as official as possible. And the health network needs to find scale in savings and efficiencies and access to. So I think it's twofold. So I think we'll summarize. I mean, if I just put my pure financial on, I have some of the same concerns that you have morning and we're gonna have to work hard to get there. So, you know, one of the things, and I realize that it's really a timing issue, but one of the things that you discussed earlier was the self-insurance program. And we've seen a number of hospitals, including Springfield, actually get hit with a very, very expensive tab. And I was wondering if you could share with us what your re-insurance is that you have in place and how you try to protect that. And also, if you could address, I remember reading an article probably 20 years ago now about how healthcare workers are one of the most expensive blocks to insure because they know everything that could possibly be wrong with them. And they know every single test that could be done. So it's a very expensive block to insure. Just if you could share with us some of the things that Senator Vermont's doing to foster wellness and to try to keep the expenses down on that self-insured business. So to your point, we have, I think, a pretty robust wellness program. We do pay our employees, give them an incentive to engage in wellness activities. We have a number of initiatives, both related to diabetes prevention, exercise programs, those sorts of things. So we think we have all that in place. The challenge is, when something unexpected happens, the biggest hit we've had this year is with oncological services. And sadly, that's not something that anyone can anticipate. So the hit we've taken from a benefits perspective is an increase in those type of services and the individuals that we've insured are needing to go outside of the network to receive the services that they're receiving. So unfortunately, that's a little bit of how it goes in a given year. And this is one of those years where we've been hit in that way. We keep a tight control over that and look and see what else can be do to manage that. But the reality is there are times when these things are not manageable in the way that one would like. Do you have stop-loss or reinsurance in place to protect you against? We do. You know when that kicks in, what the dollar figure is? I don't know off the top of my head about Mark, if you're aware of that. No, we don't. Any other questions? Yes? So thank you for coming in and giving us this revision. I share some concerns, I think, with Maureen and probably others about the expenses not being adjusted downward, given the downward adjustment of NPR. So my hope is that this is a conservative estimate of expenses and as you said, there's gonna be work that you're doing. I know that there is work from the hearings around care delivery system optimization and increased efficiencies that you're hoping to get through working with the pharmacy and IT and HR and all of that. So my hope is that that does come down. So my question is really to get your bottom line, you're really the line on non-operating revenue basically to make up the difference. So you didn't revise that at all. Is that, did you look into that to make sure that there were no adjustments that should be maybe they're up or down all the way down or maybe down on non-op? Or other revenue, sorry, I just said other revenue, other revenue, right, that's 16 million? Yes. Okay. So there's not gonna be an adjustment to that related to an adjustment in NPR. No, so if you do look at the year to date July annualized and then I have a little bit more of a breakdown within what you see here there. But the year to date January annualized and other revenue was about 17 million. We're projecting about 15.4 or 15.5. And there were some one-time items in the July annualized that should not be annualized already. There were some draws out of restricted funds that should not be annualized. But so we feel fairly confident by pulling that back a little bit because we didn't want to annualize a one-time item. That's also, and we know there's a high reliance in this other revenue category. More than half of it is 340B contract pharmacy. So I guess what I was wondering was if your NPR is coming down, would that also affect 340B revenue? No, it should not. Not 340B contract revenue. And we can explain those nuances of the relationship after if you would like me to work with staff, but. But I just want to make sure you're confident in that number because that's going to make up the difference there, right? Given that your NPR is lower than your expenses, you really need that to pick up the 16 million. Yes. You do numbers, you know that. So I guess, and I'm going to bring this up now but I've brought it up a couple of times in the hearing and last Wednesday, this notion of regulating the network as a whole, the entire network and giving the total NPR for the all three hospitals with the related underlying commercial rate that would go with that. And as I said last week, this was, the hope was that I think this could potentially give the networks in flexibility to be more efficient within their network. As patients are flowing through the hospitals, then those dollars would flow so that there's an incentive for each of the hospitals to make sure that care is being delivered in the most appropriate place, the most cost effective place. And I think it allows the network to leverage a positive scale better. For example, we know we've heard that UDM, the Medical Center is at over capacity now, they're in surge. This potentially looks like there's some under capacity here, there's some capacity for CBMC. So that patient flow could happen if the system was regulated in its entirety. So I'm wondering if you might provide for us with this revision downward in the NPR, what it would look like for NPR for the entire system and the associated commercial rate. You don't have to give this to us now, but what would it look like for a holistic NPR for the system given this revision? Does that make sense? Yes. So you know, rolling it up. Yeah. So just going out doing, doing quick math, I think the Vermont Health Network, I think is about 1.5, 1.6 billion of the NPR. So, you know, the $4 million shift as a percentage is way, you know, it's about 0.25%. You know, we absolutely believe managing the health network as a single entity is the direction to go. But we understand that, you know, it takes time to get there. Well, so we welcome those conversations with the Green Mountain Care Board how we could get there together. So that's about the scale. You know, this particular change, knowing that it is, we know, right even at the bottom line, you know, there's no change to see the MCs, what commercial rate ask. That commercial rate ask is, you know, more inflation and the cost shift and no more. So, and I would welcome the conversation, what was staff, Jess, if you would like to get in the further detail on that. Any questions? Want to transition to the practices, Anna? Yes, that'd be great. So, we wanted to give you a little bit more detail on the proposed decision transfer requests for dermatology, that's about 480K. Again, this is a practice that was in Central Vermont that closed. And so, we've assumed and absorbed that practice over the course of a couple of years. It was, again, it was partially absorbed in the last fiscal year and remainder would be in this fiscal year. Approximate wait time for dermatology at this point is 150 days. So, there is an access issue there as well. In pulmonary, we are having a retirement in a long-standing position. This individual's been in our community for 40 years. He will be retiring. He's an independent provider. So, we are going to be assuming his outpatient practice, outpatient clinic that he does within Central Vermont. Again, the wait time for pulmonary is about 120 days. And oncology, it's a 2 million increase. We're looking at providing services we have been for, not only Central Vermont, but also to manage Copley and Gifford needs. Our recent SG2 data, which is the intelligence firm that we've been using for planning purposes, for these kind of services, as well as for the psychiatric and patient capacity program, shows that there'll be about a 14% increase, almost 15% increase, growth and oncological services are being projected for our community. Again, this addresses the Berlin HSA primarily. The wait time currently for oncology is about 38 days. And neither pulmonary or oncology are obviously, they're not elective services. So when people need those services, they need them. So we're trying to be ready to provide those services for our community in fiscal year 20. We'll pause there and see if there's any questions for board. Questions about the transfers and acquisitions. Patrick, does your team have questions? I don't believe so. Okay. Yeah, I guess, did you want to add anything before we turn it over to public comment? Chair Mullin, I can either make some comments in the public session, or I'm happy to go up to the front and raise my right hand, because you all might have questions of me. Whichever way you prefer. Well, I think if you want to ask questions and have them on the record, I probably should go up there. I don't want to let my money guy go. He's got to stay here. Dr. Richardson, raise your right hand. Do you swear the testimony you're about to give shall be the truth, the whole truth, nothing but the truth, the whole good God. I certainly do. Thank you for letting us take a reset here. Very unusual and has been pointed out, you know, to see many, many moving parts. We did see deterioration over a couple of months. It does speak to our process that, you know, you get so far into the process, it's virtually impossible until you go through the steps like this to do a readjustment, but really appreciate that. So Anna, how many physician practice sites does Center Vermont have that you inherited? 27. And have you closed any of those practice sites under your tenure? We have consolidated two practice sites at this point. I'm sorry, consolidated, not closed. And what was the community reaction to that consolidation of practices that were a little bit over a mile apart? Those two practices were approximately one point, one mile apart from one another. We consolidated one in downtown Berry to one that was literally a mile away. And the energy from the community was high, but I think when I went in front of the Berry City Council and described the rationale for that consolidation, they understood. And the reality is that going further as part of our emergent improvement initiatives, we will be looking at optimizing the efficiency of those practices. And we've just completed a study that looks at if you were to wipe all those practices clean and identify, based on our market, where would we place practices? They would probably be placed in very different locations. So we're underscoring that analysis now. So I'm asking these questions to make a point. We didn't rehearse this at all. If you were going to, although I have heard this from Center Vermont, if you were gonna make one major capital investment to correct your current financial situation in the near and immediate term, what would it be? We would consolidate our ambulatory practices into efficient centralized locations so we could reduce overhead costs. Part of the challenge now is we've replicated all these overheads in 27 distinct locations around Central Vermont, which is a cost burden. So we would consolidate those into a probably three main locations that are geographically dispersed, but a centralized model in the Berlin community. And that would yield just on the expense base, probably $8 million of expense avoidance at least. And I bring that point up because this is a microcosm, a microcosm of all of the interrelated factors that we're taking into account and really the driver of why we brought the UBM Health Network together and worked hard to support an ACO concept to bring the others into the fold. We have to make these changes incrementally, if at all possible, and avoid the spring fields that create tremendous disruption. And Lorraine, you're absolutely right, but for coming into the network border, very likely would have been a spring field. But for coming into the network, Central Vermont would almost certainly be in dire straits right now. Hopefully we would provide other safety nets through some mechanism. But this is what we're all about in the UBM Health Network is to have as many levels as possible to incrementally change and get it on a firm footing financially and with a distribution of services. And it gets even more complex when you pick up a region in another state. Another just general line of thought coming out of this, we've embarked on a, some would say radical, I would say long overdue transformation of the healthcare delivery system, financing and operations in this region. We've all jumped into that together. We're working really, really hard. And the one of the inherent risks in doing that, you see in what's presented here and what's happened to Central Vermont. And that's that we're working with CMMI and CMS in a way that they've never worked before. So this is not a surprise. One of the major risks going into this and I've spoken with our board about this for the last five years is the ability to administer the program and some disruptions in funds flow that might occur. That's not to throw out the entire system. That's to realize that we're doing something innovative and new and there's going to be bumps. There's going to be a funds flows issue. And I think we finally have gotten to a point where between the finance folks at OneCare and the finance folks in our hospitals, we're starting to get to a place where we can forwardly look at those revenues. But we have to, if we're gonna move this to fruition and believe that this all pair model is a viable model, we have to be able to roll with the ups and downs and be able to make that happen. As Mark pointed out, we've made tremendous investments to get us on the other side in all sorts of IT. We're all on the same budgeting system, cost accounting system. We're putting in Epic, which will bring in an entirely new revenue cycle. So all of these parts and pieces, whether it's down to consolidating practice sites or the all pair model or bringing hospitals and our providers together, all are planned to have a sustainable healthcare delivery system for monitors and folks of Northern New York. It all comes together, but everything is interconnected. Everything is interconnected. We're making decisions to end up with a sustainable delivery system and a care model that keeps people healthy. What we can't do is believe the system to a point that we don't have any buffer or any resiliency to roll with what have to be, have to predict that there's gonna be bumps in this road. And my solid message is the 2020 budget for our three Vermont entities are crunch time. I love the fact, Jessica, that we would consider the three entities as one, as these budgets are constructed and as these systems go, there's a lot of dependency on the academic medical center, their operational clinical and financial health. And so I would urge that at this time with all of these moving parts on a pathway that we aren't just sort of wandering in the wilderness. We know where we're going, that we take the time and make sure that we're putting the resources in at this point that's gonna allow us to weather these bumps in the road. The last thing I would just remind, and this is a specific issue to center Vermont, at least in my calculus and our calculus, we have a couple of years, 24 months to get to the budget for the next 12 months after that, to have this organization in the shape that it can absorb the appreciation that will come online with psych hospital on their campus and on their license. So all of this, we're watching incredibly closely. I know it looks like things just fell off the radar screen. Nothing could be further from the truth. We have finance teams and even my time this past year on a monthly basis, we meet with the CFOs and the presidents and go through where they are. And it's just really tough to pick up what's a blip and what's a trend. You really need three, even four months to really understand that there is a trend with some of the marks points. So I'm wandering a little bit now, but I just want to make the point that this is a time where we need, not even really a buffer, we just need the budgets that have been carefully crafted to go through so that we have the resources to move all of these things forward. We do have employee self-insurance through our, we actually through our captive, which as of September 30th will be a Vermont-based captive. We have the license and everything is all done. We'd love you to create a promo for Dartmouth to try to do that. We actually had, we've had some conversations with them about the glide path and how that worked. I'm not, obviously don't make decisions for them, but we do have insurance stop-loss for our employee health plans through the captive, and I believe the attachment point for September of August could be 50,000 per individual per year, but we'll get your staff the specific attachment point, and then we have reinsurance on top of that that we get from one of the large reinsurers. So Dr. Rope said you really spent a lot of time looking inward on the facility planning piece for the in-patients like beds, but also you took a look at the overall facility, trying to make it more efficient. Was the 27 practices part of that, or is it a separate planning initiative? I'll let Anna speak to that, because they're planning on how that would roll out, but it's a matter of available capital and timing. And again, I think if you just looked at Center Vermont in isolation, likely the first thing that they would do is ambulatory, and then if there was no increased site capacity, they would look at refurbishing their emergency room in-patient units to a configuration that more met what the long-term needs of that three or four county section of Vermont would require. And so we're gonna have to do some work with practices because of where we're citing the increased site capacity but the plan is there, it's a matter of timing and the capacity to pull it off. So to your point, yes, we've kept our overall master's facilities plan at sync with the development of the psychiatric and patient capacity, and we studied not only the acute care campus, but these practice sites as mentioned. We took an approach where we just wiped this slate clean and said, just looking at our market, where would we position these practices? And we clearly would not have 27 to be frank. And it's hard at this point to understand the why of how we got there, but it doesn't matter really what the point is, how we move forward. And to John's point, if you were to have said what would be the two things that I would have done first, it would have been that ambulatory practice site so we could optimize our efficiencies and make it more patient and family-centered and then modernize the acute care setting which is a 50-year plan with a lot of just deferred maintenance. We're grateful that the ED will be part of the site build but know that we do have capital challenges as John mentioned and as part of the network we'll be looking at prioritizing all of those capital needs in the next few months. But yes, we have a plan for how that should all unfold to really optimize the services we provide to the central non-community. Questions for the board? Seeing none, I guess at this point we're gonna open it up to the public for any comment on the resubmission. Pretty unusual that we're seeing none. So that's a good thing. Thank you for coming back in. I know that it's a tough process that starts very early and sometimes things can change and it's better to address it now than dealing with it next year. So I want to thank you personally for Rob putting the pencil back to the paper and coming back in and we'll have answers for you by the end of the week. Thanks for the opportunity. So with that I've been invited our possible budget team up. Thank you Mr. Chair. Good morning everyone. This is day two of our deliberations on Vermont hospitals and today we are prepared to present recommendations for seven additional hospitals. And with that we'll get right into it. First up is North Country Hospital. Last Wednesday, if you recall, we approved an accounting adjustment and with that approval it brings North Country into the guidance and with an attempt to grow a 3.4% North Country is also a hospital that is in the beginning stages of the financial recovery from several years of negative operating margins and we certainly want to be sensitive to that. They need an increase here to continue to push that operation market recovery. And with that our overall change in charge is 4.2% if you find that to be appropriate. Historically they've run at the top of the five year average around five percent so this comes in within that and well under it. So with the fact that they are within budget and applying this through and through we would recommend approval. Continue to quarterly check-in on that operating performance. We have an additional recommendation regarding accuracy and timeliness of their financial submissions. We do tend to find time to time that financial statements are pulled back and adjusted and as they move through their IT integration we'd like to see that become a thing of the past. Understanding of course there are certain times that is appropriate. So with that they are within budget guidance. We find the change in charge to be appropriate to absorb inflationary expenses and promote an operation margin recovery and we would approve that. Question to the board. I'm not sure I quite understood what the recommendation was around the accuracy and timeliness of submissions. Like I understand they haven't been accurate but what are you suggesting we ask them to do differently? We really just wanted on the record that this is something we notice. Given the financial performance in the past we wouldn't want any surprises because of some of these adjustments. So we just want to ensure that moving forward we can have faith in what they're sending us to make sure that we're monitoring an appropriate financial recovery. Thank you. Did you get a response from their team on that? Could you have been working with them to try to get some of the responses and actually information because that's been a trend with them? Thank you. No, apparently we did not get a response on that topic yet. Other questions? Just want to make an observation here that I do concur with you in terms of the timeliness and accuracy of data that it's been a kind of a moving feast in a way and kind of hard to keep up with where we are here, where we are. I'm just looking at all hospitals but at North Custory's trend in terms of NPR growth and from using the data that the staff has presented us from 2014 through 2019 projected it's been a 2.46% growth rate. So this is not a hospital that has been outside our kind of target over a long period of time and that their increase at 2.6% for 2020 over 2019 is consistent with their past trends. So this is a budget proposal that I don't see any major problems with. Anyone else from the board? I'll just have my comment. I think that I can agree with this recommendation but this is one of the hospitals that I mentioned last Wednesday that I would like to see a sustainability plan from as a part of the budget order. This is a hospital that's already engaging in the review of their service lines which is good, I think it's really important. They're looking at what is the appropriate service line that they should be delivering to make sure that they can deliver cost-effective care at volumes that can sustain quality. So I think part of this should be we'd like to see that analysis. Their price increases have been high in the past. These are some of the hospitals that average annual increases have been 5% over the last five years. They're not this year, they're more in line with medical inflation but still I think the fact that they've been over 5% around 5% over the past five years suggests that they do need to be looking at sustainability. So I will support this budget that's submitted with that caveat. So I just share my only concern is that it's the change in charge that is troublesome and looking at their five-year growth rate and that it seems to be troubling for me that it's above 3.5% which is the target that we're trying to stay with under the SPAR has dealing with keeping the growth and spending at the same rate as the growth in the economy. But with that being said, if the budget is not part of our guidance, I think that they've complied with the guidance. So I see no reason not to vote for it. Would someone like to make a motion? I can do that. I move that we approve North Country Hospital's budget with an NPR of an effective growth 3.4% and 4.2% overall charge with the conditions that they do a quarterly check-in relating to their fiscal year 20 operating performance and participate in the work we've asked staff to do around sustainability planning with certain hospitals and also that the budget order make a note of concern relating to the accuracy and timeliness of submissions. Is there a second? Second. Second. It's been moved and seconded. Is there further discussion? I'd just like to add to your comment that the rate increase is above the 3.5% target, but the payer mix for North Country is significantly weaker than I think the average payer mix with only 47% commercial. So I react to the 4.2% rate in terms of it seems high but then I'm a little bit accommodating because of their relatively weak payer mix. Yeah, and I would just add to that the fact that they lost money the past two years, 17 and 18, 19, it does show that they're looking to make a margin and 20 work as well. But I factor that into consideration when I'm looking at the 4.2% change in charge. Further comment from the board? Everyone said everything I would say so I won't say anything else. So at this point I'm reminded by legal that we need to open it up to a public comment or we actually vote. So would anybody from the public wish to make any comment on North Country? Seeing none. All those in favor of the motion signify by saying aye. Aye. Any opposed? Southwest. Thank you. South Weston Vermont Center is next. This is a one A and one B type of approval. We have an anesthesia provider transfer that needs to be approved as part of this. Otherwise, and I think you all have that information from last Wednesday, we have since received the answers to that. And I'll just hand it over to Adam to speak a little more on what that answer goes. So if anybody wants to reference the financial breakout of this, it's slide 45 from the debt review on Wednesday. But just to follow up, the hospital followed up. This was in response to Chair Mullin's question and hearing about whether or not the hospital-owned practice would be providing this service at least the same efficiency as when it was independently owned. And there was a question about the NPR. So the response is, and this was forwarded to the board, that in the independent practice, it was about $2 million annually in NPR. If you break that down to nine months, because this practice goes into effect on January 1st, it's effectively nine months of the fiscal year, it's $1.5 million in the independent practice. And as a hospital-owned practice, they're budgeting $1.3 million. So it is $200,000 less. And they emphasized in their letter by underlining, so that we could not forget it, that they're assuming the same volume in productivity. So it is budgeted to come in at about $200,000 less than as an independent practice. And we wanted to make sure that the board understood that. And since that was the only follow-up to the provider transfer vote, make sure that you have that information as you deliver it. So any questions about that? Any questions about the transfer? Is it done? Are you gonna talk about the incoming change? We can review that. We went over that last week, but we can go over that again. I don't think you have to go through it in all detail, but just the summary. Let me just look to make sure. So Southwestern had an anesthesia practice up, and actually that was that they did not have an accounting change. So for them, it's just the anesthesia practice. I think you were trying to trick me there, but. Well, you have it on your slide. Oh, well I tried to trick you. So that's just the leftover bullet points. So they did not request, oh it says accounting change, none requested, not required. They did not request an accounting change. So basically the change from 4.3 to 3.5 delivered and the guidance is because of the. The 1.3 million in the anesthesia practice, yes. Perfect. Other questions? I just, just my observations on Southwestern as we go through is that, you know, this is a hospital that again, over the long term has stayed from 2014 through 2019. Projected has stayed below the 3.5% in PR growth mark. The rate increase that they're asking at 2.8% is below their five year trend. They are a hospital that has stepped into the all pair model quite aggressively with a large percentages of their MPR coming from the ACO and they have a relatively weak pair mix and clearly discussed, you know, what's going on in Bennington in terms of the weakening of the economy. My one concern with them is that they aren't booking any resources for the all pair model. But basically it takes an approach that it's a 50-50 chance that they're gonna be a winner or loser and that average is out to zero. So, you know, it would be nice to be kind of, you know, putting away some real reserves that could cushion any future misprojections. Other comments or questions? Maureen? Yeah, I would just comment that this is a hospital that continues to meet their projections both on the top and bottom line. And so it's one, when I look at their forecast, I can have some confidence that this is, they're probably gonna hit this number. They do have a relatively high operating margin but they are, they have an old facility and they're planning to use some of that cash property margin in the future to add to that. But they also talk about the fact that they're trying to get their expenses in line with what they're reimbursed for Medicare and they're focusing on that. So, you know, definitely on this one, I look at them as having confidence, you know, they ask for, you know, re-charge about this each year but I would say, you know, I look at their numbers and say I didn't feel hit, so. If anybody had heard of that and I would also like to add, it was quite informative to the fact that they are really taking proactive steps in the telemedicine field and they are looking to integrate several forms of that into their hospital for the next seven years, which will ideally save that hospital a lot of money by using those services. They've also been one of the more creative hospitals that try to fuel more shortages too, so. Kudos to them. Would someone like to make a motion? I'll move that we approve Southwestern's budget with an effective growth of 3.5% after approving the provider transfer as well, and with a 2.8% overall change in charge. Second. So, the motion, as I understand it, is to approve the. Provider transfer as well as the effective growth in the change in charge. Correct. So, is there further discussion by the board? If not, we'll open it up to the public for any comment on the Southwestern Vermont Medical Center budget, seeing none. All those in favor of the motion signify by saying aye. Aye. Any opposed? A conflict. Thanks, we have a conflict hospital. This is a hospital that, for seven years now, has been under significant financial unrest with a preceding bottom line revenues. The recovery margins does require this change in charge as the staffs visit to propel that recovery in the coming year. Additionally, the hospital does need to make investments into forward maintenance, as they stated while they were here, but the facility itself is being worn from the observer. And to do that, they can no longer dip into their day's cash on hand, they need to begin to make some of those investments on a positive operating margin for the hospital faces. Significant issues, as we really consider balance sheet having enough cash on hand for rainy days, so to speak. Their change in charge to five-year average, as you can see, is negative 1.3%. They are at the very bottom of all Vermont hospitals. So this overall change in charge here that we are recommending being approved as submitted would help make a dent in that five-year average. Certainly not make up all that ground, but they need it for survival, and we do feel that is appropriate as a corrective measure. And currently, their budget of rejection is coming in under 2.6%, which triggers that cap. However, they are making significant changes at the hospital, which should yield them an improved financial picture next year with the change in charge. That's the question to the board. I think just a question I would have really would be on their top-line forecast and how realistic it is with the changes that have occurred this year. And we know some of that is continuing into next year and the orthopedics and things like that. So I would just challenge that their top-line number may still be risky. And I think that although it's a pretty significant charge increase, they have had negative commercial rates for several years and they were cut back last year. But I also want to say that that cut back and those changes are not the sole reason why they're in this situation that they are right now because they're missing their forecast and their expenses, you know, you're not, as we've gone through multiple times, it's very hard to react to expense changes when you miss the top line. And so I definitely think continuing monitoring next year to really see where they're going to be. And I know that's in the plan and we would do that particularly because they are a hospital that's losing money. They are struggling. They, you know, are teetering on it to continue to lose that much money. How financially viable they're going to be. So I'll just pile on on that. This is the hospital that I think needs sustainability plan perhaps the most. And so I'm going to again have my approval on this budget on a significant sustainability plan. Their operating margins have been negative for the last four years. They've gone by heavily on orthopedics to carry them and we see what happens when something in that department is compromised. I just want to, I've read an article and I'm going to share this with the board, but I think this is a little bit of an element of things to come. It was in Kaiser Health News and it was discussing, I think what's going to happen in the future in terms of medical tourism and that hospitals that rely on orthopedics are going to be in trouble. North American Specialty Hospital was a organization that's recently organized orthopedic treatment in Cancun. And they now pay 40 orthopedic surgeons from the US, from the top US hospitals. They pay them to fly to Cancun to do joint replacements in a very upscale private hospital. And in this article, which I'm happy to share with anybody, the patient was literally paid $5,000 by her company to go there for the surgery and the doctor was paid three times what Medicare was paid. And even with all of that, it is still worth it for all parties to have the surgery down there via an American doctor in a very upscale hospital in Cancun. So I worry about hospitals that are relying on their orthopedic practices to make their bottom line. And I know that's been one of the ways in which Coughly has survived. So I have not really had a problem with the charge. You can know the charge is very high because of the five-year average and the rate reductions that the board has made in the past. So the charge is, I think, reasonable, given medical inflation over time. There's plain catch-up. I worry a little bit about the top line being aspirational. But I am willing to approve this budget with that very big caveat that I would like them to be looking at their service lines. Very, very carefully looking at that, what their community needs, what they can offer cost effectively at a high quality, and how they're going to sustain their hospital in the future. Obviously, high rate increases are not going to be an amendment to do that in the future. So that would be my comments on this particular hospital. And just to add to that, just maybe we can put some type of time parameter and requirement that they actually come out and present to the board, whether that's six months, nine months from now. I'm not saying that they're going to be able to do that quickly. But at least to see where they are with that plan might be something we should be considering. Yeah. And I think we have to work a little bit with our hospital legit team to figure out what is the framework that we're expecting from these sustainability plans. And I recognize fully that there need to be some parameters, some guardrails, some expectations that what questions we're hoping that these hospitals answer that it's going to take some time and it's going to involve boards. So recognizing full well, but I think these are conversations that need to happen. Hospitals need to figure out what they can truly cost effectively deliver in their communities, given their volumes, given the patient needs in their communities. So I think it's a conversation we need to start. If I could just jump in. I think the Coffley board actually is one of the boards given with their leadership change that they have started to think about sustainability in a different way. I think they obviously are probably of more work to do as well because they just started it. But I do think that they have been starting to talk about making sure their community has enough primary care and focusing on other more diversified avenues. But I agree that they are definitely a hospital that I'm concerned about. And I agree with what both of you have said so far. I also am a little concerned that there is no way they're going to get to 3.5% NPR given that they're 6.3% under, whatever they're under. 6.6% under, sorry. That's 6.3% over projection. Right, I agree. Yes, thank you. Just to reinforce what I think has been already said. I mean, the South Spuddle has a good track record over the last five years in terms of its NPR growth that has been a growth rate of 2.6%. And their expense trend over the last three years, since 2017, has been 2.8%. So they seem to be able to manage at a scale that's below the 3.5% target. I don't really have a problem with their rate increase, because if you go back over the last five years, their five-year trend on rate growth has been a negative 1.3%. I think maybe the only hospital that has a rate growth trend that's in the red. I fully agree with Maureen's concerns and about the top line and bottom line growth rates. They seem to be pretty balanced here, but pretty tenuous in some regards. And I agree with Jess in that this is a hospital that might want to diversify its portfolio in order to not just be soberland and orthopedics, because we've seen in the last year or two when a couple of doctors are ill or that it jeopardizes the entire underlying viability of the hospital. But in the interviews, and this is probably Maureen's question, but in the interviews, we questioned Ms. Dorian about their utilization projections. And I kind of like what she said. She said, I feel pretty good about the utilization assumptions. Some folks were saying that it could do more. And I said, let's wait and count our chickens when they hatch. I prefer taking more historical analytical approach. So if they're not, don't have aspirational chickens, but are waiting for them to hatch, I think that's a good approach. So I support this budget as presented. And I would just add, Tom, and Rob, to maybe alleviate some concerns. Their total increase over their 19 projection right now is $4.3 million. And not that we want them to get there this way, but $3.6 million of that is change in charge. So the rest would be their pay or mix or utilization and knowing they had some downward pressures in 19, some of which they're working through. It doesn't seem like a significant risk. I mean, I think there's always risk, but their increase, I guess, unfortunately, is rarely driven by their commercial charge. Those three concepts. Would someone wish to make a motion? I'll move that we approve Copley Hospital's budget as submitted with the conditions that they participate in the Sustainability Planning Initiative and that they have monthly check-ins for their fiscal year 20 operating performance. Is there a second? Second. Is there further discussion? Before I open it up to the public, I just want to say that I view this as a one-time correction and I don't want to send a message to people to come in next year, seeking a 9.8% rate increase because I don't think it's going to happen. On the same token, I agree with Robin that I think this is a board that's been working tirelessly to try to figure out what Copley is in the future. And so, I'm willing to recognize the past and try to make an adjustment that allows them to move forward. So that'll open it up to the public for any discussion. Hamilton. I just got a comment on all of it and that is that the pace and the acuity of the move that's obviously going on in the board to look at service lines, to look at sustainability, to look at whether these costs and the quality make any sense at all is way too slow and it might judgment. And it's far below the curve of what's actually happening to the hospitals. You're going to have more spring fields if you don't move faster. Other public comment? Seeing none. All those in favor of the motion signify by saying aye. Aye. North Wester. North Wester and Vermont Medical Center. Similar to Copley, this is another hospital that's been under several years of financial duress with bottom lines receding. Our major concern with this hospital is the fact that when we look back, we saw that their cash on hand days has evaporated by over 100 days and they are leading cash to make up for these negative operating margins. And even though it appears now that they are still well above the state average, that type of recession is not sustainable over the long term. They are in the last five years just above Copley with their five year approved change in charge of 0.8%. As many other factors are contributing to this recession in operating margins, they are also struggling with the implementation of their Meditech electronic health record. And they really need some focus on that as they move forward, as that impacts every corner of their institution. The 5.9% overall change in charge of the staff is appropriate for this hospital given their financial situation. And also as a caveat to that, would allow them to focus their energies on getting that Meditech electronic health record straightened out in the coming year. As you can see, we've recommended an exemption to the 5% cap in this hospital. We've already approved the two provider transfers, one transfer in, one transfer out. And this hospital certainly should require ongoing monthly check-ins or quarterly check-ins however the board sees fit due to the financial health concern that we have with this hospital. Questions from the board? Just my observations here are that this is a hospital that has recent trends where the top line is not keeping pace with bottom line expenses. Over the last three years, the NPR growth has been 3.5%. The expense growth has been 5.5%. In this budget proposal, we're looking to keep expenses at a 2%, I think it's a 2.2% growth rate which if they can do it will be a good thing. But they've got to do it and in order to kind of reverse this trend of operating margins that are in the red. So my observation is that there's some heavy lifting ahead for Northwestern and they've got to be committed to doing that heavy lifting or they will continue to be in the red and eating weight at the cash that they have. Yeah, I would just comment on their year over year change. I think 2019 is, their top line is being depressed obviously by this change over there having with their ambulatory system, medical system. And that gives me confidence at least that this is not as much as an aspirational budget as it is getting back what they lost to kind of some one time losses in 2019. They're bottom line performance though from a budget of mid $2 million to losing like $6 million. I mean that $10 million swing is a real concern and therefore, I think we're kind of out there giving them this change in charge and giving them the increased year over year but really monitoring their operating performance. I mean they're one that's having issues with the incumbents. I mean, this is not sustainable long-term obviously they've had cash they could rely on but this is one of the hospitals that's both concerned and will continue to be until we see that change. Jess? Yeah, I'll just add that again this is a hospital that I'd like to add to the condition that they submit a sustainability plan. Particularly I know they're actually undergoing a review of their service lines and trying to think carefully about what they can cost effectively delivering in the community so it would be helpful to see what that analysis is, what criteria they use to evaluate what they can deliver cost effectively. I know they're undergoing expense management discussions. We see some of those reports. So I'm optimistic that they're gonna get their expenses under control. I do agree with Maureen that I think their top line miss to some degree is affected by their EMR transfer and then they may catch up and be back where they were but again, sustainability for this hospital I think is gonna be passed from my vote has to be part of the budget. I would just try to think before somebody makes a motion that I agree with the monitoring but again I would argue just as I argued last week that I'm not necessarily short needs to be monthly and that every other month would probably be sufficient. Would somebody like to make a motion? If I can just add one more comment. The rate here, the rate increase does seem high at 5.9% but to give that some context over the last five years the overall rate growth for Northwestern has been 8.1% So obviously this rate increases not consistent with their past trend but they might be making up some lost ground here. It's also possible that it's been very aggressive with trying to find ways to reduce their expenses. I think they should be credited for that work. Any motions? I move that we approve Northwestern's budget with an effective or a rate of 3.5% due to the provider transfer approval and with 5.9% overall change in charge of the condition that they participate in sustainability planning and check in every other month for operating performance. Is there further discussion from the board before I open it up to the public? Seeing none, open it up to the public. Jill, did you have something you wanted to say? Thank you. No, thank you for considering this budget. We're very committed to the financial sustainability of our hospital and caring for our community. Our board took a first, well not a first step, a next step in strategic planning just last week and are really coming together with the medical providers because it's very important to get the medical staff engaged in this process going forward. So we're very committed to managing this budget going forward, thank you. Other members in the public? Jeff? Yeah, I just wanted to underline a point that I think we'll remember almost made about the sustainability plans which is that I hope there's some degree of specificity about what those are to look like so that you don't get five different kinds of things that don't answer your questions and that maybe put hospitals through hoops that they may not want to go through or be able to do. I think we were pretty clear last week, Jeff, that we were gonna invite people in from your organizations to help create that structure. Great, okay, thank you. Hamilton. Can I answer your last name, please? Jeff Thiemann, CIE MA for the Hospital Association. Hamilton. Mr. Chairman, I just wondered if you'd ask the hospital whether the Meditech electronic medical record system is compatible with, in order to facilitate vertical integration, whether that system, Meditech system is compatible with Epic, I think, which is true at both their referring hospitals, both UVM and average. Joe, would you like to address that question about compatibility? Yeah, the Meditech system, we find the smaller community hospitals going with the affordability of Meditech and integration across the system, and we're hoping over time that there will be linkage between Epic and Meditech, or there is some way that in the future, who knows, that maybe UVM Health Network can host the system at more affordable rates for community hospitals. So we're very motivated about that. We actually use Epic right now in our hospital because we have rotating physicians from UVM Medical Center, so we're able to access those documents to care for our patients. But we have a ways to go, but we're motivated to make those linkages over time. Okay, any other public comment or questions? Seeing none, all those in favor of the motion signify by saying aye. Aye. Any opposed? Okay, Northeastern. Thank you. So before we get into this, I just wanted to pause for a second and say the next three hospitals you're gonna see, Northeastern, Prattabar, and Grace Cottage, all submitted budgets with NPR that was quite elevated, citing mostly increases in utilization. So there's some consistency there with the next three hospitals. And when we were making our recommendation, we wanted to go back and look at some of these things and what's causing it. And upon further analysis, as it relates to Northeastern, they have seen an increase this year. They are a 3.6%, I believe, budget projection. So they are seeing, well, some of it, their claiming is coming from New Hampshire as we're still confident in the institution. The rest of it is coming from their local populations. But the spike really does occur in 19 only. And so we felt the staff, the 7.2% growth rate target on NPR was a bit high. We wanna give credit where credit is due that they are seeing these spikes, but we also wanna allow for a little bit more time as they finish out this year 19 and move into 20 to really support that from a growth perspective. So our recommendation is between 4.5% and 5%. That way they have room to grow in the coming years should that continue and materialize, but also come back into an enforcement time if there's room to increase that ceiling based on the further growth that they're showing here. Overall, we would approve their change in charge of 3.5 or reduce to reflect the offsetting increases in utilization where volume or makeup for that reduced change in charge. We do wanna see a little bit more from them from the perspective of cost savings initiatives. This is a hospital whose NPR has grown over the years, but the bottom line remains solid, but relatively flat. And to one of the board members points out during one of the budget hearings that they're seeing hospitals under financial duress who are seeing their bottom lines improve due to some of these cost savings measures that they're taking on. So they're finding a way to do it. How can we get Northeastern on board at the same time? But overall, the hospital performs very, very well and we would approve at the 3.5 or we leave the door open for a reduced change in charge. But we do wanna see the NPR come down from what they're rejecting. Questions from the board? Mori? Yeah. I think on this hospital, I don't necessarily agree that they will only come in at four and a half to 5%. I think a large part of their change is in 19. So they're exceeding their 19 budget by about 3.6%. So, and I think that needs to be addressed and we need to talk about that. But bringing them to either a 4.5 or a 5%, I don't think it is realistic to where they're really gonna come out because this is where we get a little bit caught with budget to budget. So on a budget to budget, going up 7.2% is significant. When you go to their actuals, if we were to reduce them to 4.5%, it would only be a 1% increase over where they're coming out in 2019. I still don't think that's addressing some of the situations. I don't think they were able to adequately support why things are coming in so high this year. I mean, it just, it was like it's just happening. It's, we're getting this utilization. But my concern is that for 20, if that's to continue, we could actually see much higher than even what they're requesting. So I think this hospital is gonna have to be monitored on a different set, you know, a different way. So what I mean there is, you know, they're coming in 19 to the budget, they're up 3.6. So they're really up 7% against where they're coming in for 19. And now what they're asking for for 20 is not such a significant increase on where they're trending. So I would just be concerned that, you know, putting out a 4.5 to 5% is probably, you know, they're gonna come in where they're coming in. And I don't think that's gonna happen. This is a hospital where last year we did reduce their change in charge by 1%. They're still coming in on their profitability that we requested or that they requested. You know, I don't know what the right answer is. I don't know if we look at change in charge, you know, but I would just propose that, you know, to the board as far as an option on this one, because partially because they're beating their 19 by so much. And that would be something we can address when their actuals fully come in. And whether we take any course of action there or we could start to look at it now. But just wanna throw that out for discussion. Other comments from the board? Yeah, I agree with Maureen. If you look at, you know, their longer term trends, their bottom line has been growing at a rate faster than their top line, 4.9% for NPR and 6.2% for expenses. But, you know, their request for 2020 is a three, just a three and a half percent over their 2019 projection. So they've already made up a lot of that ground. And one thing about this hospital is that they have the most aggressive, both trends say over from 2014 to 2019 projected at 6.4% or to their proposed budget at 5.9%. There's no other hospital that profiles that aggressively. So whether it's a, probably I think Maureen is right that if we do address this it should be on the charge side because they're coming in so strong in 2019. What that is, I don't know, but I don't think it's necessary here to go with their request. Can I just pop in here? So two things, in the follow up information that they said to us, I found a couple of pieces of their evidence telling one was the growth rate in their median age relative to the rest of the state. It does seem to be growing a little bit faster, which may explain some of their increased volume. Simply because they have an aging population that seems to be aging faster than the rest of the state. But more compelling to me was the inpatient NPR community, New Hampshire residents. So in fiscal year 2018, they have about 464,000 New Hampshire resident visits. And in 2019, it went up to 753,000. The growth for outpatient NPR community New Hampshire residents went from 1 million, roughly 1 million, 1.1 million to 1.3 million. So just looking at that, you can see that they are basically getting some growth from New Hampshire. Again, I remind folks that that's economic development to the extent that that's being paid for by commercial payers in New Hampshire and the Medicaid and Medicare from New Hampshire. So I worry less about that being the source of the growth. I also wanna say, and I wanna thank them because in their supplementary materials answer to our questions, they estimated what they could be doing to reduce preventable ED visits and in fact said that they could initiate some changes in access to Saturday clinic hours, expanded office hours, et cetera, et cetera, that the NPR impact would be about a $310,000 NPR reduction. So I think for, that's not quite, but maybe it's about 1%. So at the very least I wanna thank them for coming in and saying I think that they could reduce NPR by doing some initiatives to reduce preventable ED utilization. So I think that's the key, that they have to be introspective and try to figure out what is continuing to be, at least this is my third year going through budgets and each year they had a message that we're seeing older, sicker people and I guess I'd like to reframe that into what can we do to keep our people healthier and out of our hospital. I think that a reduction is appropriate, not sure what the correct reduction in NPR is, but I think it's appropriate to try to push them to continue to find more efficiencies and more ways to keep people out of the hospital. So would anybody like to make a motion? I am not gonna make the motion on this one. I don't feel like I have a good enough sense of where we are. I would say personally, I guess what I would need to understand is for the NPR from how much of the NPR, how much of the 7.2% accounts for the New Hampshire residents because what I would lean toward doing is having a better, like an actual calculation of that so that we understood that impact in relationship to what we're approving. And probably some of you math people could quickly do that, but I'm not gonna attempt that myself in a public meeting. And then I would maybe be inclined to reduce the charge to account for any, assuming that there's some of the growth that's not accounted for by out of state because I agree with you, Jess. I think we've in the past consistently held people harmless if you will for out of state growth. But what concerns me about this without really understanding how much of that 7.2% is out of state is that NVRH has for a long time been working on a unique model that's really supposed to be focusing on population health and community engagement. And I just, I don't really see the impacts here. And so that concerns me. So I would just like to have a better understanding of the New Hampshire piece in relationship to the 7.2%. So I wonder if we don't need a little more homework on this one. So I think we probably should hit the pause button on this one and come back to this on Wednesday. Anything that staff would like to add? No. Anything from the public, Hamilton? I'm just curious whether one would be a better way to come at it by looking at not at the New Hampshire traffic, but to use the Diva figures on what the volume of performance is for Vermont residents, which Diva actually has. A Vermont patient has to go across the New Hampshire any time they want. Same way that New Hampshire can come over here. But if you looked at what was happening per capita to the Diva patients, the Vermont Diva patients, then you would be able to tell whether what you were looking at is increasing in utilization, in actual medical utilization patterns, rather than traffic across the world. So Patrick, if staff could reach out to Diva and get that information for us for Wednesday as well. I'll just say, I think it's unrealistic. We would even get that information this week, but I think we should reach out for it. I just want to, I think it's a great suggestion. I just don't see it necessarily being feasible even by Friday, but please do reach out, I think. One of the thoughts that I'll just throw out there to the board to consider is we can agree or disagree about the volume estimates, maybe that they're aspirational too high or maybe that there's unwarranted utilization that we want them to reduce. I would be concerned about reducing the charge to the extent that medical inflation is real. We know what it is. We know it's about 4%. So the ask of the 3.5% overall change in charge is probably reasonable. And we want to make sure that they can make a margin on the care that they are delivering. What we want to also ensure is that they're not delivering care that they shouldn't be delivering. So how do we identify volume that doesn't need to be there and to the extent that they are coming in and saying we can reduce some of our preventive utilization, that's a start, perhaps there's more. But I think this issue here is more volume than charge. I would just add one thing to that though. I don't think that they're requested as aspirational because I think, again, when you base it on where they're actually trending. But what we hear so much from hospitals is the fixed cost issue. And when things go down, you don't leverage from the fixed cost. But when things are going up at a 7% clip, there should be some efficiencies that they can gain that helped offset some of the medical inflation. That said, their charge increase at the 3.5% equals $1.3 million. So it's also not a significant number. So adjusting a percent or something, even if we did that, I'm saying this could work both sides. It's only $400,000. So it's not that, hey, it's going to significantly reduce the overall ask, but I just want to put those things out in perspective. So even if we were to say change in charge, I'm not saying that wouldn't be significant. I'm saying it both sides, right? Reducing by a percent is $400,000. Is it worth going through that? But the point of really understanding more, are they getting efficiencies? Is their 2020 estimate actually reflecting some of the efficiencies they may get by changes in ED, et cetera? Or is it even going to come in higher? And we're going to, I would not be surprised on this hospital if we were here next year and against budget, they're up seven percent. Because again, that would only be a three and a half percent increase against the prior year. So it's not saying we rebased or anything, but I just think from the consideration, when we look at a lower number of four and a half or five, we really need to also translate that to, what is it over the current year and what's their trend then? And I think that would probably be an unfair burden to say to come down some of these numbers, which would be year over year increase of a small amount. So I think we'll debate more on Wednesday about it, but. Anyone else from the public? Not, we'll move on to Browderboro. Okay, Browderboro. So much like Northeastern, their budget was driven by utilization increases that they're forecasting, theirs would be primarily coming from the Springfield area. Currently they're operating 7.10% under budget for 2019 and their request is 7.2%, which of course exceeds our lever there. They are telling us that they anticipate utilization coming down from Springfield and when the Springfield incident occurred, there really wasn't enough time between that and their budget prep to appropriately account for that. So with our recommendation here to reduce to 4.5 to five, we wanna be realistic that they're not meeting their budget this year, but they have the potential to grow there from Springfield. But as we know, primarily what they're accounting for here with this growth is from the Birthing Center and with Springfield's numbers at the Birthing Center, we just weren't sold on 7.2% growth to NPR based on the trickling down of those services from Springfield. That said, we wanna give credit where credit could be due in the coming year when it regards picking up those additional services and Brattleboro has said they're staffing towards that potential need. So you could say that when they see lightning, they're ready for thunder, so to speak. They're change in charge of 3.4%, we felt was appropriate. They are third from the bottom in their five year history when it comes to improved change in charge. They are one of those hospitals that in the last couple of years has seen some financial stress and this year is a rebound year for them and we feel that maintaining that 3.4% change in charge will assist in that recovery moving forward. But also bringing that NPR down just a little bit to absorb some of that business coming over from Springfield and those patients, but not quite taking that budget above and beyond what we consider to be reasonable. Okay, question to the board. On this one I would just say, I don't think they've adequately supported where their 7.2% request is coming from and I've asked a few times about the percentage, their gross to net percentage is really changing and that's what's creating, they're actually saying they're gonna get more dollars from the gross income that they're receiving and that's what's generating some of this increase and my concern about this is I think it's an aspirational budget on the top line. I don't think the top line is going to come in where they're saying that the 7.2% their expenses have now been loaded in to increase to get some of this. They lost money in 17 and 18 and they're finally making some money this year about 900,000. They're projecting to make a million dollars next year but that won't happen if they don't get the top line. So the reducing of four to five, I don't have a problem with it, they may even only get like they're 3%, they're missing their budget this year and they turn around and say they're gonna get this significant increase. I don't think it's gonna happen. Not so worried about taking it out of change and charge because I think they're gonna need that. So it's a tough one, I think it's just, I don't think they're gonna hit the number. I don't think they've shown us how they're gonna get to the top line number that they're asking for. And so if we were to reduce the top line, it's not saying go back and cut your services or changes. It's kind of saying it doesn't seem like you're gonna get there. Maybe one of the ways we help to accommodate that is when we look at this as far as one of the conditions is that they're coming back in showing us where more quickly, where did they end up for 2019? Where did they end up in the first quarter for 2020? To see if they really are trending to this higher number. Because even with the changes in Springfield, it doesn't seem like it's enough to make this number up. So it's just a tough one because I just think their forecast may be aspirational again on the top, like hot on the top one. So I agree with Maureen and also I just wanna say that this board has repeatedly tried to send the message out to hospitals that don't be afraid to come in for a midterm adjustment. And if God forbid Springfield were forced to close under bankruptcy and all of a sudden hospitals were seeing increase in numbers, we would welcome them to come in and make that presentation to us. So at least in my opinion, I think that the NPR should be reduced. I don't have a problem with the change in charge. They've been historically one of the lower increases of 3.4%, I think is an appropriate number. I think I'm gonna, I agree with both Kevin and Maureen on this one. Again, I'm okay with the change in charge. I'm concerned about the volume. And I would say that some of the supporting materials that Ralph Rowe gave us about where the volume is coming from, I'll just give you some of the numbers here. This is what I'm concerned about. So for example, rehab visits, their fiscal year 19 budget was at 40,000. They're projected this year to commit at 38,000, 39,000. And they're jumping up next year in the budget to 45,000. So they're not making this year's projection on rehab visits and they have a huge jump next year. And the same sort of analysis comes through when you look at MRI scans, radiology and CT scans, total discharges where they're coming in under budget this year for those particular services. And yet there's a big leap in budget for next year. So I'm concerned about the aspirational nature, I think. Lisa, I didn't see enough supporting evidence in here to understand, really understand why their projectings such a large increase in some of these areas. So again, I don't know what the right number should be, but I think a download adjustment on the NPR really driven by volume not charged is probably warranted. I think we're all on pretty much court here. I'm looking at a kind of traditional three year trend where they've had 5.4% growth in NPR and 3% growth in expenses since 2017. And they have just finally, since 2017, they've just finally kind of got themselves on a projected basis for 2019 projected into the black in terms of an operating margin. And I just think this is one of those things where we need to count the chickens after they hatched as well rather than before they hatched. And on the expense side, they're looking at a 7.2% increase against a recent trend of 3%, which is quite aggressive. So I think 2020 should be a year of caution. Let's just see if these, the revenue comes in. I don't have a problem with their rate increase because their multi-year trend has been 2.9%. And but I'm on an expense side that they could be swinging themselves right back into the negative operating margins if they aren't cautious on the bottom line. Anyone like to make a motion? Can we talk a little bit about what, where people are with the NPR and that I'd be happy to make a motion? I would just be picking a number without really having a sense of the group, I would say at this point, if I were to make a motion. Well, I'm kind of at 5, if that helps you. Yeah, their gross charges that they're requesting are up by 5, they're up by 5.3 from their 19 projection from where they're trending right now. Just to put perspective on where I had a concern is because their revenues from deductions were at 56.4% in 2019 and they're improving at 54.5% in 2020. And typically when you have a rate charge increase your deductions actually go up as a higher percentage because you're not getting the reimbursement from, you're getting it on commercial but you have a higher deduction on Medicaid and Medicare. And that's where I've asked them to go back and try to give us some more answers on that because they're actually showing bad debt and free care going up quite a bit. So that's offsetting some of the change. I would be okay with the 5% but I still think there's some, there may be some risks that that's still too high. If no one wishes to make a motion, we could put this one off to a Wednesday. I can make a motion. I was just waiting to see if anybody else said anything else to say. I move that we approve Brattleboro's hospital with a 5% NPR increase and a 3.4% change in charge increase. Can I make a friendly amendment please? Which would be that again I think this is a hospital that we should have a sustainability plan for. So I will add that but the other piece would be that there should be a corresponding reduction in operating expenses that goes with that NPR reduction. And I also would add that this is one we should have them come back in whether it's via phone or whatever, just really talking about how are they trending on their NPR year over year change so that if they are missing that number that we'll be able to react more quickly to try to adjust the expenses. So rather than let's make it more formal, where are you two months in? Are you up 5% or are you up 3% and what adjustments are you doing? So I can withdraw and try again. But Maureen, can I just clarify? Were you thinking so the staff had said have them come in at enforcement I see as an option but it sounds like you think they should come in sooner than that? Yes, yeah, okay, yes. So are you thinking like quarterly or just checking in a couple months to start and then we can. Yeah, because enforcement typically we don't do until February, March and that's for their year end in September. So I think we wanna see where did they end up in the year end. I think every two months, so six times a year to just be checking in on where are you trending against because even when we have their actuals for 2019, that takes a lot longer because of the full P&L piece. They should be able to get where are they trending on certainly grossed and if not at NPR much sooner than that. Okay. All right, so I'll try again. I move that we approve Brattleboro's budget with an NPR of 5% and a change in charge of 3.4% with the corresponding reduction in operating expenses that's to the NPR and with conditions that they participate in the sustainability planning and come back in every two months with an update on their budget. Is there a second? Second. It's been moved and seconded as a further discussion. If not, I'll open it up to the public for any discussion on Brattleboro Memorial's budget. Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Grace Cottage. Thank you. This is our last hospital of the day. This is Grace Cottage. They are another hospital whose NPR course is being driven by, or cited as being driven by utilization increases or anticipating utilization increases. As you can see, they're currently falling short of their budget to projection by 3.2%. And they're requesting 8.7% of the budget for a 12.8 or 12.3% increase over their 2019 projection. We do not see this as realistic moving forward for Grace Cottage. They have noted that their primary practices are very well staffed now, so they could fill the utilization need, but we did not feel that it's on this reflective control grid budget and it would reduce their NPR 3.5 down to 3.5 to 5% in that range somewhere. Again, as has been our theme throughout today, leave the change in charge untouched over those inflationary costs. So we have approved that as submitted. This hospital is one of particular interests. They never perform well on an operating margin and it comes in negative on a regular basis. They do have a lot of donor support in their community. However, with talks of a pandemic recession ahead of us, we would be concerned that if some of those donations were to receive, where would that leave Grace Cottage from a financial solvency standpoint? So we do have the additional recommendation here to check in that would probably be amended to quarterly, just to make sure that as the market fair out in the coming year that their donors don't tighten their belts a little bit and cause more financial strain on this hospital with that non-operating revenue. But other than that, we would reduce their ask again to recap between 3.5 and 5% to give you a range of course volume reduction and operating charges. Review their MPR again around the enforcement time or as we've just heard, perhaps something along the lines that same as Brad and Merle every couple of months and then approve their change in charge as submitted. Any questions for Sal? I just have a clarification. So I think we should pick one period of time that they would be checking in on operating performance and how they're doing versus MPR, right? So we can discuss what we think, whether that should be every couple of months or quarterly. I have a minor that would help you, Maureen. Yeah, I'm just looking at one of the... This is, as you pointed out, I mean a hospital that continues to lose money on a straight operating margin without the help from the community. So they lost a million three and 17, lost 600,000 and 18 came to us with a budget of a positive margin of 151,019 or losing 1.3 million. This is coming in at a loss of 264 for 20 with a very optimistic top line. And even if we reduce to the lower end of your suggestion here, which is three and a half percent, they're running behind budget by 3.3%. So that would still be about a almost 7% increase year over year where part of the reason that we put in this 5% number on top of where a hospital's coming in is to prevent this. And this is one of the hospitals, if not for their community really coming in and standing behind them and giving them money, they're continuing misses on their top line and bottom line is a trend. This is a Springfield except they have the backing of a community behind them because they keep missing every year. So to think that they're gonna come in and get this growth rate, which is not eight points, it's 8.7 plus 3.3. They're asking for a 12% growth rate year over year. And they miss every year. We've gone through this each year. There's a reason why they're gonna get it and it doesn't happen. So I don't object to the change in charge. I just object to the fact that it seems really that they're reaching to get there. They did put in some primary care. They have some reasons why, but I do think this one definitely needs to have a monthly check behind it as you put in here. And just an understanding, I think it's just it's been put into state, where do they, this is less of sustainability because they don't offer as many services, but what are they gonna do if they don't get there? Because they have staffed up and they have the expenses. So this is a hospital that rather than trending to the million loss they've had for the past several years could quickly turn to like a losing $3 million if they don't get the top line and they already have the expenses in. So it's a challenge of saying, want them to be successful, want them to get the primary care. But historically, it's only once, only twice. They've come in each year asking for a higher number and they miss it. And then to come in with a 12% increase and partially justify it on it, we're small, it's total dollars, it's not a big deal. That's true. But it is when you miss that top line total dollars by a small amount and then you miss your bottom line by three or four hundred dollars. So I think it's just gonna have to be a watch and see it. We can put in a lower number as we expect it is gonna come in lower, but they'd need to make some changes on their expenses in order to get there or really support month by month, week by week, how they're gonna get there. Okay. Other questions or comments from the board? I'm in full agreement with what Maureen just profiled. The only point I would make here is that their payer mix is only, I think, 28 or 29% commercial. Let me just make sure it's very small. It's very small, it's 28%. If you look at the increase that they're asking in terms of the burden on commercial at one point, it might gain then 36,000 dollars. The other 3.2% change in charges is valued at 116,000. I certainly agree that we need to put pressure on their maybe aspirational and PR growth, but for this small town in Vermont community hospital, I wouldn't mind an increase in their charge beyond the request of 3.2%. It doesn't cost the system, it costs the system peanuts at 36,000 dollars a point, but it might say to that community that does spend, you know, it's very active in supporting the hospital. And basically looks at it as it's the cost shift. They're out there raising the one or two million dollars that they raise. It just to cover the Medicaid cost shift, it does say to them that we appreciate their smallness and that we appreciate their effort to support the community. And, you know, if we give them a 5% increase change in charge, it is insignificant on the macro scale, but on the micro scale, I think it's important message. Other comments or questions from the board? I would just say that I'm very reluctant to give someone more than what they requested. So I don't think I would vote for that as much as I appreciate everything that Tom said as far as really the smallest beautiful mentality about what happens at that facility. And they're not trying to be more than what they should be. Their focus is on primary care, which is the right thing. And so I really think that the change in charge should be granted as requested, but a significant reduction in the NPR. Whether that's three and a half percent, I don't know, I would leave it up to others to try to figure out. Again, I think it's a stretch even to get there. So, other comments from board members? Yeah, I mean, I could support going into three and a half, which would be a 6.8% change year over year. Understand what you're saying, Tom, about the commercial, but it's so small, even to go up a small percentage, is only $30,000 for 1%. And I think they're also trying to balance in their community, not increasing their commercial to those people that are paying the commercial rate. So I don't think it's, I think it would be not misleading, but that's not gonna help them make their bottom line number or top line number any better. I mean, of their increase, it's $100,000 of their total increase year over year. So. I mean, I agree if this were a bigger hospital, I wouldn't think that offer, but I think it's a small gesture system-wide on the commercial base, and but towns and being a very, very small town, it would be appreciated, I think, in terms of their effort, efforts in the community to keep the community generous in their contributions, but I understand the conflict in that suggestion. Is anyone there to make a motion? I'm happy to, but I just, did you, what are you thinking about in terms of sustainability with this hospital, given that they are pretty different from the others? Yeah, they are different from the others in the sense that they don't really offer surgeries and procedures the way the other hospitals do. Their service line is really limited, largely to primary care, but I do think that given potential economic downturns, I think they do need to come up with a better way of ensuring their sustainability other than relying on donations from their community. So, I think there could be some line in the budget order that suggests they need to start to think about other ways to meet their bottom line without relying on charitable donations. But not necessarily include them in the group? I think, yeah, I mean, I'm okay with that. Not including them in the group. Yeah. A different request of them. Okay. I mean, that makes sense to me, just given that they are already so different. I agree that they do, to what both you and Maureen, your points earlier about. They should be thinking about relying on other sources, but given it's such a different place than the other hospitals, I wasn't thinking that makes sense to include them in the group. So, I can make a motion. I move that we approve Grace Cottage's budget with a 3.5% NPR growth with a corresponding reduction in operating expenses and a 3.2% overall change in charge with the conditions that they do monthly check-ins on their fiscal year joint operating performance and that we note concern in their budget order about sustainability, relying on donations and recommended that they pursue some planning around that issue. So, I would just ask to, for you to consider it from the amendment that, I think that we're already getting information on a monthly basis as they transmit their financial. Financial performance to us. And I think that a monthly check-in is probably overkill. Well, the reason I say that is because, what they were asking for is a 12% increase year over year. And if we check month one, and they're up 12, and I believe they had also talked about the fact that they were more fully staffed by now, it's just taking time to build up those practices. So, we should be able to see, are you coming in at 12% over last year for up until the end of the 19 and the beginning of 20. So, I'm just not sure how large it has to be, but this was to help them potentially if they really are trending higher to be able to come in faster to ask for some type of adjustment and to give us confidence that they're gonna either hit that number. So, I think it's more important earlier in the year than later in the year and that we could back down to going to a, whether it's every two months or quarterly, but that was really my point on why, because the information gets so lagged, but by the time we get it, there's not a lot of reaction time. But my counter to that would be that, would we accept one month as being a trend? And I don't think it two months before we start to try to determine if a change would have to be made is inappropriate. I just hate to put a more regulatory burden on these entities than is necessary. So, that's all, it doesn't, one way or the other doesn't matter. And I don't know how does everyone else feel? I mean, I could go with every two months. It's just, it's trying to help them be able to come in and react faster. I think where I'm at is, I would go with every other month, understanding that they can, any hospital can come in really at any time. So, I hear you, but I think I'd go with every other month given that they will already be, I mean, because the reality is, if we see their financials in month one and have concerns, we can call them and ask them to come in early too. Okay, that's fine. I'd like to offer a friendly amendment here, just to follow through. So, I'm looking at their 2020 budget over their 2019 projected, and one of the expense increases that they have is $47,000 in hospital provider tax. That's something that is out of their control. They explicitly mentioned in their testimony the burdens of the provider tax, and the fact of the cost shift of Medicaid. And so, I would like to propose that we increase the charge, change in charge from 3.2% to 4.2% to cover the significant portion of that increase in the hospital provider tax. I just wanna say, I wouldn't suggest we change any charge to any hospital without talking to them about that. You may think that's a good thing, but they may not look at that as being a positive thing. If they wanted to ask for more, they could have asked for more. So, I don't agree in pushing back and asking for a change in charge, and assuming that they would even want that. But that's, like, what do you think about that? I'm not gonna, the innovation is just my proposal. And I would have felt bad leaving here if I didn't make it. First of all, we have to know whether or not the maker would even consider it to be friendly. So, sorry, Tom, but I'm not gonna go with it as a friendly amendment because, for the reasons that Maureen said, for, we don't know how their charges compare, for example, because the HSA is included with another hospital, we can't even really know how that hospital compares to Bravo, so we could be dramatically increasing somebody's, what somebody would pay in their deductible without really understanding that, which then could drive volume to Brattleboro because it's 20 minutes away. So, it's not like going to Brattleboro is particularly challenging. So, before we get lost in a procedural mess, is there a second to the underlying motion? Right, I was just gonna say this won't be the first time that there hasn't been a second to my motion. Well, no, I'm asking for a second to Robin's underlying motion first. Second. So, it has been seconded. I'm excited. So, now, Tom, you have the right to offer it as an amendment to the motion. You have that right, if you so desire. I will offer, as an amendment to the motion, the, you know, as we've been through the rate review process, we know that insurance rates are kind of broad-based. In nature, not specifically applied to, you know, at the town level. I always have great respect for what Robin says. So, and I know which way this vote's gonna go, so I just don't waste your time anymore. Thank you. Is there a second to the amended? Seeing none, we'll consider it as a failed amended motion. Is there further discussion on the underlying motion? If not, I'll open it up to the public for discussion on Grace Cottage. Hamilton. I have a question in that comment. Does this budget include a budget to run an emergency run? Yes. My comment then is, that's ridiculous. They have 20 minutes from Brattlebrow. They've talked for years about whether you need it. We still have it. We're still running an emergency run in Springfield. And it's a hospital of this size, running an emergency run makes no sense at all, given how close it is to these other things. Operationally, that's operationally, that's just a waste of money. And if you, and the overall question in this hospital, why it's a hospital in the first place, it ought to be an FQAC. Okay. Is there other comment from the public? Yes. Okay, for us, the health care advocate, I just wanted to say that I appreciate the board giving so much careful thought to not increasing a charge, especially considering how many comments we see about the public's trying to deal with high deductible health plans. And anytime you increase the commercial charges, it makes it harder for people who have not yet met their deductible, even if it doesn't have a huge impact on the overall rates. So I just wanted to say I appreciate that. Thank you. Okay. Other public comments? Seeing none. All those in favor of the motion, signify by saying aye. Aye. Any opposed? So Patrick, I think I heard you say that that is the extent of the recommendations that you have for today. Correct. That would work. Well, it doesn't conclude our work, but for today it looks like my math is correct. We have five hospitals left to go. Yes. All three of you can help network on Scotney and the formerly paused north and south. We'll be up for one second. Okay. With that, is there a motion to adjourn for today? Second. Is there any old business coming before the board? Seeing none, is there any new business coming before the board? Seeing none, I heard Robin make a motion to adjourn. Is there a second? Second. All those in favor, signify by saying aye. Aye. Any opposed? We'll see everyone Wednesday at nine.