 Good afternoon and welcome to the Green Mountain care board meeting. My name is Kevin Mullen, chair of the board, and we're about to get started. The first item on the agenda is the executive director's report, Susan Barrett. Great. Thank you very much. I have a couple of announcements regarding public comment. So first, after and starting today, per today's discussion on the FY22 hospital budget guidance, we will be opening a public comment period to comment on that guidance. We're encouraging folks to comment as soon as possible. There could be votes on parts of the guidance as early as next week, but we know we need to have the guidance out to the hospitals by the end of this month. And when we have a date certain, if we have a date certain, we will update the guidance. Chair Mullen or Patrick, do you have anything to add on that? I would just say that if we don't conclude the guidance at next week's meeting that the public comment period will be extended. So until the guidance has been finalized, the public comment period will be open, but we will start to take votes next week, hopefully. Great. And I know Patrick will probably talk more about that during his presentation. And then a second ongoing public comment period that we have asked our advisory, the Green Mountain Care Board advisory group, as well as the primary care advisory group, to provide written comments on a potential subsequent all peer model agreement with the federal government. And that information is located on our public comment section. We also encourage members of the public to share your comments so that we can share that information with the signatures on the model, that being agency of humans services, as well as the governor's office. So that is all I have to report out. I can turn it back to you, Mr. Chair. Susan, were you going to make the announcement about the rate approval or is Mike? I believe Mike will do that. I didn't have that information, but I think he could do that as well. Mike Barber? Yeah, thank you. So the announcement is that on Monday, March 8, 2021, the board approved SIGNA Health and Life Insurance Company's 2020 large group premium credit rate filing. The docket number is GMCB00920RR. And the board's decision allows SIGNA to provide a premium credit to its guaranteed cost large group policyholders with effective dates from May 2019 to April 2020. The credit will be equal to 10% of each eligible policyholders average 2020 risk adjusted monthly premium and will be applied to the April 2020 build premium. And that is the announcement. Thank you. So just nobody gets too overexcited and expecting a significant credit. The outshoot of that is it's really only one month's 10% credit. So it's really about 0.0883. So just don't want people to have expectations that they're going to have a huge credit that doesn't come to bear. So with that, the next item on the agenda are the minutes of Wednesday, March 3rd. Is there a motion? Second? It's been moved and seconded to approve the minutes of Wednesday, March 3rd without any additions, deletions, or corrections. Is there any further discussion? Hearing none, all those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show the minutes were approved unanimously. So as we discussed at last week's meeting, this this meeting next next week's meeting and possibly the the week after that's meeting is dedicated solely to a discussion of the 2022 hospital budget guidance. And as we all know, we are in very uncertain times. Hopefully we're coming to an end of those uncertain times. But even that is not certain. And what we do in the budget guidance may be the right decision whenever we have that vote sometime in March. But it may still have to be taken a look at again as we move forward and get closer to budget hearings if circumstances completely change. But we will proceed with making the best decisions possible in an uncertain world. We want all our hospitals to be sustainable moving forward. But we have the obligation under statute to Vermoners to do the due diligence, do the crunching and move forward. So with that, I'm going to turn it over to Patrick. Thank you, Mr. Chair. Good afternoon. Good afternoon, board members and members of the public. We are here today as the chair just discussed to kick off the fiscal year 2022 hospital budget guidance. So with that, will you please let me know when you can see my screen? We can see it. Super. All right, let's go. So this is the roadmap for the next few weeks potentially. Just a brief outline of the potential meetings and content moving forward. And today, beginning on March 10th, we'll provide an overview here in the slide deck about some of the items in the guidance. Most importantly, items that have been altered from last year. And in that, we'll review the appendices and the draft budget guidance with those alterations. And with feedback from this week, we will make any appropriate changes that are to be considered by the board and move forward into next week's meeting on the 17th. And as the chair and executive director Barrett discussed for a potential vote. And if we still have some refinement to do, then we'll find ourselves meeting again on the 24th. As of right now, these are the three placeholders for meetings on the FY22 hospital budget guidance. So to provide a brief overview, some of the priorities this year coming out of the impact of COVID, lessons learned from last year, the hospital budget debrief that we had in late November and early December were the priorities were hospital financial health, continued work to align some of our regulatory processes where possible, really fortify some of those points in last year's process that may have been a little weak on the details because we really were thinking on our toes. If you go back to March of last year, we ended up having to suspend our process with the onset of COVID and we didn't get back to approving a budget guidance until late May or early June. So we really had to assess the situation that the hospitals were under and what was possible at that time. And once we got to the budget process, opportunities arose throughout that that we felt that we could build into this process without creating too much undue burden on hospitals themselves. And finally, creating reasonable schedules and turn around times. There were some changes last year to the timing based on the suspension of the guidance process and whatnot. So turning those back around to more historical time frames and expectations has been a priority throughout this process. As part of the process, we had limited involvement with hospital CFOs, VOS and the healthcare advocate. Primarily because we were responding to communication from VOS back in, I believe it was December to really give the hospitals a bit of arms length so that they could do what they had to do to care for the people of Vermont as COVID underwent a resurgence. So we really capitalized on that opportunity to work with Mike Del Treco and VOS and refining some of the items we're going to talk about today. And given any feedback in the inter-meeting period, we hope that communication and work with VOS can continue if there's areas for refinement even after today's discussion. We don't think that should stop because we're at this point in time. So if there's something there that we can continue to work on or clarify, then we're happy to do so. We also internally collaborated with our legal team to outline this guidance and sought ACO team feedback to continue to regulatorally align with some of the ACO information that we need to tie those two processes together. And finally, we find ourselves here, the public process where we engage in a lively discussion across the various board members and based on what the staff is providing and so that offers the public opportunity to comment as we discussed earlier, either in these meetings or in written form to our webpage. So moving forward from process, the outcome is to get a final budget guidance continuing to align the hospital narratives for the presentation for ease of navigation and also updating some of these appendices to support that narrative presentation. And you'll see throughout that we really take a financial centric focus this year because that is what that is what's important as the landscape continues to shift on us with respect to COVID. So we really want to make sure that we're getting ahead with some of those potential details so that there's less questions at budget time. That's kind of been the hope for this process is that we get the board members what they need in advance. We have lessons learned from last year in that process that we've built upon for this FY20 process. Next up on slide four, some of our staff recommendations. We start off with the obvious caveat that the board understands the challenges created by COVID-19 and how that can impact budgeting. And they've asked us to develop a thoughtful some thoughtful and collaborative recommendation. So one of those would be continued streamlined hospital budget submissions. We'll talk a little bit more in detail about what that looks like. It is slightly different from last year returning the submission date to July 1st as long as we deliver guidance by the statutory date of March 31st. And part of the abbreviated streamlined process was last year having to think on our toes. We created an alternative Excel spreadsheet for hospitals to populate. Ultimately they ended up having to go into adaptive anyway to submit their submitted budgets in November and then their approved budget. So we actually unintentionally created another step. And as part of correcting that this year, we are asking that they fill out these worksheets in adaptive and we'll talk more about that but that would be the income statement, balance sheet, payer revenue or payer mix utilization, staff and capital expenditures. We're not asking them to go into service areas of departments to enter this information. That would be far in excess of detail that is going to actually be helpful given the situation that continues to evolve as it relates to COVID and their finances. So it would be those documents at the level that they're at and that's it. That's one of our recommendations. And to help refine that data that's going into adaptive and help tell their story, we've also built in a variance analysis financial workbook to support those narratives and presentations. So we're returning the bridges table or reconciliation tables, budget to budget and projection to budget. We noticed a few hospitals used this format or their own version of it last year in their presentation. So it seemed like it was something that the hospitals were comfortable with in telling their story. So we wanted to bring that back. The charge increase in MPR detail that we've worked on for several weeks with VOS to recalibrate that look. Utilization estimates from a dollar's perspective and how that's going to impact their budgets. Inflation components. This is something that continues to percolate year in and year out and understanding the influence of inflation on the operating expenses. And then there's some COVID related items that are of necessity if we're really going to tell the story of the hospitals. And one is carving out the revenues and expenses of vaccine clinics and the testing that they're doing and the inoculations that they're doing and understanding what that means from a revenues and expenses perspective. Furthermore, we have the value based participation. We've had some changes and fluctuations in value based care this year. We're looking to broaden that look and understand how the attributed lives may have changed. The Vermont State Employees Union is now signed on for the coming year. And also Rutland has joined the Medicare program. So we'd like to see how those attributed lives are contributing to the move to value based payment. And finally, COVID-19 funding. Last year, again, thinking on our toes, we passed the hospitals to fill out revenue replacement form that touched on the advances from government and commercial payers and also CARES Act and other relief funding. Well, we've refined that a little bit this year to understand what's been used and what's still sitting on the balance sheet so that we can get a better picture of what that relief funding has done for those hospitals. And finally, keeping with the financial picture this year is we're recommending to eliminate the non-financial reporting requirement. We took a look at that and got some feedback from folks in our organization. And we came across a few conclusions that some of the data doesn't shift enough year to year. So let's take a look at how often we collect that in the future. Some of the data is going to be very skewed by COVID's impact, and some of it will be actually late in arriving. So it makes that work product a little difficult to digest this time around. But just to reinforce that there are parts of this we are collecting, one of them is around wait times. And we'll talk about that and getting a little more detailed feedback on that instead of collecting simply a numbers table. Really, what we're getting at is how has COVID affected your wait times? How have you had to mitigate the impact of that? And what types of mitigations efforts have you undertaken as far as logistics or the rise of telehealth and telemedicine? But we're also asking for the Community Health Needs Assessment, which is traditionally collected in the non-financial reporting, but we'll be pairing that with the request for the 990 on September 30th. So that's a high level of our recommendations, and we'll do a little more deep dive into some of those items as we go through this presentation. And that leads us to our next slide where we will walk through the guidance and accompanying appendices. And then we'll touch on hospital budget guidance policies. The real one that we're going to touch on here will be legal has put together a standing enforcement policy, and we'll bring that up once we get through the guidance and appendices, and we'll have legal speak on that a little bit as to why they feel this is the next step in the enforcement policy. And then some points for discussion for your consideration that you're going to hear today is, once again, due date returning to life first. The Board needs to consider what the MPR-FPP gross ceiling will be. We'd like your feedback on the charge request table that we've recalibrated with assistance from laws, the inflation table that is making its way into this process, and then the COVID vaccine clinics and recalibrating the COVID advances, relief funds, and other grants table that we've put into the appendices. So with that said, I'm going to navigate over to the appendices and we'll begin to walk you through those items. Okay, let me know when you can see my screen. All right, very good. So this is just an outlay of what exists within this sheet here. Might be hard for people to read it, but that's better. So all right, great. So again, we're returning the Bridges tables back into the equation to show the reconciliation between their FY21 budget and their FY22 proposed budget and the same thing for revenues and expenses in both of those budget to budget looks, and then the same thing for projection to budget looks for revenues and expenses. We've added a component this year that will factor in from another tab, the impact of the vaccine clinics and testing, and what that total change would look like without those vaccine clinics, revenues, and expenses. So that is something that's slightly new to this, but this should look pretty familiar to most of the hospitals who have filled this out, but the exception of last year in years past. We're collecting a lot of information on the next tab as well. That should help better inform the perspective of how the rate impacts the request for this year. But as you can see, we also have the bridges for operating expenses. This is nothing new. And again, how did those down here in line 54, what's the impact of those COVID-19 vaccine clinics and testing on those operating expenses, and what does the reconciliation or bridges look like without that? Just to give a better perspective to the board of how much of an impact those clinics have had on the revenues and expenses budget to budget. And then we have a relative look below that of projection to budget and bridging that difference as well. And again, this is to eliminate budgeting that may not be realistic to some sense. So bringing out those finer points about what's actually driving the increase or reduction in NPR and operating expenses for each hospital. The next tab is the charge and NPR detail. So the board had asked us in the hospital budget debrief to revisit the charge component of what the Green Mountain Care Board reviews every year. And we met with board member Holmes and board member Lunge and Mike Del Treco from Vlaas. And so the team and Mike set out to provide a different perspective on charge from the past. And it really begins with the charge increase. What are the increase in this example? What are you looking to increase your charge master plot? And what does that mean in dollars and what does it mean as a total percentage? So what is your charge increase that you're bringing before the board here on line 16 as a percentage point? And then the hospitals will go and they'll factor in their utilization assumptions and acuity and to some extent payer mix. And that charge factored with those items will begin to trickle into gross revenues by payer. And over here we have these broad areas of service. So we'll see the year to year budget to budget change. And then we'll see how it trickles down into these various payer categories from a gross revenue level. And this should tie to their income statement for these two years. This end result here. And from there they're going to factor in their deductions from revenue. And that's going to trickle down into NPR. So we're trying to show this chain from request and then gross revenue, net revenue. And we round it out because FPP to some extent is not related to charge but it will round out the income statement seeing how revenues are moving through that component as well. And we're not saying this is going to be perfect this year but we're hoping this repositions us in a way in the future where we can gather better information on how this component relates to the income statement and the overall request that comes before the board. And there's probably room in the future to continue to work on this product but we think that it offers the board more detail than they've ever had before as to how these requests are impacted on a payer and area of service level. And we hope you will consider that for adoption this year in the hospital budget process. Next, this is an item that was left over from the pre-COVID world after we had meetings with CFOs to understand better how utilization is impacting gross revenues. So this is kind of a quick breakout of that impact as well. We wanted to show that because utilization and rate are two of the main drivers of what creates the financial, the revenue side of these budgets. And it is of equal importance to that of rate. And those two working together are how we get to where we get when we're looking at MPR. Moving along on tab number four here we have inflation. Now we're looking for the price effect here and we've outlined some very specific areas that we would like the hospitals to weigh in on. And then we've got a few areas underneath that where if there are substantial inflationary impacts, please highlight those for us over here in lines 13, 14, and 15, specifically that we would be looking for the increase over prior year and percentage in dollars. And then what percentage of your operating expense is that category relate to? So you can see we have an example here around wages and compensation medical staff that we've just given a very broad example. But we want to understand how that impacts on your budget. Inflation continues to be a topic that's mentioned in several narratives and several presentations. And we were going to try to introduce this last year, but given the need to roll back some of the items we were requesting, we scrapped this to streamline the guidance last year. But it continues to be a factor. And we feel that this would really help inform board and understand the inflation aspects of things like wages, drugs, and supplies, which are some of the big three when people refer to medical inflation. So we really want to highlight that factor this year as well because that's not going to slow down in any sense, pandemic or no pandemic. Next, we're looking for a breakout of the vaccine clinics, as I discussed earlier. The hospitals are going to submit their entire budget into adaptive for record keeping purposes, but we want to be able to show the board what the breakout looks like here as far as NPR allowances go. We don't want to see the staff anyway, don't want to see hospitals be criticized for operating expense growth or maybe even revenue growth that's related to standing up this public good. So we wanted to highlight this and break it out for the board to see and understand. And when we go to do the staff analysis, we'll present to you their budget with and their budget without vaccine clinic dollars in it. So you can see the comparison to each and really see the impact. And we really don't know now if it'll be material or immaterial. The supply chain appears to be keeping up with the demand. So that's the positive thing. But we also want to make sure that hospitals aren't if they're if they're losing their shirt on these vaccine clinics that that that is acknowledged in this process, or if things turn out too well for them, we want to make sure that's involved in this hospital process. Again, as I stated, value based care participation, we've had some pretty substantive changes this year, especially around who's involved in one care. But we're also really looking at value based care all around, not just with one care. If there are value based programs that hospitals might be involved in, we'd like to hear about that too. It doesn't necessarily just have to be one care centric. And that's a bit of a change from the past. But value based care is where the state is looking ahead. So we want to continue to gather some of that information. And finally, on the appendices, as I stated before, last year, we built a revenue replacement table, not really understanding what the future would hold for the treatment of those revenues or how much the hospitals would need. It was really a wide open landscape at the time we issued guidance back in May around what federal funding, state funding, etc, would look like. And we have some lessons learned from last year to refine that view. We now know that the guidance on that is changing. We now know that some hospitals are reserving these funds on their balance sheets and liabilities, such as deferred revenue. And we want to understand what's been recognized and what continues to sit in those liability accounts. And we built this based on some of the items that the hospitals reported to us from their FY 2020 year-end narratives. So some of this may look familiar to a few of these hospitals. And again, if the folks at VOS or whatever seeing this for the first time have input, we'd like to hear it because we want to make sure what we are bringing to our board is the best information possible and that we're not leaving anything out. So the best way to go about that would be to hear from VOS and their constituents at the hospitals, making sure we've captured everything here appropriately. That is basically the snapshot of the appendices. And as you can see, it's just building on financial details that pertain to the budgets anyway and hopefully contributing to the presentation and narrative component of our community hospitals. And we'll go through the guidance next here and we will outline where those items fall for your consideration. So here we are on page three of the guidance. I will let everyone know this timeline is subject to change. We are still working on budget hearing dates as of this time. So this is an estimated timeframe in which that will occur. But please keep in mind that it's not final yet. And we do have a tentative date here on July 28th to provide a preliminary budget overview at a public board meeting to the Green Mountain Care Board members. That is something that time did not allow for last year. So we're also returning that to the time frame as well. But you will note we are shooting for March 31st to deliver guidance with information and input and questions from the health care advocate and then requesting submission of these budgets by July 1st of 2021. And then we'll move through our review and analysis and make sure that these documents tick and tie with the other documents they're going to submit around errors and presentations. We want to eliminate as many oversights or errors as possible before we get into hospital budget presentations and also put together any final questions on items that we may think would stand out to the board to round out that discussion. Fast forwarding past the budget hearings, which you've already mentioned here. September 1st through 15th would be deliberations and votes at public board meetings with final decisions issued by September 15th per the statute. And then on September 30th we're requesting the most recent 990 IRS tax form and updated community health needs assessment and or progress report. And we'll most likely be reaching out to hospitals to whom that would apply. We've got to get caught up on where folks stand after not collecting it last year. Normally we track that but we're going to have to go back in transparency and make sure we're collecting for the right folks. And then finally October 1st we will submit budget orders and send them to the hospitals after working with our legal team. So Mr. Chair I plan to just go through this and highlight the areas of change. Is that okay? That is fine. Okay good. All right so we do start off on page 5 making folks aware that we understand this environment is exceptionally difficult and it's going to take some time to recover from the impact of the financial impact of COVID. This is left over from last year and it's still pertinent now from the staff's perspective. We are still in this pandemic as we've discussed on this meeting already. But one thing that we wanted to point out here is this sentence here that GMC policies related to budget amendments, adjustments and exemptions from public hearing and hospital enforcement can be found in part D of the appendices and historically some of this stuff has actually been within this document but because they don't change very often we're pulling them out and putting them in appendices to really put this document on the platform that this is what the Green Mountain Care Board expects. So those policies related to those items are more support for this guidance document. So in terms of efficiency we've moved that out. That's not the major change. Next we have NPR and Fixed Perspective Payment Growth Ceiling. The Board will have to decide on what that will be this year in 2022 and then we have this piece here. This will be trickled in throughout through the presentation and narrative sections that the Board is permitting an allowance for NPR and FPP revenues and expenses related to the COVID vaccine clinics. So it's very upfront that this is something we would expect to see brought out by the hospitals and I'll cite you back to the appendices on that note for where we intend to collect that information. Again another technical component here is traditionally we've had in section two instructions around adaptive and that didn't really seem like it fit in a guidance document that's providing budget guidance to the hospital. So again we've pulled that out that is a supporting element to this document. So we've moved that out to keep the flow moving around what the Board expects and how they expect it and then the adaptive submission is its own separate piece. So we brought that out and down to the bottom. We've made no changes to it. Aside from what I mentioned earlier around the high level request for income statements, balance sheet, payor mechs, etc. Moving into part B here year over year changes. Again we've highlighted in more specificity for the hospitals to discuss the vaccine clinics and the breakout and the effect that it's had on your projection and your budget for 2022. For those who know the RFP that they had to fill out for the state the initial period I believe is 12 months and there's the option to renew for two six month periods after that. So total duration could be 24 months. I hope that hasn't changed or I'm stating that but we could be looking at vaccine clinics running into well into the future should the hospital feel the need to continue to stand those up to inoculate their communities. So moving into the charge request piece, a little more detail around that is what's in the reference the data submitted in appendix two and explain your overall charge request and then explain the impact on gross revenues, MPR, and how it trickles down through those components by payer and what those and what assumptions were used in quantifying the requested increase or decrease for those tables. We're asking that they describe the how the charge request affects the area of service inpatient outpatient growth from this MPR and MPP and explain the assumptions and methodology used in that allocation. And again after that after we've done every year give us the dollar value of 1% of NPR and that is also in that appendix table. So it's right there with everything else as it relates to charge and the impact of charge. Here in other operating and non-operating revenue we're looking for them to please discuss the advances relief funds and other grants received and that is of course in appendix seven of part b that we've already reviewed and the respect with treatment of each funding source as of year end 2020 and projected year end 2021 and budget 2022 and this is all considering that we don't know what could come out of this next stimulus package that potentially could be approved today so we wanted to make sure 2022 was in there in the event that federal guidance changes on the current figures or that other revenues can be derived from the newest stimulus package coming out of Washington but again refining that and asking them to talk about how they've utilized those funds to shore up their hospitals in this time of need. Operating expenses really the biggest change here is the discussion around inflation and the relevance of those items on your budget and operations. This is also a place where discussions on cost-saving measures could occur and how you're combating against some of the inflationary items that you're seeing and overall how have you changed the way you've handled your operating expenses as the pandemic has continued on. Operating margin and total margin we've added a piece here following last year about asking hospitals if their budget request in fiscal year 2022 will include support or a need to support any other entities outside of the physical hospital. An example of this would be a higher operating margin to transfer the surplus to a subsidiary in support of that entity and this really stems from a post-spring field world in which we feel the board should understand the request in front of them and how it might impact other entities if there's a direct relationship there and it's not to say that the board doesn't approve of these transfers it's just to have a better financial picture of what it is they're approving so if there is a transfer that's going to occur should the year play out the way the hospital is budgeting we think the board should know what the impact of that is overall as far as transparency is concerned. Down here and risks and opportunities we've added a couple of sections that we'd like to hear but we hope the hospitals won't limit it to what we have on here because certainly this pandemic is providing probably more than enough of each of those topics so we'd like to hear again this goes back to the removal of the off-cycle or non-financial reporting please describe the impact of COVID on access and care wait times of your organization including the use of telehealth telemedicine COVID-19 related safety protocols and other relevant factors and that's really we didn't think numbers on paper would do much as far as informing the board so we think there's more value in getting to the heart of how is it impacted your organization how have you taken measures to mitigate that impact or even improve wait times in your organization we wouldn't necessarily derive any of that from some of the numbers on a spreadsheet so let's get at some of the the more beneficial value-based points of what the hospitals are doing to recalibrate care during and after the COVID-19 pandemic and then we have more of a broader one here in number three discuss any lessons that you've learned in the pandemic thus far and any positive changes the hospitals adopted their plans to adopt in the future now certainly the dust has not yet settled on what this pandemic means but the folks at these hospitals are extremely intelligent people and they're certainly looking for what the world will be afterwards and there's no better point of contact in that discussion than the folks who are working in that environment every day so we feel that that certainly offers again added value to the budget discussion to understand where the hospitals are going next we'll move into part d value-based care participation we are looking for as we discussed already in the appendix we're looking for are you participating and in what programs and of course in the narrative here we want to hear more detail on that than just the the appendices that we have to support that narrative we also want to understand what you're projecting for dues and what your maximum risk liability by payer is going to be so please discuss that with the board and also we got a couple of other items here around value-based care where we'd like to know to support our other regulatory processes as the hospital and if so how is the hospital changed the way the hospital lives care as a result of participating value-based programs which value-based program funding sources were most instrumental in driving that change next we have what factors support or inhibit hospital participation in more value-based payment programs we know that there's going to be a renewal of the all-payer model coming up so it's very important to understand um what factors have supported or inhibited each hospital's enrollment in value-based programs to date that is a data gathering measure that will help better inform the future of value-based care in the state of Vermont and then we have what barriers and opportunities are there to further delivery system reform in your community and again trying to inform the next iteration of that process in the state of Vermont and then finally last year we requested from the hospitals a risk reserve table we didn't distribute that until the fall and we'd like to collect that again but understanding it might not be pertinent to this process here we still want to collect it so we will be in touch with a date on that later but it will most likely come later this year after hospital budget so that again we can take that information and better inform our other regulatory processes coming down into section e capital investment cycle we touched on this at a very high level last year and we're statutorily obligated to discuss capital investment but last year we really scaled it back and we heard from a lot of hospitals that a lot of those investments were put on hold and rightly so given the financial uncertainty we're still hearing that to some extent so that began to get our wheels grinding that this can only go on for so long eventually investments are going to have to be made and whether that's equipment replacement for building renovations or building construction we want to start showing the board in this budget process how those plans may have changed on a hospital by hospital basis and what that ultimately means for the future of the budget process because as I said they can only put off these projects before for so long before they've got to start ramping them up again and that's for the benefit of not just the organization but the patients that they serve so we really want to start you know getting out ahead of that and getting a better understanding of yes they are on they may be on hold now but what does it mean looking forward so with that those basically capture all of the items that we've put into this process this year again in front of us here we have presentation content with the caveat as we did last year this is an opportunity to discuss the effects of covid that certainly trickles through everything these hospitals are doing and the presentation content in front of you mirrors what we've talked about already in the narrative and that's something that we made happen last year so that board members when they're taking notes on narratives and they're hearing the presentation aren't having to flip back and forth so that's more of a internal technical item that we want to keep going because it seemed like it worked pretty well last year so mr chair that concludes the hospital budget guidance piece i'm going to turn it over to either mike barber or ross mccracken to talk about the hospital enforcement and i will project that on the screen for them right now great thank you kate this is ross mccracken i'm a staff attorney with the board and i'm going to take this one um bear with me ross no problem Patrick thank you i appreciate you sharing it uh so what we have is a draft enforcement policy that was included with the materials um wanted to uh just what just provide an overview here um and highlight a slight difference in approach that we're taking this year compared to um other recent years and great there we go so for this policy our proposal our suggestion is to create a standing a standing policy for hospital budget enforcement rather than uh reviewing and adopting a new policy each year um we think it it takes away you know it relieves the need for um adopting a new policy each year and also improves the consistency from year to year by having a standing policy um my understanding is there's some precedent for doing this going back a couple of years so Patrick if you want to scroll down just a little bit this is based on prior enforcement policies that the board has adopted um with some slight changes to make it a standing uh policy rather than specific to any um to any fiscal year but to highlight it um specifically with regard to NPR and FPP uh it says that um the amounts established by the board may be enforced and the board may review hospitals who have a variance of 1% um or more above or below the approved NPR and FPP um the board is not necessarily going to review all those hospitals and such a review would not necessarily lead to some kind of enforcement action uh by the board um other aspects of this I think are consistent with prior enforcement policies but uh the budget review would include a comparison against results of the total hospital system um the board can establish particular requirements uh for reporting to to facilitate that review and hospitals certainly have an opportunity for a public hearing in connection with that that review um um the enforcement actions here uh track back to GMCB rule 3.0 on um hospital budget uh enforcement and we call out a couple of the specific actions that the board may uh the board may take in connection with enforcement um one last point to make for consideration um is that there's not currently an enforcement policy in place for FY 21 um as this policy is drafted it's a standing policy and it would take effect uh when approved and so therefore it would also apply to FY 21 so it's a question for consideration to the board whether um the board would like to have this policy affected for FY 21 um or take some other course of action with respect to the FY 21 budgets um otherwise once once um if this is adopted it will apply for FY 22 and years going forward until it's modified or rescinded and that's all I had to say about uh the enforcement policy. Thank you Russ did you have any follow-up comments Patrick? I do not no um we are in agreement with legal that a standing policy would be best moving forward and then the board can either choose to enforce that year or not but the policy would still stand year over year so the staff support that. So before I turn it over to the board members for comments and questions and I'm going to go in alphabetical order just to prepare you but I wanted to um point out a couple of things um Patrick you said that it um the way you phrased it um someone might be able to interpret that it was a foregone conclusion that the model would be extended I don't think that anything is a foregone conclusion what we know is that everybody will be rowing in the same boat to try to continue health care reform in the state of Vermont in that for the most part everybody wants to move away from fee for service to value but I don't want anybody to take it that there's um anybody's come to a foregone conclusion that it will be an extension of what we have currently or similar to what we have currently um the second point on um the reporting on the value based care um I think the language covers my concerns there but um the way you mentioned it I just I just want hospitals to go beyond just saying what they're doing um with attributed lives for uh one care one thing that we do know is that even those lives that are attributed there's not enough that's based on fixed perspective payments and still too much depends on fee for service um restating and and so I'm hopeful that hospitals will be reporting some creative ideas that they're doing in their communities to um move away from the from that volume and to value and you know talk about some things that they're doing differently than they did the previous year and um you know in my mind it doesn't necessarily have to be limited to attributed lives it could be something as a community project that's done with other organizations in the community that tries to create a continuum of care um that um is different than um the way we do things today so I just wanted to point that out so with that I'm going to move to board member Holmes Jessica great thank you um so first of all Patrick and team thank you so much this is really what thoughtfulness put into this I think is streamlined a lot of the processes I think there's a lot more clarity I like the changes in the document and then the the tables especially I like the change in charge table I think being able to create an apples to apples comparison across hospitals is going to be really helpful this year where we had we haven't quite had that before so understanding how the change in charge drops down to gross revenue net revenue by payer by service area I think is going to be really helpful but um so I have uh that's kind of an overview just a thank you and I think it's it does seem like an improvement I have a couple of thoughts around a couple of minor things um and potentially one larger but I actually Kevin if you don't mind I'd like to hear from other board members first so I'm going to take my I'm going to take a pass and if you can circle back to me it because I want to hear what other people are thinking first as I still frame my thoughts okay board member launch Robin thanks um I also overall thought the changes in the guidance were good I'm interested in hearing um you know public comment and feedback on that as well of course um in terms of the NPR FPP growth ceiling it would be helpful for me to have some discussion um around what makes sense given the volatility that we saw in 2020 actuals and and what we might expect or really have no idea for 2021 um just trying to think through like in general in the past I've liked the approach of of sticking with the three and a half percent because while it's not a one to one to the total cost of care of course it sort of keeps us in that all pair model total cost of care direction um but given some of the uncertainties around utilization um I'm wondering if that still makes sense so um I just wanted to put that out there and again as with Jess I'm interested in hearing other thoughts on that um and I I have to think a little more about the enforcement stuff for fiscal year 21 so I will uh do that while others are talking and over the course of the remainder of the week Tom well thank you uh um I think I'm going to wait for Jess to speak first no just just a joke I'm going to yeah three uh once there are some minor edit issues and clarification things I'll I'll send in to Patrick just in an email um that weren't significant one small thing that may or may not be significant is that I noticed in all the vaccination clinic accounting there was never um a record asked of how many vaccinations were actually made you know at the chronic level so I think that that would be helpful um I know that having been recently vaccinated that um they they they keep meticulous records about about you know who's been vaccinated and the number and I just think that you know to be able to include that um on the vaccination tallies that would would be a helpful context the the major area that I wonder about is the FPP part of NPR FPP and I noticed uh in the you know we're we're in the fourth year of the all-parent model the third year of the ACO um I noticed in the 2021 budget process relative to the 2020 budget process that basically the um share of of of NPR FPP that was FPP basically stole that around of 14.4 14.5 percent and that's that's that's worrisome to me um and uh um but the the the highest um uh hospitals uh one of the highest hospitals with the southwestern vermont medical center at 22.2 percent and then I I kind of want to reference this of vermont digger article you know that that was out recently that talked about and I just read a couple of phrase quotes from it but it's talked about how they are addressing um a kind of transformation uh at that hospital and so it's so you have some quotes like southern vermont medical center flipped from 80 inpatient and 20 outpatient to 79 outpatient and 21 patient that's a big move um they they won award from this uh lounge or institute or organization for um how they've restructured their nursing core into transitional care um and here's a another quote from the article as the system moved from mostly inpatient to mostly outpatient the fee for service health care model in which hospitals and doctors are paid for the amount of care they deliver instead of the quality began to deteriorate and further the state was looking at health reform for the future and payment reform I think we all came to the conclusion that there has to be a better way than Thomas did um and one final uh just quote uh among many uh nurses at southern vermont medical medical center got together for a retreat then began to outline how a transitional care model might look at the hospital as they began to provide free care at risk patients in the community unnecessary hospitals hospitalizations at southern vermont medical center decreased by 55 percent so my point is is that you know you read this article you think you know I and I'm not assuming cause and effect here but even the officials at the hospital are saying that as they migrated off a fee for service to fixed prospective payments um they were allowed more flexibility in how they assigned their staff um and some fairly apparently a fairly significant better outcomes for everybody um have arrived and so as I look at at these budget guidance I'm wondering whether or not we should ask each of the hospitals what is your long view in terms of fpp um uh given that some have stalled um in the 2021 budget process and looking forward you know what do hospitals think same question that we ask the aco by the way you know what is what is the uh the amount at that hospital of fpp that will leverage the kind of reforms you know that that we hope in in the old hair model um is it um 14 percent I don't think so could it be 22 percent well it looks like southern vermont hospital is doing quite well in terms of making that transition um so having a an outlook of not just kind of current metrics relative to reform but a two or three year look forward um I think will help help us understand where each hospital wants to go relative to health care reform and will help us in terms of our rate review process to try to integrate into the rate review the uh the ability to have the insurers and the payers better aligned with the providers so that the fpp amount can can be increased so um you know I wouldn't I say this because you know we're in a maturing environment the all pair of model we're in the fourth year the aco we're in the third year um and uh um it looks like we have at least one hospital that is doing tremendous stuff consistent with the model um but um if if if the reform movement kind of begins to stall as maybe the the budget the 2021 budget over 2020 might have uh uh indicated with the amount of fpp staying basically flat um you know uh we we might need to be in a position to encourage the transition a little bit more disciplined as opposed to just asking hospitals you know to report to us about where they're at but that's my only major major comment um but uh the contrast between that that digger article and I suggest everyone read it the contrast between that digger article and the progress of reform there versus on the grander scale that the fp levels of fpp are basically flat lined uh 2021 over 2020 uh was striking to me and um I you know I I think it's an area that is needs encouraging rather than just reporting thank you Tom Maureen sure um first just a couple comments um and thank you for doing all the hard work on putting together all the materials um on some of the materials and and one is when we talk about the risk and opportunities and we ask for them to talk about the positive changes that they might maybe doing because of COVID I would take positive out and just say changes right because there could be changes that they're enacting that um we hope they're positive but but it may may not always end in a positive result there may be things that are coming in so I would just take that out and then you know also on the the table that was in appendix that dealt with all of the funding that was received um I think there's a couple changes um on that on that table that could be helpful one is I'm not sure if we had a line in for the ppp program separately and I know maybe not a lot of hospitals got that but um you know clearly that would be a line we would want in there and the other thing I think on this chart is the amounts received putting it in by year that it was received because you know it's good to know did we get it in you know did hospital get it in 20 did they get it in 21 did they get it in 22 um and then there might need to be totals on the chart at at some point to to kind of reconcile how much money was received in total over the years and how much has been recognized as revenue and how much is recorded as liability or you know still kind of hanging out there um I don't need this pause for a second um Patrick we're getting a little feedback occasionally and it looks like yours is the one lighting up could you just mute mute your volume while marina's yes I have my windows open I apologize no problem and another area for this I don't know if we have it here or in the in the um in the basic part of the report but just commentary on you know on the what they received did you do are they gonna have to pay it back or or you know how did it flow through um for the impact because thankfully it looks like several of the hospitals it really helped get them at least on a balance sheet and and um you know bottom line operating margin close to what their budget was even though their top line certainly was a miss and I guess now if you can go to the the discussion page uh that we have because ultimately we have to make some some decisions right and and it may be helpful to to look on that discussion page and I have another another one I'd like to throw out for the board to talk about potentially as a discussion and I think everyone knows we can't talk about this privately so I'm gonna throw out um when you know typically we we focus primarily on the NPR and you know we're looking here at a ceiling and there's so much uncertainty on what's been going on um you know who knows what the right number is going to be off of the you know off of their budget because it may depend on how much they have to catch up next year right so so it may be similar to what happened last year where we thought people would be coming back into the hospitals so maybe it's going to be three and a half maybe it maybe it needs to be higher I don't know um but I'd like to throw out looking at a change in charge and potentially putting some guidance around change in charge as a concept and certainly this won't be without controversy if we if we do that but but the reason I want to you know I'm throwing that out there is is a couple things you know when we we when we don't put in a change in charge and a hospital comes in and we had a hospital with a very high double digit number uh commercial rate request and they were falling within the the guidance of the top line it was almost like well we can ask for a 20 increase because we're below a three and a half and so you know I think maybe putting some parameters on on change in charge as something that we're going to look at because that's been brought up several times so it's a question do we do that or not and and the other part of this is last year we had put in this concept of bifurcating the rate and putting in a kind of temp what we thought would possibly be a temporary rate and when we sent out all of the final the final um for all the hospitals for we we didn't put that in we we you know it was clearly in there that we said for many of the hospitals that got a six percent rate we had said it would be four percent base and a two percent covid and we were very concerned about putting something out as a temporary covid with the threat that maybe they wouldn't be able to get government funding and so that that was for me I think last year the driver of why we we said let's not put that in there as a separate rate but we did talk about considering that or I know I publicly stated we would I would consider that in the next year's review so we did have I think two three four but eight of the hospitals got a temporary covid adjustment ranging from one to three percent and six of the hospitals did not and so you know one one way to look at this potentially would be over over a two year two year rate right so so one way to potentially do this and again just throwing this out there for board members for discussion is you know if on average the hospitals got and I'll make up kind of a number it's not on average but three and a half percent was the base rate three and a half to four percent last year and then if if this year we were to say again just throwing out a number seven percent you know combined for the two years um that would take into consideration those hospitals that got an extra last year and if we think about that extra we thought was going to help accommodate the some of the issues that were occurring because of covid we didn't know how much additional funding hospitals would get we don't didn't know what their financial condition would be but we said you know in theory that the rate they got for the current fiscal year we're in was was maybe inflated and that we would adjust for that that would go away we didn't do that in the orders clearly but but one way to accommodate for that would be to expect that those hospitals that have that and it's carrying forward for the orders for the current year we're in may get a smaller rate the next year so if somebody got many of the hospitals got six percent rates and we originally intended it was going to be four percent base and two percent covid so in this example if we said seven then the expectation would be they'd only come in with a relatively small rate increase one um if if we said seven so just trying to throw out a concept also just going back to what we said last year originally in the orders um we talked about you know due to the pandemic the hospital may request the board may consider two types of changes in charge one request to reflect standard price growth and a second time limited charge to offset fiscal year 20 commercial revenue losses due to covid 19 the hospital should justify its covid 19 related charge requesting the factors and the time limited covid related charge requests may be reviewed and adjusted based on fiscal year 21 year-to-date revenue and utilization data and that last sentence is really important because um when we when we do these we kind of make it a blanket you know all hospitals get the same thing and all hospitals are the same and that's because we don't try to regulate to each individual hospital however the reason I'm stating this is because we do look individually at each hospital when they come in and so this you know when we review what actually happened in 21 and their their revenue utilization and I would also put operating margins and profitability it may impact whether we would impose something like this and so you know for example if a hospital received tremendous support from other sources that charts seven we just looked at on the appendix and that they're in good shape right that they actually they didn't get their npr but their bottom line their balance sheet is in good shape and they may continue to get funds in this current year that may impact of the fact if they got a covid rate increase last year or what are in a higher rate you know I guess we can't really say it was covid but if they got a rate you know above three and a half four percent then maybe we would consider in in the guidance this year um looking at that and making some adjustment for that so don't have it all worked out just wanted to throw that out there and know you know that in order for anything if for us to vote on anything like that obviously you know three of the five of us would have to even want to consider that so you know I'd like to put it at least on a discussion point for consideration and as people go through I know we're going to go back to Jess at some point and and we haven't heard from Kevin don't know what your response is to that and you know so that that's um that's really all I have to add to this and you know should we decide to go down that route at all then we could kind of work out some specifics of of how it would work and what that concept was mean I was just trying to look into how do we consider what we did last year what the intent of what we did last year and some hospitals benefited others didn't now we know a lot more about um you know again funding and the financial health of hospitals and that will play a role both negatively or positively so I just before everyone comes back at me you know hospitals that are in poor financial condition you know we may not be able to do that as well as other hospitals but um that's all I have thanks thank you marine all all very valid points and uh I get the uh uh uh perception that just wants to back clean up so I'll make a few observations but um hold back the ability to say more but um I just want to say that um as far as the discussion points that have been enumerated by the team um I'm okay with the caveat that um I want to hear from the hospitals if there's a problem um and I want to hear from the public if they view a problem but I'm okay with the due dates and I'm okay with all the tables um unless somebody points out a problem that um makes it uh harder on the hospitals uh to meet those those uh tables and the due date um like marine um I really have focused in on on two areas and that's the uh NPR FPP growth ceiling and the uh charge request and as I said after we debrief from last year's budget process I really think that we need to be clearer on what our expectations is otherwise people um submit their budgets and they are in compliance with the guidance and I feel uh um almost a moral responsibility at that point to them um so I just want to uh be very clear that I feel that change of charge is just as important as NPR FPP um and on that token um one of the problems that I've had this year looking at 22 is that um NPR FPP will be looked at compared to budget and we all know that a number of hospitals are significantly below the budget so um you know marine brought up a a two-year look I don't know if that's the right thing or if somebody has a different idea but I do know that um I don't want people creating aspirational budgets and the reason why I say that and again this is all anecdotal but the stories that I hear from providers and consumers around the state is that there almost seems to be a charge to do as much as possibly can be done to try to keep the cash register going um and this is kind of blunt speak but and uh it's not really fair to the hospitals because if I was in their situation I understand there would be pressures to bring in the revenue so um but I do want to point out that um you know we're trying to um get the right utilization and you know the right care at the right time in the right place and I do think that um it could be a return to aspirational budgets um looking at the revenue to the budget so that's a major concern for me and also I think that we have to be very specific on what the ceiling is that we're putting forward now again even the revenue is a ceiling it's it's not a target so there's nothing that would require people to come in um at that level and we saw last year several hospitals came in significantly lower because they had more accurately um forecasted what they thought their revenue was going to be um for this year um and keep in mind that's not a dig at any one either because this is like throwing darts at a wall um when your world completely changes from day to day whether it's the onset of the pandemic or when we'll be coming out of it when people feel safe to go back all these type of things um do some of the changes result in permanent changes like as this pandemic resulted in the right people using the emergency room versus the overutilization that most studies pointed to pre-pandemic um we just don't have all the answers so I think that um just as we do in revenue we should be setting a gross ceiling in the the charge request and I think that's really important because otherwise given some of the large increases that were given last year I think that we may be setting a base moving forward that is going to jump start whenever there is some normalcy um a growth in in healthcare costs in the state of Vermont and it has been our goal all right along to try to keep the growth of healthcare costs um more in line with the the growth of the overall economy so um I'll probably have uh more to say after uh hearing from Jess but those those are my points Jess yeah no I just really wanted to listen to everybody because I do think this is such a challenging year um because it's spring training and you just wanted to back clean up no I really you know no I really wanted to hear where others were thinking about these things I've given some thought to it but obviously more thought has to be given to it um one quick note I like Maureen's edits to the stimulus funding table so Patrick you got a second vote on that um that's really helpful thank you Maureen um you know I think everybody's comments were really interesting and helpful it's one thing I'll just add about some of Tom's comments about Southwest I'll just add that I've been reading a lot more about this movement to hospital at home and so I'll just say as a note on the side CMS has actually just created an acute hospital at home waiver or pilot program that's allowing for reimbursement uh in the home for a lot of patients that otherwise would be in the hospital and I think it's a really interesting model and I hope that hospitals in our state are looking at that because I do think that it has many implications for in terms of staffing you know reducing staffing stresses for reducing the cost of remote monitoring and also potentially could be improving quality because less infectious you know in hospital-based infections so it's a really interesting model a lot of folks are suggesting that's what's going to be happening that a lot more uh you know care is going to be delivered in remote settings because technology is now allowing remote monitoring to take place but anyway that's an aside so it was interesting to hear Tom's comments about that um I share uh some of the uh Robin's concerns around how do we set an NPR and I'm interested in that conversation particularly in this you know in this huge world of uncertainty that we're living in I can only imagine that building a budget during these times is a significant challenge for our hospitals and I completely appreciate that I wondered if um you know on the one hand I could I could see us doing a 3.5 just out of the consistency with the all-payer model and then you know allowing hospitals to to uh respond as they're seeing the needs changing over the next few months but using that as as a ceiling I could also potentially see us maybe taking the fiscal year 19 actuals kind of the pre-covid actuals and rolling forward what would have been 3.5 over the subsequent years and sort of looking at a cumulative you know look um at what uh what NPR could potentially be that would accommodate the low revenue during the COVID you know peaks but also compensate for higher revenue to manage pent up demands of somehow looking at it that way um I'm interested in the conversation around change in charge I I I hear Kevin's concern about and others and Maureen's concern about maybe the having some guidelines might be helpful um to the degree that if you know if somebody meets the the NPR target but then their charge increase is in the double digits you know that's something that we would look at and we have looked at and we have reduced and so having some guidelines around change in charge might be helpful um I would say to Maureen's point if we do review the the time limited charges from last year the COVID kind of uh charge that we put on it will be really really important to look at the fiscal year results um because I think many of the hospitals that turned out needed that rate needed that extra rate so I'd be reluctant to just claw that back if it turns out that their financial situation they didn't get the stimulus money that they you know anticipated or even with the stimulus money their their bottom lines were harmed so I think we do have to look at that um in you know one of the things I was thinking about was um you know in light of the pandemic and the stresses that you know we're hearing from all the hospitals in terms of trying to deliver care during this you know pandemic and trying to deal with vaccinations during a you know the crisis that we're in we could once we figure out what the the thresholds might be we could propose that hospitals that submit budgets to the green mountain care board let's just say you know with an NPR growth of under 3.5 percent and let's say a change in charge under 3 percent for example would not be required to have a hearing in august so if they were under the NPR target of and I'm putting this as a placeholder in 3.5 and under a change in charge of less than 3 percent if they met those two thresholds um we could say you know you don't need to come in for a hearing you have to the hospitals would have to you know submit their budgets um all the reporting requirements would have to be you know met including the narrative um I think the budget assumptions in there would have to be deemed reasonable in line with prior years budgets so nothing out of the ordinary the hospitals uh cash position would probably have to be strong for us to want to do that and the hospital shouldn't be undergoing any kind of big significant restructurings or reorganizations and they'd have to you know ask for that waiver but I'm thinking you know that could reduce some of the administrative burden or at least the you know having to come in for a formal hearing if they were below maybe those two um levels if I don't know then just throwing that out there um I like the standing enforcement policy that's been put in there and I guess I would suggest that we would waive that for 21 just given all the uncertainties it's hard to imagine how hospitals could necessarily have necessarily have met a budget that was made under such uncertain circumstances um and this is just another this is a such a minor piece but I'm going to throw it out there last year during the budget process thinking about quality we heard from a couple of hospitals at least one or two I think about the benefits of participating in NISQIP as a quality assessment tool for for surgical if you know um the surgical aspects of their business uh not many are using it right now because I understand it's a bit costly um that's what we heard I guess there apparently there used to be funding for it the funding was taken back and a lot of hospitals dropped it because it was costly but my understanding is it does provide value and improving surgical quality and so one of the things I was thinking we could do to encourage more hospitals to use it was allow an NPR allowance you know maybe that goes above whatever we decide for an NPR to cover those additional costs of participating in NISQIP and perhaps VOS could negotiate some kind of volume discount across all the hospitals but I think it sounds like it's a valuable instrument to improve surgical quality and the hospitals that participate see great value in it and if we can encourage that through our budget process I'd like to see that so those are some of the thoughts but honestly I'm really interested in hearing from the hospitals I'm interested in hearing from other stakeholders I'm interested in hearing from again from more board members as we start to unpack this I'd love to hear from the hospital budget team where they might see a growth steering ceiling set and what are some of the ways that we can set it in response to all the uncertainty that we're in so those are my thoughts thanks Jess and it's good to hear your thoughts I'll give you some quick feedback on some of what I heard I always want to make sure that we use the the term ceilings even though they're not true ceilings because we know that this board has been willing to blow through the ceiling to give higher requests in the past to make sure that it works for a given institution but if we were to give people a pass on the hearings maybe there should be a little bit more of an incentive to say something like a hearing would be waived if you come in below these requests and I don't know what the right amount below it is but if you came in at least a half percent below on one or the other or a combination that would equal that between the two or something like that just add a little bit more incentive that would be something that I think is worth exploring I don't know what the reaction might be from hospitals if it's even worth it to them to not have the hearing but I'd like to hear that from them I think it's an interesting concept so I applaud you for thinking outside of the box there did other board members wish to say anything before I open it up to the public I mean I have a couple things to comment on after Jess's comments and I think maybe for the discussion points for consideration you know Patrick maybe adding the couple things we've talked about so possibly putting in a change in charge guidance as well as this topic on hearing you know whether we would waive hearing or not I might be able to get there my my initial reaction would be I'm okay with setting up some guideposts and and saying that a hospital is approved I still wouldn't mind hearing from them knowing their company maybe talking about the risk and opportunities or just giving them a you know a discussion maybe it's a lot shorter you know instead of being a three or four hour window maybe it's a you know an hour and a shorter window and we're limited to questions but really just to get you know to have that conversation because there's so few times that we actually have the hospitals in and we we just get to talk about what's going on how how's the business what's you know what you're how are your finances so even someone that might meet a rate request because many of our hospitals even last year you know they didn't ask for exorbitant rate requests and we had several hospitals we approved as submitted when you go through the orders there were I think five or six hospitals that were approved as submitted so so we do do that as everyone knows you know we do and um you know but but having them at least come in and and even giving them you know a forum to be able to talk about what's going on with with covid what money they received what their risk and opportunities are what they're worried about so I would I would throw out a hybrid maybe potential if we didn't just wave completely but um you know maybe it's a real skinny down you're you're approved so so that you know we can't rescind that type thing you know if we if you meet these guideposts whatever you know and do what Kevin throughout with just throughout you're approved but you know we still would like you to meet with us and I think right now it's still scheduled to be a zoom so it's that that would prevent or we at least if we are back in person by then at least those could be zooms you know like we would allow that to be a zoom meeting and and just come in so I would put that in um for enforcement um I guess I would like to you know circle back on when do we have to make that decision and you know enforcement is plus or minus so you know I was the one vote last year that said I don't think we should give it up but it wasn't because we were gonna come down on the hospitals and be enforcing you know you have to cut your rates and do this and that I mean again it's a time to talk about what happened in the year you know we just we get this from the consolidation that that the staff does which is very helpful and from the written commentary that the hospitals do but you know there's a missing element of of talking to to people who are working there and you know kind of being able to talk to them about what's going on so I you know again the the enforcement is plus or minus as we saw and you know from for the most part it's been on the minus right we have maybe not often but I think we have you know brought in hospitals to give them an incremental you know commercial rate or something to help them when they've been struggling so yeah for me enforcement I don't think we need to make that decision now but I would defer to legal to find out when we when we need to do that um and you know maybe it's not under enforcement but I do think we need some more forms of just being able to talk to to the hospitals we we do regulate and when was the last time we all met with them it's been a while so but thank you for those comments Jess and that's thank you Maureen other members of the board actually Kevin can I just ask a quick question about um it occurred to me you know we have this other process ongoing with the sustainability planning and um I'm just wondering what other board members think about the role of the sustainability planning effort in the budget guidance if there is a role certainly the sustainability planning was part of the budget orders from last year so I'm just you know I realized how should we think about that in in this budget guidance is it a separate process all together the expectation will hopefully be that they'll participate in the sustainability planning as a result of the budget order from you know this year that we're in uh just thought I'd throw that out there and I would just say a quick reaction to that is that um if everything um works out as everybody hopes I think there's a possibility for that but you know if all Americans aren't truly given the opportunity to have the vaccines by the beginning of the summer it may require a little bit more of a push off but I don't think we're in a position today to make that decision but that's just my view other members of the board yeah I had um some reactions and a question um I so I definitely am interested in hearing feedback on the change in charge guidance because that was something to Maureen and Justice points that we discussed quite a bit in last year's both guidance and hearings and I do think I'll just speak for myself I would have been less comfortable with some of my votes on the amounts if I had thought that those were built into the base for time memorial so I do think it would be good to be able to take that into consideration this year with that said we are still in the middle of the pandemic and so it may be that that gets kicked the can gets kicked down the road for another year there because I do think um you know depending to Kevin's point depending on how the vaccine rolls rollout goes and whether they're you know whether and when boosters are required and all that kind of stuff it's just hard to know what normal will be and when normal will come back so I think for me that I want to be able to have some flexibility there both in terms to consider it but also to then maybe not consider it if if we still feel like the the situation warrants it um and I I did kind of like your idea just about looking at and I think Maureen actually had suggested this in previous budget guidance looking at like 19 actuals and kind of rolling the NPR forward so that we're not really tied into the COVID weirdness right so trying to really look for a longer term trajectory given the uncertainty and all the challenges uh in the last last year and this year um so those were my comments um I did have a question um for Tom Tom I'm wondering if you had a more a more specific idea about what you were thinking in terms of leveraging the FPP um to be honest I wouldn't be surprised if FPP is fairly static this year given the COVID situation because FPP is going to change when more people are attributed and that depends on more primary care joining the ACO and given the operational challenges around COVID I can't imagine that uh providers are going to be focused on any sort of operational change other than COVID since that's been really a consistent operational change for the last year um so I'm intrigued by the idea I'm just not sure if this is the year given the COVID situation but I but I did want to say if you had something that you wanted to build into the guidance um I think I would just want to know a little more specificity about what you're thinking and I do think you'd have to build it into the guidance if you wanted to use it in your decision making on the budgets well I mean that's a very fair question and I don't you know I haven't uh I don't have any silver bullet here my my thinking on it was that um you know we've always had this two canoe kind of a concept of one foot in FPP and one in fee for service and uh breaking out of that I think is a little difficult for hospitals I can understand that the fee for service is something folks are very comfortable with and it's uh it's something um allegedly that they have some ability to manage do but you know through the number of procedures that are ordered um and the other hand you look at uh at least you know and I haven't validated it myself but I look at what seems to be happening down at southern Vermont and they seem to have you know found or found a path to put more of one foot into FPP and lessen the load on fee for service and so um you know my concern is that that that that with COVID the comfort level with with fee for service that that healthcare reform gets gets uh kind of stale and stalled and uh so um if there is a window in the budget process to ask hospitals okay here's where you were in 2020 budget here's where you said you'd be in 2021 which system-wide is basically level funded walk us out three years and and and give us a a profile of what is your thinking about where you'll be in three years relative to reform and it might be that um you know we find that hospitals you know really haven't thought that through um they just kind of making it up as they go along other hospitals maybe have really thought it through and and or and have a plan um you know I as a board member voting on uh in in in rate review you know where board members have some influence on encouraging insurers to participate in uh in a fixed prospective payments um it's a marriage between the provider and and the payer um so if there's a window there I you know I I I I would support it because I I'm I'm worried that we're stalled you know on a very practical level that the momentum of fee-for-service um is is uh is strong and um you know some have kind of breaking breaking the constraints of it but others you know may uh may not be so I'd just like to know where hospitals think they are going and where they will be um three or four years down the road in the same way that that southern romont looked at this three or four years ago and we find them now in a position where um they're impatient uh procedures are down and they are um a much more um reform based so to speak of of provider other board members yeah I would just like to add my thoughts I I um I agree with I got a a phone behind me kind of uh with an answering machine answering if that's what you hear but I I I agree with marine that um the what we did last year in terms of hospitals and the kind of covid kicker is something that shouldn't be taken for granted um it was intended to be um a one-time event um and then it became complicated and we built it in into the rate but I don't I don't feel that that those covid rates were were embedded they may be needed now circumstances may be changed now and you know we have to deal with the reality it's out there in the street but um I I think it's fair to say that our process you know should find some way of of looking under the covers and seeing whether or not that's needed um that might be following a kind of suggestion that just had is that we we we take a look at um hospitals off a 19 uh 2019 base or 2020 base and roll that forward um and not include the covid to say okay well that's the backdrop that's the baseline you know now show us that uh that that that that covid funding is is truly needed um but it's uh that gets complicated too I I think about the fact that you know we had a 2.7 percent npr increase last year which is very good but that was comprised of uh 13 hospitals coming in cumulatively at four tenths of one percent and one hospital coming in um at five percent and so that there's an imbalance there and it would take some creative thinking as as to how to set up guardrails to um uh you know to to kind of unwind that complication I mean basically if we can simplify the process in my mind to three areas affordability solvency and reform and have a de minimis approach in terms of burden on hospitals you know that's the path I'd like to get down thank you tom other board members yeah I forgot to comment on the hearing issue um I I definitely want to make sure as you know given the current situation that we are being sensitive to the realities on the ground around covid and the vaccine distribution um so I'm I'm definitely open to the idea of waving the hearing although to Maureen's point I I would miss hearing from the hospitals I have to be honest because I do think the the qualitative part of the discussion is really helpful um for me at least in terms of really understanding more the milieu and just the qualitative nature of what's going on with them so I would miss that so that's what and I think it does provide a valuable context above just the dollars and cents um to understand where things are with reform where they are with telemedicine you know really what's happening in the field which I think makes our decision making ability better to have that understanding so that's just as I haven't decided um but you know I'd love again to hear uh from hospitals in the public about their thoughts um before we vote okay anyone else from the board okay hearing none the first hand that was raised was deal hack it um dale good afternoon that was a lot you covered you you I'm live um sorry about that um that that's what happens when you're at home and and people don't know who you're talking to and it um anyways um we need humor in our life too yes we do dale so um okay first you covered a lot I can't comment on everything obviously there I had thoughts going through my head every time you switch topics was covering a topic and I just I can't I can't record all my own thoughts as you're it's really complicated but one when it comes to reporting on the vaccination I would like to see a reporting on households vaccinated if everybody was vaccinated minorities vaccinated I think this is important for the green mountain care board to see and for the hospitals to record and share um I've got examples within my own family that I have uh family members of our minorities that entire family one person went to school got the variant of the covid and within four days the whole household had it um and they tested positive and they tested positive for the variant the idea that schools are safe not really true depends who you are um so I'd like to see them do some reporting with the vaccines that also includes minorities and our households vaccinated the other one would be the charge master versus the that was great by the way how you presented that the inflation model due to fee for service and double digit charge master it becomes pretty obvious that you're charging to balance your budget that's not a sustainable model it may work but it's not a sustainable model consumers really don't like seeing things like that I think there is a connection there that I am trying to make as to this gets at some of the things consumers really complain about as far as cost and health care FYI by the way I was just listening to senate education or house education when it comes to uh uh costs and health care their budget school budgets are really being they're taking a nosedive in terms of the cost of health care versus how it's taken away what can be invested in children um the public the one the public budget process you were talking about streamlining it I would just remind you that making it quick might not be a good idea in one respect it's also supposed to be transparent to the public um and I don't know more about that that's the end of my comments thanks deal I just wanted to shoot back at you on the school budgets that um I agree with you that it's a huge cost driver to with the taxpayers but I also want to point out that the people running the health insurance program for the teachers have purposely not tried to move away from fee for service and more towards value base care and it's reflective of the actual um costs that are incurred by teachers in the state of Vermont and that schools should really be focusing more on what they can do to keep their personnel healthier and away from the most expensive care but that's my uh soap box for the afternoon um I saw two hands go up at the same time because Mike you work for Jeff I'm going to let Jeff go first unless he wants to defer to you Jeff team and hi thank you mr chairman um I will go first um I I just want to start okay um I wasn't sure if I was muted or not on screen um so thanks for your support and and I appreciate the Green Mountain Care Board's willingness to to examine and kind of discuss a budget process that makes sense given all the changes and the amazingly unusual year we've we've had I have to agree with Dale a lot of stuff surfaced today um some promising ideas and some problematic ones um and I think we'll need some time to process some of the thoughts shared and glad that there's a an opportunity to do that um we do understand that you've worked hard to understand the situation hospitals are in um the uniqueness of COVID um and I really do hope this is the only time ever that we have an extended conversation about how a pandemic affects regulation but we do have to have that conversation and hospitals as you know have been an amazingly big part of Vermont's success managing the pandemic as well as if not better than most states around the country um and given that and how busy and preoccupied it made us in our most recent letter to the board we had asked for a complete suspension of the budget process or at least a very limited version um which was authorized by last year's emergency legislation and as I said in the letter this wasn't to dodge responsibility or a vert accountability um but to focus on the core work of caring for patients during such a difficult time so if that request is not under serious consideration we do appreciate the guidance being slimmed down um and we want to make sure that it collects only the critical information that is needed and that the process itself is minimally disruptive given everything hospitals are still doing which I enumerated in detail in that letter and of course all the unknowns were still managing from clinical circumstances to financial um conditions that are still very much changing so I think we're going to get back to you with some specific comments and ideas on simplifying the process which I know that conversation is already taking place um one that I did want to comment on just briefly hearing the conversation today is the hearings um I am somewhat compelled by Jessica's idea of possibly being able to opt out of the hearings if a hospital meets certain thresholds um but I will say as some of the other board members expressed that many hospitals like to tell their stories believe it or not as much as you like to hear them I think where it becomes problematic sometimes is in the follow-up and sort of protracted Q&A um or more requests for information that become burdensome and difficult to manage um and then the last thing I would say um is that I I do agree with board members who said we should extend the no enforcement provision for for FY 21 I think it's just obvious that this year will be as unusual and unpredictable as the last one um and should be subject to the same standard as always thanks for the time Kevin thank you Jeff Mike um good afternoon everybody just to echo Jeff's comments um thanks to the board for their hard work here Patrick your team and I have been meeting quite frequently thanks for your time um everything you presented I think should stand as presented um I do question the additional value of some some of the added discussion um and would suggest respectfully suggest how do those new information points change your decision making or even improve some of the information you have I suspect that um many of it is nice to know and and really won't change the decision making process for 2022 um as far as um the 10-1 rate increases go um the industry that's how they look at that you we call it change in charge in the regulatory space um to limit or put parameters on those um you already sort of adjust as as necessary and and take into consideration net revenue and rate increase at the same time to put parameters would would and could jeopardize those organizations with unfavorable pair mix even further because they need higher rate 10-1 charge increases than other organizations with more favorable pair mix so I think the way you do it and the handles that you have on it today allow you and history says you do make those changes as you evaluate budget so I think that would be a problematic move as far as fiscal year 2020 um and your look at 2020 and how it relates to 2021 and moving forward to 2022 we have to remember we took in 190 million dollars of CARES Act funds that's 75 percent of of the total amount that was not loan based we have a system with three million dollars of margin six of our hospitals are um in the red so the notion that we have a healthy organizations is really hard for me to hear um we we have an organizations that have limited net revenue growth over the past years from upwards of eight and a half percent to below four percent and our operating expenses have tracked right along with those and it's by no mistake that operating expenses and operating revenues or net patient revenue and FPP align very closely our organizations as you know rely on non-operating revenue to fund their budgets and it's it's this notion of healthy and we can cut our way out of these things that is very problematic to hear as part of the industry I think the board and their deliberation should take some of this into account and really I thank you all of this is said with complete respect and your and your appreciation for what's going on in the industry within this pandemic and so thanks and um and my plan from these materials is to get them out to CFOs have them look at some of these appendixes get some feedback to Patrick I don't think they'll be very significant changes or or discussions that would be problematic but but Patrick will be in touch to work through those so thanks again and I appreciate the time and as much as you can do that in an expeditious manner will be greatly appreciated Mike you bet I'll um I'll get it out today uh chair mullen and and seek feedback uh by by the first part of the week thank you Kevin this is am can I have a can I have a hand up um you can uh Mark Stanislaus had his hand up first but I'll put you in the queue right after him thank you Kevin he's shorter than I am hey well that's an intro uh thank you Kevin so Mark Stanislaus from the university of first aid for my health network so you know I mean very much appreciate the open conversation and I like Mike think the staff did a very good job at you know walking us through this as I also think the board did a good job at sharing their opinion so you know um I do have to say that there's a lot to digest here so we're going to take this all in and provide constructive feedback or you know we hope it to be constructive feedback but there are two high level points that I would just kind of like to share and and you know this isn't a question this is just more of an understanding and it goes back to what Mike said I think there needs to be more focus on what a sustainable margin is this meeting is following up a review of historical performance through FY 20 and if you just look at that trend line from a total hospital system that's not sustainable there's a lot of items that go into that candidly and there's a lot of variables but I think we need to have more conversation on what a sustainable hospital system is and that needs to be balanced with affordability and there's components of rate and utilization that all need to be balanced but you know I really worry about that I really worry about that trend line and we need to find a way to pull that more into this conversation understanding that there's many items to balance so that was one point and then the second point that I wanted to share is you know as we think of change in charges or maybe it's commercial rates or you know how it rates as we talk about guardrails I think we need to have conversation about what drives those guardrails I don't think it's as simple as saying three and a half percent I think I would throw out a slight concept to think about is you know what commercial rate lift is necessary to cover inflation I mean and that's going to be different based upon what the different hospital types are because they're paid differently that's going to be a lower number for critical access hospitals because there's less of a cost shift that doesn't mean there's no cost shift by the way and you know how the cost shift comes into that so you know I like the idea of isolating out the inflation column but you know there should be a direct correlation of the impact on the commercial rates and that's how we should think about it more because I think it's difficult to just say here's our guardrails without putting those assumptions in place that helps us identify what those guardrails are but those are very very high level thoughts and like I said you know we're going to take our time and we're going to think about this and we're going to respond in a very timely manner in all aspects of this so you know thank you very much for the opportunity for this conversation and we look forward to working with you on you know how we think about you know continuing or establishing a sustainable hospital system through 2022 and beyond. Thanks Marky. We did hear from your legal team and my understanding is that you will have your comments to us by Friday. Yes we're going to do our best to do that Kevin so I mean if it's not Friday it'll be Monday morning first thing but you know we're going to try to make it work on Friday. We'd appreciate it if you could thank you. And Jess were you saying something? Yeah I just wanted to respond to that last point by Mark I mean I wonder if one thing to better understand the change in charge requests would be for us as part of the process to ask the hospitals to back out you know to basically do an analysis of their change in charge requests what proportion is due to inflation right the straight up inflation what proportion or what is the amount that's due to cost shift and what amount is due to trying to get a margin right I mean that's effectively I would imagine the three components of a change in charge some of it's just flat out medical inflation and other inflation right part of it's hey because the public payers aren't paying their fair share we've got to cover some of that through our commercial charge and then some of it's hey we need a margin so if maybe there's a question in the guidance that asks hospitals to back that out I think that would be really helpful going forward I think understanding those three component parts of a change in charge would be really helpful to all of us so maybe you know building on that base I'm not sure Patrick if there's a way to add that or think about that in the guidance I agree Jessica and I think there's two other possible items that could impact that is um uh any significant changes in payer mix um and and and also um any significant changes in bad debt and charity but that's where we think the conversation should focus more is really what the components are that are driving it and then you know what we can figure out how that balances against affordability and you know you know continue that conversation together but that's really where we think it should be focused is what are the components that are driving and they are slightly different by hospital too so that's why I think it's hard to put guardrails and when I say hospital they're different by hospital type um um so anyways but you know we would welcome the opportunity to have that conversation in more detail with the board just to give you a heads up mark as we uh try to start fleshing out language on change in charge I still have the goal of having one set definition of what comes forward and I know that we've given you guys a pass in the past about doing it differently than the other hospitals but I do think that there has to be uniformity and um that discussion still has to take place so ham thanks Kevin I've got several points I'll make them as tight as I can I I'm writing my book now on healthcare reform um you'll probably hate that but the you've been doing that for 10 years um I know well it's a lot has happened and that's and it's still happening um and one of the pieces I'm going to use today is your comment about the fact that that we're not you know we're completely stalled and getting um and getting increases in actual risk contracts and I think that's right I think the uh the the whole reform in Vermont is dead in the water and the huge question is whether it's dead completely let me just say why number one on your comment about the hospitals need to look at this the reality is that the question of whether you're going to have a risk contract is not up to the hospitals completely they have to agree okay but the main decision has to be made by the payers and what we have now is neither neither Medicare nor Blue Cross has any interest in anything but a shadow fee for service contract that gets reconciled six months later so the whole incentive of a fixed contract is gone okay so the question really is the question really the people to have really have to change is mainly Medicare okay but also Blue Cross uh secondly my second point is this the uh reality is I think that the you're too big you're too academic medical centers tertiary care uh level one trauma centers and all of that is the uvm and Dartmouth Dartmouth has no real interest in taking risk they're very reluctant and I and I don't be super nobody should be shocked if Dartmouth completely drops out of this system if they do that if they completely drop out of reform then there's no real reform structure on the whole east coast and that includes Bennington because Bennington's main tie to a tertiary center well part of it's Albany Med but mainly to Dartmouth thirdly the the reason why fee for service is so powerful and so hard to uproot is that fee for service makes way more money and if you want it so if you say well what is uvm going to do well uvm is in its sixth losing quarter and that's two of those is before COVID okay and there and the and so the question is can either DH assumes that it can't afford to do this uvm is in a position where I don't know where they're going to get the money let me just my fourth point is there's a huge issue here about what is happening nationally okay there's a council of 25 of the biggest players in the United States that the council that act as an advisory body to the American Hospital Association okay it includes all the big feet it's got Mayo Clinic it's got UW Seattle it's got Johns Hopkins it's got Yale New Haven it's got you name it they've got it's got them all none of those people not one of those players wants any part of the kind of risk contracts that we're talking about in Vermont none now they understand that so the issue of whether they change they don't expect it and they don't really want it but what they're looking for now is the question of what Joe Biden does the only way to resuscitate the real momentum behind behind reform of the type that Vermont has led on okay is if Biden decides to do that most people don't experience the big players don't expect him to but if they do then it can come back okay but the reality is the the the reality is that when you the you make so much more money at fee for service the just running upstream and so so it's very interesting to see here we neither neither Dartmouth nor UVM is any longer in a position to you to really move lead in this direction they have to back up and there's nothing we know we don't even know what money is going into DH it maybe it is I think it's up to at least four to five hundred million dollars a year but in any event we simply don't know and Dartmouth Hitchcock wants no part of anything that gets them tangled up with the green mountain care board in Vermont if you think they do you're just wrong the the finally is I'm not sure what the the problem with UVM okay UV you may want to look at UVM as as the same as a 25 bed critical access hospital but then not that's like the dip that's like refereeing at the difference between refereeing a sumo wrestling match and a badminton game the the reality is the reality is that you that the that the decisions by the board have drained more money out of the out of the UVM system because of not being able to get any approval for any of the cost shift okay then then the then the hospital is now publicly underwater okay so Mike what that's those are just my comments I just don't we're dead in the water okay the thing that kind of all the kind of detail messing around that you're talking about with these budgets is not going to reignite reform not going to happen thank you well here now that you left us with the thoughts of sumo wrestlers playing badminton um we'll go to anyone else with public comment and I see that Dale has his hand up again Dale yeah this is slightly different but the model that was mentioned that Southwestern has uh Jessica commented on it and I think you commented on it between the two of you that the feds also are embracing this type of model if that shows a lot of promise just a suggestion that in one of the green mountain care board meetings soon that be presented with more detail so that everybody understands what that model is going forward that's my comment if we could only have the days where we could have traveling board meetings would be down in Bennington having that conversation Dale but one of the things that the board has been reluctant to do is put any ass on hospitals as they're dealing with all these other things and and so um if if Tom D wanted to come forward and volunteer that he has the time and the ability to do that then we certainly would be receptive to that but we're kind of reluctant to uh put further demands on their time right now totally understand that thank you other public comment well board and team I think uh it's clear that we have a lot of decision points that we have to start to flesh out that we really need the feedback from the hospitals as soon as possible and that you know there are areas of agreement and areas of uncertainty moving forward but I think and hope that next week we can start to slowly make some decisions and we'll leave it at that thank you Patrick and please thank your team members for all the work that you've put into this guidance very helpful and is there any old business to come before the board is there any new business to come before the board is there a motion to adjourn still moved second Maureen has moved to adjourn seconded by Jess um all those in favor of the motion signify by saying aye aye anyone opposed signify by saying nay thank you everyone have a great rest of the day I can tell you that it's sunny and 50 degrees here in Rutland hopefully you're all uh sharing that same weather in your areas bye bye thank you bye