 you on as well. Yes, I'm here, ready to go. Okay, great. Then I'm going to reconvene the meeting and we have three hospitals that we're working on and I just spoke with Patrick and we're going to start with Mona Scottney. So Patrick, when you are ready. Thank you, Mr. Chair. So we went back in to look at Mona Scottney around the 0.3% discussion that has a value of about $135,000 on their overall change in charge. And their original budget submission actually had MPR growth of 4.7%. And that came down to 4.6% with the current budget due to the reserving of funds on the income statement which lowered their NPR FPP. So if you were to accept their current budget, the NPR growth would actually be less than it was originally submitted. And it doesn't move the needle a whole lot, that 0.3%. But the difference is the fact that they are reserving for a little bit more on their income statement. So it's, you know, the board can probably go either way in relation to that change in charge piece. So questions of Patrick about Mona Scottney from the board. I think there was just one question about the provider tax. Okay, I wanted to talk to Jess. Oh, I was just gonna say, I thought one of the questions we had was about the provider tax, whether they had actually in fact underestimated the provider tax. Given the overall size of the provider tax and knowing Dave Sandville to be a conservative person, we don't feel that he would underestimated it by a million dollars, which would be a significant amount in accordance with the size of their tax. So we focused on provider taxes that we felt were over budgeted, not under. If it's under, then the hospital's gonna have to account for that somehow if it does come in higher. So we weren't too focused on that. We don't think Dave would have missed it in accordance to our very quick calculations by a million dollars. We feel he's probably pretty accurate on that. Okay, Maureen, were you the other one speaking? I was gonna say the same thing, Jess, just about the provider tax. Okay. There's that question, but... Does any board member wish to make a motion or further questions or discussion? He actually had a motion on the table because I don't think I withdrew it before we broke. And was your motion the 4.6, Robin? No, it was the 4.3. Okay. And that was properly seconded, correct? Yes. That's my recollection. Are you still comfortable with that motion? Struggling a little bit, even though it's only 0.3. So that's... I definitely agree with Jess that we don't... Like we wanna be consistent in terms of ensuring that folks are not building their ACO participation in the rate. So on the other hand, if they're... Since the NPR came down a little bit, I think I would actually... I'm talking myself around here. Since the NPR came down in their new proposal, I think I would revise my motion to the 4.6% change in charge. So as submitted. And is that agreeable with the seconder? I think I seconded that. I just wanna clarify the reason their NPR came down is because they put in a reserve for the ACO, isn't that correct? Correct. So that's why the NPR came down. So their gross wasn't coming down. It's just a working reserve. I don't know if that... We think sure reversal or not. I don't know. It would be helpful to me to have more discussion on terms of where other people are for sure. So maybe I'll just withdraw the motion to start and then we can talk. Okay, further discussion? Motion withdrawn? I do like the fact of being consistent. And if... So that's what draws me to the 4.3%, but it's not a killer either way to me. One potential way to adjust for it is to move it from the exchange in charge into the COVID rate. Because then we would again would be able to revisit that. That is a good idea. Because I was compelled by Tom's argument that there was conservatism in the budget. And so I think that's a great idea Maureen. So that would make it a 2.5% COVID increase? Yes. 2.1 base, 2.5 COVID. Do you wish to make that motion Maureen? Sure. So moved to approve the Mount of Scottney Hospital and Health Center budget as submitted with a 4.6 increase from 2020 to 2021. And we'll go away. 2.4%, no a 2.1% standard increase to overall charges and a 2.5% COVID bars. I can't read the rest of it. Increased overall charges and subject to the standard budget restriction. I can't read the end of my mind. I think you got it. So as I understand the motion, the motion is to approve a 4.6% change in charge broken down to a 2.1% standard increase coupled with a 2.5% COVID-19 reduction. Related increase. It would be subject to the standard budget conditions as outlined on slide 27. And that I guess, do we have the finalized NPR is the 4.6 correct Patrick? It should be correct. With a 4.6% NPR FPP. Further discussion from the board? If not, I'm gonna open it up to public comment. Would anybody in the public wish to comment on the motion for the Mount of Scottney Hospital and Health Center? Hearing none, all those in favor signify by saying aye. Aye. Aye. Aye. Those opposed signify by saying nay. Let the record show it was unanimous vote to approve the motion. Patrick. Thank you, Mr. Chair. Laureate, you could please navigate to Central Vermont's first page. Thank you. So we went in and we ran the calculation based on the $430,000 difference that the network had pointed out. And if you were to remove that from the 6% overall change in charge, it would reduce that to 5.5%. And if you were to cut that equally from the commercial effective rate, it would take the 8.5 down to 7.8. It would effectively reduce their NPR budget to budget growth to 8.5% from 8.7 to fill in on those figures provided. And I believe that was the only component that we were to check on during this. And I don't think Maureen ever got to really conclude her thoughts around bifurcating any of the rates. So we didn't run any additional calculations not knowing what the end result of that thought process would be. Okay, questions of Patrick from the board or board discussion? I can go ahead and start. So I have been wrestling with this one over the lunch hour quite a bit, including I went back and looked at actually our staff presentation around patient origin and patient migration, which I'll come to in a moment. I'm supportive of bifurcating. I'm gonna start with the change in charge. I'm supportive of bifurcating the change in charge. I'm a little higher than what Maureen had indicated she was earlier, which I think was for underline standard into COVID. And I would probably do a total of seven and either do four and three or five and two, depending on where other people were at. And the reason for that is because of the several years of losses, the cash on hand being in the low 100s and the ongoing financial challenges. And I think that's more consistent with what we've been doing with some of the other hospitals that have had financial challenges. My concern, which is aligned with what Maureen had talked about earlier is that it seems like the NPR is pretty much driven by the expense growth. And I don't think that the expense growth is sustainable over time. So that worries me a lot, which then made me remember from the testimony, folks talking about how the volumes for CVMC were pretty variable. At least that's my recollection from the testimony and that that was the unpredictability of that made it difficult to the staff for, which I'm sympathetic to. And when I went back to our staff presentation on where the people who go to CVMC where are those patients from as well as where do people in central Vermont go? And these were preliminary. So not, we'll need to be finalized, but it just struck me that it was consistent with sort of my anecdotal experience living in the community, which is that particularly for inpatient, CVMC is drawing from the local community. There's not a lot of people from other areas that come for inpatient. Some for Morrisville, it looked like. And then for outpatient, it's broader. A bunch of folks from Randolph and then for primary care, it's even broader. That seems to attract a lot more people. But when you look at Vermonters who live in central Vermont, we have a lot of choices here. And so you do see a lot of people going to probably or people going to Alice Peck Day or Dartmouth or UVM. And so I think that also creates other challenges for CVMC in terms of trying to figure out the right staffing level. So I think for me, I would err a little bit on the side on a higher change in charge than I normally would because of those factors. But I did want to also say that I think the expense growth is not sustainable. And I think grappling with some of these issues around the kind of care patterns in this area may be helpful in addressing those. Although, I leave that to others with much greater operational experience than I to sort out. But so that's where I landed on the charge side and some of the things that I've been kind of fretting about over the last hour and a half. Thank you, Robin. Patrick, I guess the baseline question for me to you is, this morning you expressed that you didn't think the 430,000 was an accurate number. Having had a little time over lunch to look at it, do you have better faith in that number? Or you still believe that it's still understated? I'm not doubting the accuracy of it. I'm just stating that we never walked through the methodology of the math behind how they arrived there. So we can't personally support it from the staff's perspective. We weren't working in tandem with them. They found this and then reported it back to us that they thought this would be kind of an overstatement and there might be wiggle room there. Our piece is still around whether or not the board accepts the justification for the provider tax increase as outlined on slide 135. It is a change in accounting methodology that's driving that year-to-year appearance of growth up as high as it is. So the difference from our mind is the network is doing what it has to do to appropriately account for it, but should the commercial payer have to support a budgeted increase based on a change in accounting methodology, that's where we stand. There is nothing in the history of either this or the medical center that says the realized payment is gonna go up that much. So like I said, when we started this, we're not gonna hang our hat on any particular number, we just don't feel that that increase has been appropriately justified, despite the explanation around the accounting change because Diva does not recognize the matching principle of accrual accounting when they're factoring that tax. So in reality, if this is how things move forward, this new methodology that they're employing here will keep them a year ahead of their tax every single year. So what they actually pay versus what they account and budget for, they will end up with a positive on their cash flow at the end of every single year ahead of the next year's tax. So that's where we stand, we're not gonna put a specific number on it, but we think the trend analysis kind of speaks for itself when it comes down to the growth is actually gonna be. Patrick, can I ask a clarifying question? And if you're not, is that what you're saying, if you're not willing to put a number on it, does that mean that your recommendation for reducing the change in charge to 5.25 no longer holds? Cause I thought that was all provider tax. It was all provider tax, but it doesn't sound like we have the confidence in the board that we've made our argument thoroughly enough to continue to support that. And we didn't wanna change it because we've already presented it as such. So now it's up to the board to decide where they wanna go with that. They can either accept that. We've tried to hang our decisions on financial trends and other financial figures that we've analyzed throughout this entire process. But if we haven't done our job in justifying that for you all, then you should feel free to take an alternate route in this. So I guess that would be my statement on that component there. Okay. If I could jump in here a little bit. In terms of your due diligence around the provider tax, you did talk to Diva. We spoke to a person at a contact at Diva that we communicate with every year around the provider tax. Right. And you did talk to Nolan Langwell at the JFO, who is their expert on the provider tax. Correct. So, and do you know of any other of the hospitals that use accrual accounting to determine the amount that they put in to adapt it for their provider tax? Not beside, I mean, that discussion has only been had with these two hospitals based on the significant increase that we noticed when analyzing budgets this year. That is all. This has kind of been the jumping off point around that discussion. And I will also say that when the network initially submitted their written response a couple of weeks ago, there was no discussion in that response around a change in accounting methodology. They basically explained out to us how Diva does it. And we did not find that to be, we still couldn't figure out how they got to where they got with their tax. And it wasn't until we came out last week with our initial recommendation that discussion started up again around while we've had a change in our accounting methodology. And has any other of the 13 remaining or 12 remaining hospitals have they been offered the opportunity to adjust their accounting methodology? Coming down the home stretch of a month's long review of a budget. I wouldn't know that UVM is adjusting theirs based on, from what I understand, based on advice from their auditors. But you could agree that there is a one set of accounting that could be whatever UVM and central Vermont use. But then there is our adaptive system that we use. And the information that you use to base your recommendation was on the information that was submitted to you by the hospitals. Yes, correct. And if you look at that bottom quote there around the 6% tax, I would say that that hospital is probably trying to match their fiscal year end projection for 20 with what Diva is actually going to assess them. Now, if they took UVM's approach, that response would be a little different. It would most likely be up because their fiscal year 21, the year in which that quote unquote, that tax needs to be matched is higher than it is in 20. So I'm guessing that that hospital there is looking at their fiscal year 20 projection and saying, okay, where are we going to come out with on our tax? Our figure, our taxable base is coming down, therefore our tax is going to come down. So you could have had a hospital that kind of looks at their 2020 projected NPR sees that the COVID situation has really dropped to the revenues. And in order to preserve capacity in other areas, they may have lowered their tax in their presentation to us, whereas other hospitals could have used the Diva methodology and because it is based mostly on a pre COVID calculation, their estimated provider tax might be higher. Well, I think with the Diva calculation, I mean, that methodology's been in place for some time now. So most likely the hospitals who are looking at the Diva methodology are factoring in some of that potential for true up. So it would move a little bit. The needle would move a little bit for them and they would probably factor that in. The difference with the accrual one is UVM is looking forward at fiscal year 21. And they're saying there's gonna be a tax assessed eventually on every month in the next fiscal year based on what we earn. Well, with your taxable base is going up with those budgeted NPR and FPP numbers, your tax will go up. The reality of the situation is their NPR FPP in 2020 in which Diva will assess that tax is coming down. So the Delta there would be that the UVM and central Vermont end up ahead on a cash position in perpetuity with this methodology. Not to say that it's wrong or right, but that year to year growth is not happening organically. It's happening because of a change in accounting methodology. Well, I agree with that. I feel a little uncomfortable having gone through this lengthy budget review process and get to the very last day and all of a sudden have an accounting methodology change drive our decision making when there's been ample opportunity that the numbers we are using are numbers that came from the hospital and there's been ample opportunity to scrub those. And that opportunity has not been available to everybody because they used, for example, the maybe the Diva methodology. So I'm just worried that here we are about ready to after hearings and healthcare advocate oversight and this whole other process that we have getting to the very last day and having a significant change having to do with the provider tax be used to the advantage or disadvantage of one or two hospitals. All right, so maybe I'll jump in here a little bit. So this is a hospital on my mind that's in trouble or on the brink of trouble, right? They've had four years of negative margins. They are projecting only a 0.5% operating margin and that's if they hit their target, they'll get that, which they haven't always hit and in the last few years have not hit their target. So I worry that this is a very, very slim margin that may or may not be reached. Their expense growth troubles me as it does others, 8.2%. I think it's high, particularly for an affiliated hospital that should be able to benefit from bulk purchasing and economies of scale and other sorts of reasons why we do see some benefits from affiliation. So all of those things point to the importance of sustainability planning and why the board is asking for that. Their days cash on hand are low below the, the state average in the hundreds and low 100. And so it's a hospital that worries me. And this is also the hospital that is gonna need some margin to be able to help prepare for that psych unit, that inpatient psych unit. I know that's being largely bankrolled by UVM, but to the point that it's on their campus it is gonna have an impact on their budget. And so I worry about this hospital. So as we're thinking about this there's a couple of ways I think we could go. And I think largely people are focused on the commercial rate, right? That's what seems to be the most of the conversation so far. We can accept it as is. We could reduce for the provider tax although that debate seems to be going on. The range seems to be the 5.25 from the staff recommendation up to the 7.8 which is now the reduction in the commercial rate coming from UVM from that estimation of their now downward adjustment to the provider tax. So that seems to be the range in the commercial rate 5.25 to 7.8 that comes just from looking at the provider tax. But there's another way to maybe think about this which is to build up to what seems reasonable. So in my mind, I start with a 3% which is medical inflation, right? And UVM health network has articulated that their medical inflation is 3% in the presentation and some of their materials. I think that if we look at their change in charge over time, their approved commercial is 2.27. So I think that if we're looking at the approved commercial over five years, sorry, that was the five year average, that's low relative to the median. I don't know if you can flip to your new slide seven, Patrick and Lori that you did over lunch. Thank you for that. Okay, so this is the new slide seven. And I think it is important to realize that the bottom has changed a bit because of the calculations that are done for the health network where there were some discrepancies between overall charge and effective rate. I think going forward as a side note footnote to this, we really need to in the next budget process ask for apples to apples from every hospital because it makes charts like this very confusing to think about, is this the effective rate? Is this the overall charge? It's not all apples to apples. But in the end, whether you're looking at the approved commercial rate, which is 2.27 or you're looking at overall approved 2.4, it's on the low end, right? It's on the bottom part of the distribution of change in charges over five years. So I guess where I'm at is I could see a 3% medical inflation. I could imagine adding a 1.5 to 2%, which is in some sense a catch-up. You can think about it as a catch-up from lower than median, commercial rate increases over time. Maybe you can call it cost shift that you're willing to add to the commercial rate part of the cost shift, not all of the cost shift, but some of the cost shift. And then if we wanted to, that would get us to four and a half to five as a base. And then think about a COVID adjustment, which consistent with other hospitals that are in financial difficulties, they are, we've been giving about 2%, right? And so with all the uncertainty around COVID, this is one way where we're sort of trying to smooth out that uncertainty, allow for it to sunset at the end of the year as we understand more about what happened. So I guess I'm throwing this out there as we can go back and forth around whether the provider tax should be calculated this way or calculated this way. But the other way to think about it is just to build the commercial rate from the bottom up and see what we feel is reasonable. Given the financial situation of the hospital, the need for a bottom line, particularly if we're hoping that they will be helpful in contributing to the buildout of the inpatient psych unit and recognizing their low days cash on hand and their negative margin zero over year. So I throw that out there as another way to think about it to maybe get us away a little bit from the provider tax. I will say doing it that buildup way gets us right in the middle, roughly there of that range of the provider tax. So it's kind of a little bit of a robustness check. Does it even make sense? I guess from my point of view, there doesn't seem to be any argument about the 430,000 piece of it. And from there, it starts to get into the argument and I understand the argument that you just made just, but I look at this, if we're gonna look back at the Kager for five years on what the change of charge is, then this whole process is a farce and what should be done is every year, we should just say the change of charge for every single hospital is X. And it's not gonna deviate from hospital to hospital. And that's what it's going to be because otherwise four years from now, we're just gonna come back and revisit a decision that was made four years previously. So it just, that's the frustrating part for me. And I probably shouldn't be as frustrated as I am, but maybe it's because I had a salad for lunch instead of a sandwich. Yeah, I'll just add a few things. I agree, I think we've beaten the provider tax to death. And I could talk both sides of, are they doing it right now or wrong now? And we could look at other hospitals. But as we know in a budget, every single number on the page is wrong, right? So we're not really scrutinizing every number as much as we are this one. And I do realize it's a little different because we have a calculation and we could go back and look at that calculation. I do like the way that Jess is approaching it which is really kind of looking at it from the bottom up base. I don't agree with the, necessarily with looking at the change in charge and the new mapping without putting it in context of they requested some of those lower rate increases like 0.7 to in 2018 because of being over in prior years and things like that. And we also didn't start with where are they starting from? So what is their cost average compared to the other hospitals again? And then looking at that base. So I appreciate, there's a five year average but the five year average is impacted by things that the hospitals have done and requested in the past based on their past performance. So it's one indicator and we should look at all the indicators but that's one of the reasons why I'd have a little bit of a concern with focusing so much on where that aligns. I'm looking more at the 4% that we've kind of aligned on with a lot of the other hospitals as the base rate and then flexing with the COVID rate and whether that's an additional two or 3%, there's been some ranges of, I was really, I'm at two to get them up to 6% but with the difficulties they've had in the past and the time to try to get their expenses aligned with their revenue, which I think they need a lot of work on. I could go along with people saying the 3% and getting up to potentially a total of seven with that 3% COVID, again, something we look at next year. And at that time, there'll be a lot more clarity on what are they booking for the provider tax? That's just one line, right? But what did they get for all the reimbursements? Because we know even with what they had requested in the first round, there's a second bite of the apple. They may get more funding there. None of us have any idea on what's gonna happen with utilization in the future. Will it come back or not? Every hospital has made assumptions and worked hard to get those assumptions right but we won't know that until we're through this. And there's just so much uncertainty that I'd be willing to put more into the COVID piece, which then gives us time to review that next year. And if it carries again, some of these COVID pieces may carry on year over year. And some of them may not if we see things are turning around. And we know that the hospitals will all act responsibly to try to get to the best numbers that they can. And if we can get away from using the COVID in the future, we would do that. Because again, one of our responsibilities is to look at what's the commercial payer pain. And we've heard so much and we know so much. The strain that that puts on individuals who don't even go to seek care, which isn't even factored into this, that people don't go for care because they don't have coverage. Their deductibles are too high and that just creates other issues. So it is the chicken and the egg which one do you work on first, right? Getting the patients to be able to come to the hospitals for the care that they need or price continually pricing them out of the market so that they can't come to the hospital or they choose not to because they're putting food on the table and paying for their rent or mortgage. And that's a factor we do have to consider. And I know when we look at what's written up about this after the fact, people aren't considering that. It's just saying we're cutting hospitals back and these are hard decisions and we know we're all working together to try to get to the right place, but that's why I would err a little more on putting the COVID piece. Maureen, can I ask you a clarifying question? Sure. So when you're talking about four and three, are you talking about effective commercial rate? Or are you talking about overall change in charge? Because they're so different. Yeah, I'm talking about their commercial change going from 8.5 to either six or seven. Okay, so what I think I heard you propose is like a seven with a four plus three. Yes, either four plus two or four plus three, but I'm willing to move on that. It would have to be a recalculation on the overall change of charge. Yes. And again, I think as Jess pointed out, the network kind of does this differently than everybody else in some ways. And so it's hard to look at kind of an apples to apples comparison, but the way I try to look at it is, they're gonna get what they get from Medicare and from Medicaid. Some of it obviously is depending on what type of hospital is based on their expense structure as well, but that's a little more out of our control than what is the commercial rate piece. Yeah, so, you know, in math because I haven't done any math on it, but my expectation would be that the overall change in charge would probably somewhere around five given the scenario that you laid out with the four plus three. Am I in the right ballpark, Patrick? I believe Lori has a spreadsheet that we can calculate that off of. I would imagine it would probably come down at a relative rate to the reduction in the commercial effective rate. So short answer, yes, somewhere in that ballpark. Okay. Yeah, if it stays the same relationship, it's 4.96, so it's 5% overall change in charge relative to a going down to a seven and six would be obviously slightly lower than that. Other comments or anybody desirous of making a motion? Well, I'm not desirous to make an emotion, but I like the direction. I leave that to Robin, and she does it so much better than me and certainly me, but I like this direction for a couple of reasons. One is there is so much uncertainty and the COVID rate is, could be a one-time rate increase or it could be get folded into a base at some point down the line. I'm noting that central Vermont in terms of the healthcare stabilization is was on that list for $7 or $8 million. But even there, there's some risk around that that the feds could come in and audit and say, uh-uh, this was wrong, this was wrong, this was wrong. Whereas our COVID rate is something more of a guarantee at least for a year. So I like this concept. I can make a motion. Great, thank you, Robin. I move that we approve central Vermont medical center's budget with a 7% effective increase to effective commercial rate, which would be 4% increase in the standard rate and 3% increase in the related to the COVID charge with the commensurate reduction in NPR FTP for fiscal year 20 to 21 budget and commensurate reductions in expenses. And of course, subject to our standard rate or subject to our standard budget conditions and outlined on slide 27. A second. It's been moved and seconded to approve central Vermont medical center's budget with an effective commercial rate overall of 6, 7% of which 4% is the standard increase and 3% the COVID-19 increase and subject to the standard budget conditions outlined on slide 27 with staff calculating the new NPR FPP. Is there a discussion on that motion? Hearing none, I'm gonna open it up to public comment. Excuse me, Patrick, did you say something? Nope, I was clear my throat. Oh, your thing went blue. So I thought you were talking. Okay, public comment. Anyone from the public wish to comment on central Vermont medical center's budget? Hello, Kevin, this is Mark. Hey, Mark. Okay. In the motion, there was no reference to change in charge and I just wanted to share that change in charge has no impact on NPR or very, very, very little impact on NPR because CBMC is one of those organizations that we negotiate the commercial rate. So I would say since the motion on the floor is 7%, that I would just throw out there about keeping the change in charge the same because what changes the commercial is really that 7%, not that 6%. So I would just throw that out there for consideration. So you lost me completely, Mark, because what the proposal was was a 7% increase to the effective commercial rate. Okay, well, I thought under discussion, there was some discussion that the change in charge would be proportionate to what that was. So- So the overall change of charge should come down if your effective commercial rate is being decreased from what you asked for, the overall rate should come down as well. What am I missing? It's not the way that it works, Kevin. I mean, it is like the difference between the list price on the car and what you actually pay. So I just throw that out there for consideration. That change in charge has little impact on commercial rates whatsoever is the effective commercial rate that drives that. So I just throw that out for consideration to the board. You know, that's it. I did wanna make a couple clarifying statements on the provider tax based upon some of the discussion that was thrown out there. So to clarify something, we have always submitted our budget. CVMC and the University of Vermont Medical Center submitted our budgets based upon the accrual accounting methodology. That is no change from what we have ever done in the past. Okay? Okay? What is slightly different is the actual booking. So that reduction in revenue in which the tax will be assessed at a later date for FY20, that reduction in tax now will get booked to the actuals under FY20. But to clarify things, there is no change based upon how we submitted this budget to any other budget. Okay? And then the other thing that I would like to throw out there just in relation to some of the comments that this seems like it's a late in the game, okay? We had just heard that there was a discrepancy based upon how the staff was calculating the 21 tax to the tune of $2.4 million for CVMC and $8.3 million for the Medical Center. As soon as that came up in the presentation, I think I said under public comment well that we need to have some conversations. So, you know, this came up because of the staff, the way that they were looking at it, not that we injected anything new into the budget process late in the process. So that was a reaction well to what one of the presentations was and I understand how the staff came up with that by the way, our difference in opinion based upon accounting methodology is when do the actuals hit in FY20 or FY21. So I just wanted to throw that out there to clarify things. Thank you, Mark. Can I just ask Mark a question about that? Certainly. Because what you sent us was this and this was how I interpret the statement. You wrote, historically we have recorded the provider tax based on the actual payments made. This was not the proper accrual accounting which says you record a revenue or expense when it is incurred. For the provider tax, that means you record the expense when you generate the revenue that the tax is based on. In the last few years, the difference between recording the expense based on payments versus what the actual incurred has not been material. But this year with the significant decline in revenue from the COVID slowdown, there's a material difference. As a result, we've been adjusting our provider tax expense down in the actual revenue we have generated. Our original fiscal year 20 projection was based on March. By the end of fiscal 20, the record will be based on the actual revenue generated which is the proper accrual accounting. So I'm not sure that the statement that you sent the written statement that you sent us. Maybe I interpreted that incorrectly. Actually, okay. So I do think it is like everything in that original or in that statement was based upon how it's booked based upon actuals. Everything in that statement will refers to actuals. So the only clarification that I wanted to make is that our budget has always been submitted on the accrual methodology. It was the actual booking for the actuals that that statement was referring to Maureen. If that helps clarify. Okay, so that would mean that one of those is wrong, right? So if you booked it on your projections on an accrual and then when you did your year end, you did it on actual, right? So that's what's actually hit the books. So if we were to fast forward then under that methodology to the end of 20 and the end of 21, you would have a different, you would book the actuals in 20. We would have booked the actuals in 21 which would have been based on the 20 year end which would have been lower. Which is, you know, so you're mixing apples and oranges, I think, I mean, I think we've beaten this up a lot, but you haven't been consistent. The only inconsistency has been on the actual side, not the budget side. So that's my only point is the way the provider tax was submitted in this budget was based upon the FY 21 revenues and in every other budget, it was submitted based upon those revenues for that budget submission year. That's it. So now are you changing your process for what will happen with actuals for this year? Yes. So that's an accounting change. And before you were mixing two separate things, which I'm just not sure why the accountants didn't pick up on that, because usually you have to provide work papers for your, I've gone through many audits, you provide all your work papers for the approvals, you provide all your work papers for the actuals. And that's a significant number that goes into your budget. So I'm just surprised that it was never found or reconciled because usually accountants are to the penny. You know, that's what I've always dealt with. So, you know, Maureen, that's exactly what correct. I just don't think the difference because of the consistency in the revenue before, also that across the materiality threshold. But the statement that you said, I agree with. Okay. Okay, is there further discussion? If not, I'll open it up to public comment on Central Vermont Medical Center. I'm assuming you didn't have anything else to add, Mark, is that correct? No, that is it. Thank you for asking, Kevin. So others, anyone else who wishes to offer public comment on Central Vermont's budget? Hearing none, I believe the motion and correct me, maker of the motion, if I have this incorrect is that we would be approving an overall 7% increase in the commercial effective rate with 4% being a standard piece and 3% being a COVID-19 piece and subject to the standard budget conditions as outlined on slide 27. Do I have that motion correct? Yes, and adjusting the, you said adjusting the NPRFPP accordingly. I did not say that after what Mark said, it's because I was so confused, I wasn't sure. Actually, Kevin, my reference was related to gross charge. I can follow to give it a. Okay. The NPRFPP would come down. I think, I'm not trying to speak for Mark, but I think I understand what he's saying with the change in charge. So I'll use my $100 example, right? So if the charge is $100 and they keep the change in charge to go up to 106, it goes up to 106. And if the commercial reimbursement on the $100 was 80% and they paid $80, now what we're gonna do is the $80 is gonna go up by the 7% and the top line can still go up by the 6%, but the deduction will be different so that the change in charge could go up overall by a different number and then you fix it by the other. Is that right, Mark? Yes. And Mike, only question about that is, does I understand like, certainly you don't want your charges to get below your negotiated rates? But are there, is your Medicare reimbursement tied to the change in charge for this type of hospital or does that have any impact on other payers? Is that a question Mark can answer, Kevin? I think so, Mark. And I agree with Robin's question. Does somebody that doesn't have insurance have a higher bill if the overall rate isn't adjusted or how does it impact your government payers? That has very, very little impact on the government payers and as far as the South Pay, I believe our South Pay policy is a standard discount based upon the average commercial discount so that would be factored into that deduction analysis that Maureen referenced. Thank you. Okay, is there any other public comment? Hearing none, I'm gonna try this one more time. As I understand the motion, the motion is to set a commercial effective rate of 7% of which 4% is a standard increase and 3% is a COVID-19 increase. Staff will calculate the change to the NPR FPP and the budget will be subject to the standard budget conditions as outlined on slide 27. Have I got the motion correct? The only sort of modification I would say is that we've been including that the expenses would mirror the top line. Thank you. Thank you for adding that, Robin. But yes, I think you have the motion correct. Okay. Is there any further board discussion? Hearing none. All those in favor of the motion signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Let the record show that the motion carried unanimously for Center Vermont Medical Center. So I think we're down to our last little hospital to go. You are correct, Kevin, 13 down one to go. So to pick up where we left off before lunch we did factor in the, I believe it was $570,000 component to the change in charge that was submitted in the letter this morning. So because the overall change in charge and commercial effective rates change in charge are the same, the reduction of those dollars would bring that down to 7.85% respectively for each of those and NPR would shift from 5.7 to 5.66%. Not a very large reduction there based on the figures that were provided. So can you just repeat the overall, what the overall change in charge comes down to? So well, based on our prior discussion it may not move at all. However, the commercial effective rate would come down to 7.85%. Should those $570,000 be removed from the change in charge component of this? So- And NPR is 5.66? Correct, yes. Thank you. Yeah, certainly. So University of Vermont Medical Center, FY21 budget requests represents 5.7% growth over the fiscal year 20 budget request and that is in excess of the 3.5% growth ceiling set forth in the guidance. As stated, overall change in charge and commercial effective rate as submitted are 7.97% respectively. The hospital's justification is that their tertiary care volume continues to grow. If the rate increase is not sufficient to cover inflation, the only option is to impact the margin. The only option to impact the margin is to get back on solid financial funding is to begin the elimination of services that lose the organization money. They also cited the increase in volume and patients create an increase in expense. They need a 3% revenue increase to cover their inflation costs. And if they don't receive 3% from the government payers and the ACO, they need to get 6% from commercial payers, 50% of the revenue to keep pace with the expense inflation. They also cited given those volume numbers that they need to increase their staff and the numbers that they provided there are 18 position FTEs and 129 non-position FTEs. Lori, if you could navigate to the operating margin. Screen please. So this is a hospital that was operating 0.7% below budget coming out of February and into our new COVID world. Their operating expenses are set to grow 8.7% in this budget. That is the highest CVMC comes in second highest around 8%. This is a hospital that has seen regular revenue growth over the past several years. But contrary to that revenue growth has seen margins declining at a pretty rapid rate from a high of $75.6 million five years ago in fiscal year 15. With this year's budget request, NPR is budgeted to grow beyond $1.4 billion with a margin of 2.5% that values at $40.3 million for the University of Vermont. If we fast forward to their change in charge slide because we focused on that a bit more approved overall gross charges. There's several years where nothing was submitted and nothing was approved. Therefore their blended five year rate takes into consideration those several years of non-asks. So they're approved and submitted are 1.1% and 1.2% respectively. UVM has for several years now focused their budget requests on the commercial effective rate. And those rates dipped in 2018 and have begun to rise slightly since then in the blended five year average there is 3.04 for approved versus 3.54 for submitted. So moving forward to the motion again this was kind of in the same context essential amount around the provider tax. However, as has been discussed that's been talked about ad nauseam. So our initial recommendation probably does not stand with the board any further. So with that we would turn it over to the board for discussion and dialogue on the University of Vermont Medical Center budget for fiscal year 21. Board members, questions of Patrick or comments on the University of Vermont Medical Center budget? Well, this is one that kind of structurally is difficult to kind of embrace. Just some, when we talk about sustainability what is the number that we should be talking about or that we do talk about? And to me it's the 3.5% which is grounded in economic data that is readily available of over a 15 or 20 year period. It's embedded in the all pair model at 3.5%. It's the guidelines that we put out on the budget is 3.5%. So for me that is kind of a working definition of what's sustainable. And so here and even I think that the board did a very good job with the QHP insurance. If you take those two rate increases for Blue Cross Blue Shield and MVP that we approved and divide them by two, you get 7.4%. So that's kind of the world that we're trying to corral healthcare spending and healthcare revenues. And but this proposal has some just striking context for me. It says that if you take UVM Medical Center's requests out of the mix and just look at the increase in NPR for the other 13 hospitals, it's nine-tenths of 1% versus with UVM in the mix, it's a 3.3% increase. In terms of total operating expenses with UVM Medical Center in the mix, it's a 5.3% increase across all hospitals. With UVM out of the mix, it's a 1.8% increase. If you look at the total commercial requests across all the hospitals, that went up by 4.5% from 1.49 billion to 1.56 billion. UVM's commercial request is for an increase of 8.2% from 804 million to 869 million. That's data that you can get from the payer mix. So it's just because UVM Medical Center is so big that it's easy for them to kind of absorb all the oxygen in the room. But I get very concerned that their growth comes at the expense of other hospitals having access to commercial rate increases, the most flexible money that is in the system, it's not Medicare, it's not Medicaid, it's commercial money. And if UVM Medical Center, especially with their favorite payer mix, are accessing those revenues aggressively, then that means in a zero-sum kind of game that other hospitals don't have access to it as readily, that when the insurers negotiate their rates, the other hospitals get treated differently than does UVM Medical Center, I presume. Independent providers don't have access. They're kind of the, I'm trying to think of analogy which I won't use, but the last one's very often to get consideration. But more importantly, and Maureen and others have referenced this, it's the commercial rate payers. In terms of premiums, co-pays, and deductibles, and we saw through the QHP process that, you know, over 1,000 comments on it. So I'm inclined to be aggressive here in terms of looking at trying to get UVMs. Tom, you went dead. Can anybody hear Tom? Am I back? Yes. Okay, I put my hand on the table and I guess it flipped the switch here. So just to end, I'd like to kind of push this down closer to what our metric for sustainability is, which is 3.5% and kind of work toward that goal. There are a couple of ideas I had, you know, one of them obviously was the provider tax and we'll see how that flies. Another one that kind of caught me during the hearings and testimony is that UVM presented that they projected a 1.7% increase in patient volumes in 2021. And depending on whether you look in the narrative or you looked in the slide presentation, that was a $58 million or $45 million increase. But that when you work that backwards, if 1.7% equals say $58 million and you work that back to just the math to get to 100%, you're looking at 3.2 billion. And that's nowhere near what UVM's overall budget is. So, I mean, it's, you know, and I think, I mean, in my experience, there's never enough money. You know, as finance commissioner for nine years, 10 years, there's never enough money. And, but we had a sustainability goal. And I'm happy to say that the state budget during that period, general fund and transportation fund grew at 2.9% because there was an agreement, you know, on the goal. And here I just worry that expense growth is driving requests for additional revenues. And I just worry that it's so out of scale if it continues on, there would be no hope for the all pair of model. There will be no hope for some of the independence and the overall system will just become very unstable and unbalanced. Other board members, everybody became quiet or else we have a muting problem. I'm just gonna talk a little bit to the NPR for a minute. I just, I don't, Tom, I understand what you're saying about the three and a half percent where I have a little bit of a difference opinion is if you look at their 2020 budget, it was 1,348, and the 20 projection now is 1,0215. So that's down $133 million from their, from the, from the, where the budget was. And one of the things we had thought might happen, although we do not know was, was some of the volume that didn't happen this year, maybe we'd come back next year and we would be willing to have that as somewhat of an accommodation. And if you look at now where they're the million 424 that they're looking at for 21 against their budget in 20, that's an increase of, I think I had about $77 million. So the, no, I lost my numbers. The 1,424 minus the 1,348, yeah, $76 million. So they lost $133 million in 20 and they're looking for a $76 million increase to the next year, which does bring them over the three and a half percent but does not bring them over if we were to look at what we had talked about for enforcement, which would be, you know, the two year they would be allowed to give that back. So that's just one data point. That said, of that growth of $76 million year over year, half of it is a commercial rate ask. So 38 million of the 76 is a commercial rate ask. So they're going up by 76 million in their top line requests. I keep going back to the 20 budget because, you know, it's very difficult to look at the 20 projection and their expenses are going up the 1570 by 125 million year over year. So that is concerning with the 1570 21 budget to their 20 budget going up 125 million with their top line going up 70 something million and half of that is commercial rate. So again, price, price is a piece of that. So that they're way out of line for their expense growth compared to their revenue growth. And I think we've talked some about where they talk some about the inflation and different things like that, but I'll stop there for now. I agree with that that they're operating expense budget to budget is up 8.7% and their NPR requests is I think 5.7%. So those two are not well aligned. Maybe I'll jump in a little bit. So I agree that the expense growth seems problematic and I think we should, you know, perhaps address that in some way, presumably maybe through the sustainability planning, even maybe in the budget order. But Tom, I want to just talk a little bit about your comments. A lot of this is driven and we've heard this year over year by patient traffic, their NPR is growing to some degree by patients choosing to seek their care there in increasing numbers. And they showed some data for increased patient transfers this year, year over year. They also showed some data about their acuity, slightly increasing. All of that is going to contribute to increasing NPR that may require us to make some adjustment for that 3.5. I don't want to treat every hospital the same way. The 3.5 is a target, but if one hospital is seeing more patient migration, that has to an adjustment has to be made for that. And to Maureen's point, if we look over the two year period, they're still within the range. The other thing I just want to say is, you talked a little bit about treating them differently and I think it's, you're right. And I think that's justified to treat them differently. I mean, this is our academic medical center. This is the institution that we rely on all of us when our care, you know, our health is seriously compromised. So I worry about the declining margins that we're seeing, which this slide perfectly shows, the medical center seeing declining margins between 16, 17, 18, 2019. And the reason I worry about that is because it puts their capital investments at risk, right? And we need this institution to be able to retain funds, to be able to hire the best doctors when we need it the most and to be able to invest in the equipment that we want there when we need it the most. And in fact, you know, their bond rating was just downgraded in March. And so their ability to borrow in the future is going to be compromised if their margins continue to decline. So I also want to, you know, they are different in the sense of, you know, we've talked a couple of times today about the inpatient psych. And when the state had no ability for expansion of that capacity, which was much needed capacity, which was compromising all hospitals budgets by the cost of the borders, the place that we turned was the Academic Medical Center. And the reason, because they did have capital built up, right? They had some, you know, they had retained some capital that would allow that investment. And they had some overage to be clear. We also tapped into that, but the expenses could be more than the overage. And so I just, I want to point out that we rely on this Academic Medical Center for our care when we need it the most. We need them to have the resources to be able to invest in the human capital and the physical capital to take care of us. And when the state didn't have the funding to provide much needed care for our mental health patients, that was who we turned to effectively. So I just want to say being aggressive may come at a huge cost to our access to care, to our quality of care and to our ability to deliver, you know, the types of care that the state needs. So their margin for this year is 2.5. Their operating margin. I don't personally feel that that is unreasonable for an Academic Medical Center. It's well below the median for the nation. And so I'm concerned about any major aggressive moves that will compromise that operating margin. But I do agree that expense growth seems problematic. And I think a further exploration of, you know, what's driving some of that expense growth over perhaps to the sustainability planning initiatives that we're undertaking, I think is going to be important. We have to understand that. We know medical inflation is 3%. They've talked about that. So understanding some of the other components which they tried to break down. I don't believe all of that is unit price inflation. Volume was embedded in there. So I think we need to understand that a little bit more. But anyway, you know, I guess I'll, well, I'll let others throw something out. So I'll just, I just want to add one thing. Sorry, go ahead, Kevin. Go ahead, Maureen. I just want to add one thing to the, you know, some of the expense growth and when you target a operating margin which is what they're doing. So they've told us that they're targeting an operating margin and that they have targeted an operating margin. But we haven't completely gotten an answer to, you know, what the incremental costs are for Epic this year and for a Miller building. I can say looking at some of the reports that they sent us, they are changing their projections for what they said they were going to get for offset staffing this year in 21. It's going to be $4 million less than what they had been anticipated. The legacy costs will be $1 million less. So that just that one change was a $3 million increase. We know they were adding the New York hospitals to Epic which added incrementally to UVM of $2 million. And there are other costs like that. So part of the expense increase is related to some of the CONs that have been done which are not supposed to increase commercial rate. But it becomes a math equation, right? If you're working to get to a 2.5% bottom line, you have your expenses, you have what you think your utilization is going to be and then you work with your commercial rate to get to that bottom line. That is concerning to me that some of this increase and I know we could debate a bit about how much is related to that. They also had given us the numbers before of needing the 6% every year. Yet when you go back of commercial rate to stay whole, when we go back historically from 2015, 16, 17, 18, they beat their bottom line numbers quite significantly. And then it wasn't until, I think, 18, they missed their operating margin dollars by 4 million. And I showed you before, accumulatively, they were up like $68 million for those given years. So there has been some history to why some of their rate changes weren't there and they actually, you know, hindsight is 20, 20, when they said they needed 6%, if we go back and look at, they didn't get 6% and they beat their numbers. So I think those are factors to look into here. You know, I know we haven't started to throw out specific numbers, but I think again on this one, my base would be at the 4% for a base rate non-COVID. And again, the COVID we could say is gonna live on. And then obviously they were asking for an 8% overall charge. You know, I think a 2% COVID to get them to a 6% would take into account some of the adjustments I just gave for Epic, 1% charge is worth $4.7 million. You know, and I can definitely see an incremental $5 million for that year over year. I understand it needs to be in there, but in there, even when they built up Epic, they had built up their margins over time to regain to where they were gonna be. The other thing we haven't fully flushed out was, fortunately UVM was able to get, will be able to get a large amount of money from what we heard yesterday from Mike Smith. And it was more than maybe that anticipated, but the point there is hopefully these hospitals can be made whole from last year. And although that will be a 20 year end impact, it will help their balance sheet quite a bit. If they're getting that $42 million that we talked about, some of which may have been in their P&L and they still can go back and get more money. And hopefully they will get more money from the state for any losses from June through September. I tried to throw out yesterday for them to look at any incremental changes for commercial rates that would have been a change year over year, because the state was just looking at, if I had 100 last year, I should get 100 this year. And if they had a rate increase in there, they should get more than that. So some of the discussion that we did have at the meeting and some of their commentary did talk about the financial shape they were in in 2020. And at that time, that was the best information they had and they talked about possibly missing covenants on their bonds and other things, but that picture has changed with the money they received, unfortunately. So I think we do need to factor at least that in from a balance sheet perspective of where they're gonna start the year, which is not where they thought they were going to when they did this presentation. And that's what gets me more to the 6%. So 1% on some of the CLN activities, another 1% for that to get to a 4% base rate and a 2%. But definitely wanna hear what everyone else thinks about where they're at. Okay, so I'll jump in and I just wanna say that UVM's troubles in 2020 predate COVID and they're not unexpected because three pretty major significant events. You have the opening of the Miller Center, you have implementing a new health record. We know how well those always get implemented and how efficient they are right from the get go. And of course, for the record, I'm being facetious. And the third event was the Fannie Allen Surgery Center and those impacted 20 and had a definite impact on the bottom line. I would hope that those are not going to be impacting 21 and that things will improve from there. I agree with much of what has been said by all my colleagues so far. I do wanna say though that one, and I'll just vent my frustration because Jess, you spoke about who did we turn to at when we needed psych beds, but we turned to UVM. And I'll just say that UVM is the hospital in the area of the state that has largest population. And in my mind, they had not met really their community needs by not addressing the issue. And the reason why the issue is being addressed is because there could have been a 3% reduction in commercial rates that would have impacted the base and would have impacted decisions over the last couple of years, including this one. But instead $21 million was asked to be set aside for opening new inpatient acute psych beds. And so I give them credit for so much because we need UVM, we need doctors being trained, we need a tertiary medical center, but I have to draw the line somewhere and I don't want to give them credit for everything because there are things that can be improved upon just as there are at every single hospital in the state. There are real areas of success and there are areas that need improvement. And so Maureen, your thoughts on the four plus two I could support. I think anything over that I would have grave concerns about. So Robin, I think you're the only one that we haven't heard from. Thank you. I also agree with much of what has been said. I do think that part of what makes the UVM medical center budget challenging is there are no in-state comparables. So they really are the only hospital of their type whose budget we get to look at. So they're not the same as the other hospitals in the state, their reimbursement structure for Medicare is very different as it is for Medicaid. The types of services that they provide are very, very different. And they do see people from all over the state. So that I think does make it hard when we're trying to think both at an individual hospital level based on their individual financial factors as well as statewide at the same time. But it is important to me that over the two years as Maureen said, we stay within the 3.5% growth target for this hospital. And so I am comfortable supporting the 4% standard rate with a 2% COVID increase and adjusting the NPR accordingly. I do share folks concerns about the expense, increases and outpacing of revenue because obviously that's not sustainable. And I guess I'll stop there unless you want me to make a motion. If you're prepared to make these two and set the stage. Yeah, I can make a motion. Maybe Lori will switch the slide to help me a little bit. Thank you. So I moved to approve the University of Vermont Medical Center's budget with a increase in the effective commercial rate of 4% for the standard rate and an additional 2% related to COVID with a commensurate change in the NPR FPP to reflect that for the fiscal year 20 to 21 budget and appropriate commensurate reductions to expenses and subject to the standard budget conditions. Is there a second? Second. Is there further board discussion before I open it up to public comment? Yeah, I would just add a couple of things. I fully appreciate as much as I can the unique position and the importance of UVM to the state of Vermont. And last year when I dissented on their vote, I said it wasn't because of them. It was, they have a favorable payer mix and they take advantage of the opportunities that are set up before him and can't be faulted for that. I, Kevin, I agree with you on the mental health dollars. Those came from a 2017 overage in their budget and the original proposal on the floor was to reduce rates by 3%. And then the issue of investing in the psychiatric beds came along. But also at that time, we re-benchmarked their base spending by 38 million dollars and then gave them what they asked for, I think in their 2019 budget and they exceeded that by a huge amount. UVM does get special treatment in terms of that 30 million dollars because they're an academic teaching hospital. So they are apples and they are oranges. But in the end, it is UVM, I think, it is the commercial rate that rolls back onto rate payers. And that is to a great extent, as we can see from the data driven by the UVM Medical Center and their relationship with the commercial insurers. And I think that we've worked hard on the all-payer model, we've worked hard on the commercial insurance rates growth, but that can be all lost if we don't stay disciplined, relative to UVM's operating budget. And so even if they were to be pushed back, and I'm not saying we can do this, but even if they were pushed back to the three and a half percent level, that would be a 1.7% decrease in their operating budget. And as we saw from, I think it was a Scutney this morning, or maybe it was Copley, that we pushed them back on their operating budget by 1.3%. Well, I know that one is a David and one's a Goliath, but I don't think a 1.7% reduction in their proposed operating budget, which is still a huge increase, is something that can't be achieved, especially given the talent that exists at the UVM Medical Center. Very talented, very well-paid staff that I am certain if they were tasked with the effort of finding 1.7 savings in the proposed 2021 operating budget, that they could do it. Other board members, if not, I'm gonna open it up to public comment. And Mark, as we gave you a little bit of a homework assignment before lunch, if you could talk to us in the public comment about that $20 million differential between what you expected to get and what you are getting in state relief. Okay, I'll start there, Kevin. I think just to speak to first, so as far as that $17 million differential, and I think the question was, Kevin, referenced to how will that impact your year-end FY20 performance? So basically, a crosswalk of that incremental $19 million, and we're mixing purposes a little bit here, but here's my best case at, okay, when we submitted or when we did our presentation at the Green Mountain Care Board, the University of Vermont Medical Center, but based upon the knowns at the time, and our estimates at the time was projected out of a $4.1 million loss for the year. So that was based in relationship to a $46.3 million budget. So that was about a $50 million miss at the time. So now we're estimating, keep in mind that we're in the midst of closing August actual. So we do have that at hand, is that we have $4.1 million loss we think is gonna be about a break-even, these numbers are plus or minus a million or two here. Please understand that. So that's gonna have a direct margin impact on the year of about $4.1 million, okay? There is about a $9.5 million impact that is more of a timing thing is in our original estimate, we had the FEMA dollars coming in in FY 20, and now it looks like it won't be till FY 21. And that's assuming if all of them qualify, and we heard from Secretary Smith that if they don't, they might try to do something to balance that out to the best they can. So basically $9.5 million of that is a wash. Compared to our estimates at the time, and what was received, and this is an evolving number, there was a change in the AIPBP amount by about a million dollars, and that's assuming if I got those abbreviations right. And then as August results are coming in, our August results appear to be about $4 million less, $4 to $5 million less than what we projected. So that's the crosswalk of that $19 million. I'll pause there to see if I need to refer to it in a different manner, Kevin, to make it make more sense or if it all makes sense. But let me just reiterate, we had a loss of $4.1 million, that's gonna bring that to break even. $9.5 was a shift of the FEMA number or from one period to another to balance that out. $1 million was to do with the accounting from a timing perspective on the AIPBP, and then in our original projections to get to that $4.1 million loss, our August actual number is looking to be about $4 to $5 million lower. And I think that gets us in the proximity of that $19 million. What does that leave you for September projections? September projections are, hang on. Is your projection in August your failure to meet that? Is that gonna continue? The projection of August was more related to the top line, to the top line revenue, Kevin. And it was mostly related to, we were picking things back up and we were at 1%, almost 100% give or take in some different areas plus or minus, but we under-anticipated the impact that the staff and the physician vacation would have in August. So that's what impacted with the revenue. Even when they couldn't go anywhere, huh? Well, yeah, apparently, yeah, no comment. So, but that's what it's based upon is, we know, I mean, obviously we were anxious we'll get the doors open again and to be scheduling at full capacity. And that was a misdeception on our part about the impact that the vacations would have. Okay, thank you, Mark. Mark, just to clarify a question on the August piece and then the $19 million reconciliation. The money that Mike Smith was talking about yesterday was for the submissions that would have covered March through June, correct? And then the hospital can go back in for additional for March through September, right? Assuming some hospitals hadn't gone in at all. So they opened it up to March to September. So I'm not understanding how the 4.5 million loss in August translates to the difference that you are receiving from the state because I didn't think they were giving anything on future losses at this point. Well, this all balances in well to how we end the fiscal year. That's how we answered the question. And so the $19 million was an increase and knowing what we know now in August, our projection was off. So the response wasn't to that specific grant period. It was how we were gonna end the fiscal year and what was the difference in assumptions from the time that we presented to you to where are we today in ending the fiscal year? Yeah, I thought it was two things. One is when you presented to us the amount you, I believe you said you would be potentially getting back, right? Was the 12 million, which was the nine million from FEMA, three million from the state. And then I think it was right, an additional maybe nine million. And then what you're actually receiving is significantly greater than that, which is good. That's great. And potentially if you've now missed top line for August and if you missed for September, you can go back for more, which is again what this program is for. And we hope that you do and can do that. So I thought what we were trying to do is if I were building from the bottom up of the, I guess the question would be in the 4.2 million loss in your projection. What was assumed in that number? Let's just stick with these numbers for right now. What was assumed in that number for what you would get from the state? What do we now know that you're getting from the state? And then we could just keeping that as that general question, forget any of the other changes. Then we could say for August, if you're down by 4 million, ask for that too. Because that is a valid request and hopefully in September too. So I guess to go back to the question of the, to answer in your projection with the $4.2 million loss, can you tell us what was in there for what you expected to receive from the state? That should be one number. And then the second number is, what did you just find out you're getting from the state? Which we heard from yesterday. Okay, so I think to start the conversation, okay, in our projection of the $4.1 million loss, there was the $9.5 million, actually, no, there was a $12.7 million of the FEMA dollar amount of which 25% would be covered by the HHS grant stuff. So that's a smaller dollar amount of about $3.7 million. Okay, beyond that in our projection, we didn't really assume anything additional at the time. Okay, and what is equating to the big difference, Maureen, is of that $32 million, $9.3 million relates to the amount of the AIPBP number, which is just a pass-through, okay? So of the grant award of $32 million, $9.3 was related to the current estimates of the AIPBP at the time. $3.7 million was related to the FEMA cost shift, $3.3 million, and then that gets us to what was really new was the net of that $19 million to the projection. So are you saying the $4.1 million, if nothing else changed and you got the money from the state, does the minus $4.1 go to $16? Roughly, you're adding $20 million to that? If we get nothing to the state? No, if what you know you're getting from the state yet, all I want you to do to this number is say, from what we just found out from Mike Smith yesterday, you had a $4.1 million loss. Don't put any August, anything else in there. To that number, what do we add to that number from what we heard from Mike Smith yesterday? And what I'm hearing from the numbers you just gave, it's not the 32, we take away the 9.3 and 3.7, so it's just under 20 that would add to that. So Maureen, can I interject? Cause I'm not hearing the same thing because what I heard him say, the 9 million from FEMA is separate. So it looks like it was a $3 million 25% match to that, that the state was willing to pay. So you really would only subtract the 3 point, something from the 32. So you're really looking at $28, $29 million in addition. Yeah, that's what I'm trying to get from Marks. I thought the 9.3, I agree with you, Kevin, on the 12 that that nine was from FEMA, but I thought he was giving another 9.3 on the AIBPC. But so the question is from the number we got yesterday, the 32 million, how much would be added to this bottom line negative 4.1? Okay. So in the 4.1, I was answering the number before as it related to the HHH funds. What was in that 4.1 was the 75% of the FEMA number, which is about $9.5 million, which we know is going to be moved to FY 21. Okay. So there's that right there. There was the increase in the AIBPC of about a million dollars. And that leaves a remainder of about $4 to $5 million. And I know you say that you don't want to hear August, but if we would have updated our August number, that $4.1 million loss would be 9 to 10 million. Yeah, but maybe we can start again. I just want, I'll build it up with you, but I want the first answer is just for the money we heard from Mike Smith yesterday, which was what 32 million, how much of that was not in this number and how much is going to add to this number? Then we can take what moves to next year and then you have the opportunity to go back for August and September. I hope you do for the lost revenue because you have up through September 15th. You can go back and claim anything of September 15th. That dollar amount is 19 million. Okay, so there's 20 million more that goes to here. So let me say it differently. Of the 32 million, okay, 19 million wasn't accounted for that in the projection. From the state. Keep in mind a large portion of that other dollar amount was the AIPBP funds. So I'll start there. So what do you want me to explain now? What we got new based upon the information yesterday was there was 19 million dollars. Okay. So then that would bring you to about a positive 15 million. Yeah, a positive 15 million. And then built into that $4.1 million loss was $9.5 million worth of FEMA dollars, which now is being, that's gonna be an FY21 because you can't book those funds until you get an award. Okay. So, okay. There was a slight difference in the AIPBP of a million dollars, but that's rounding. And that leaves what's left, that $4 to $5 million, which is what the difference is in the August projection. Which you could go, will you go back? Are you planning to put in another submission for losses for April and September, I mean August and September, or July, August and September really, because you're supposed to include it July. Okay. I will say that there's been no pre-disposed decision. A lot's gonna depend on what happens with the FEMA dollars. Okay. We still have one more month of actual to go through candidly. But you know, our intent of these FEMA dollars was attempting to get the medical center to break even because they were dissed. Well, I should say that they didn't receive the federal CARE Act dollars proportionately that a lot of other hospitals received also. So, you know, our approach in all along with this was how do we at least get to a break even? So, you know, I think, you know, we still have some more time to consider it. There's nothing on the table right now that I'm aware of, but we are keeping all options open. And obviously, if there's any opportunity to justify it, and it's audible, meaning it can pass the audit test based upon the federal guidelines of the use of those funds, you know, you know, we're gonna be going after it. But there's no dollar amount that we have at this time that I'm aware of, and there's no specific piece of this that there's a pot of money that we are aware of. You know, we're obviously gonna keep the conversations open. But, you know, our goal with this, you know, acknowledging that our performance to budget is still going to be 40 to $50 million off. Our goal with these CARES Act numbers was just to how, how do we first get to a break even that we could regionally justify and it passes the audit test? So, that's where we are. Unfortunately, I can't provide any more information than that as that's all I'm aware of. But there's no specific plans, we know right now that I'm aware of to submit a second request based upon $20 million, or I'm just using that as a reference. There's no specific dollar amount identified or anything like that. So, I mean, this is one of those things. I mean, almost like this whole, we know what we've been experiencing all along through COVID. It's almost like a week by week basis and any new information you get, you take that and you process it to the best of your ability. I wish I could answer that with more affinity for you. But unfortunately, that's where we are right now. It's just hope that, you know, because when we talked to Mike Smith yesterday out of the $275 million, there was only requests for $100 million. And obviously, EVM would be the largest entity that would have lost the most revenue and since it was based on, you know, kind of a top line revenue loss compared to prior years, it seems like there would maybe be an opportunity for you to get more. But I'm sure you'll get whatever. Well, and just as an update, the funds have already been cut from $275 to $250 by the legislature. And depending if there's a poor application rate for this next round, it'll probably be cut further. So those dollars will be used elsewhere. Yeah. And you know, Maureen, we wanna make sure that anything that is asked for that, you know, that we are very, very sure that it can pass the audit test under the federal guidelines. So, you know, as we heard from some other hospitals that the reason why they didn't submit a request because they thought that they were close to that point or at that point or maybe some have even acknowledged that some funds need to go back. So, you know, definitely by the end of the second submission period, you know, we're gonna have to sharpen our pencils and all of that and, you know, to see where everything is. Did you have other public comment to offer, Mark? The only public comment that I wanted to share and then I wanted to reference with the numbers that I just wanna remind all of the board members that when we're looking at expense increases and the rate of growth, you know, we really need to put pharmacy in its own category because that is one of the largest drivers of those expense increases from period to period. So, you know, we would obviously, we, you know, welcome the opportunity to work with the board to speak about expense growth and we know what we can do as a combined group to help lower that curve. But a large part of the disproportionality of that growth is really related with the pharmacy. And the only thing that I would like to end with is, you know, this submitted budget based upon multiple public comments that I think with a board or receive via email is this was our best estimate of what we needed to meet the patient care goals in FY21 and not only the patient care goals but to support our people. Because if there's anything that we learn through this COVID process that, you know, we fell back on the foundation of our frontline staff to work in very, very unknown circumstances, new to everyone. And, you know, our staff and our hospital step forward for all of the state's needs for all of our patient care needs. And, you know, what is in this FY21 budget is to, you know, we talk about sustainability but we also need to ensure that we have the sustainability of services in the state. So this FY21 budget is to support the sustainability in case there ever is another crisis that we have the capacity to respond in the same manner. And that includes the NPR growth that was submitted and also the commercial rate growth. So, you know, we thank you for your time. We thank you for your patience. You know, this is a very, very unusual year that, you know, you take the information as it comes to you. We were all thrown in the circumstance that a lot of things had to be dealt with late in the cycle that would normally be dealt with much earlier in the cycle that did create some confusion in the conversation. I think from point to point, you know, we just heard from Secretary Smith yesterday. So, you know, I think the board and all of its staff for allowing us the time, well, to talk back and forth to add clarity to these items and these numbers that are evolving and, you know, sometimes are very confusing. So thank you very much. We appreciate the conversation, Mark. And certainly UVM had more than its share of dealing with COVID as the hit to Vermont really did affect your area of the state significantly. So thank you and thank you to all your colleagues at UVM for stepping forward for that. Is there other public comment on the University of Vermont Medical Center budget? Hearing none, I believe that the motion that is in front of us is for a 6% effective commercial rate increase, 4% being standard, 2% being commercial. I do not see that the language up there. Patrick, did you have the finite amount on the fixed perspective payment or is that to be calculated? I think that's to be calculated. Thank you, Robin. With the standard budget conditions and including a commensurate reduction in expenses. Any further board discussion? If not, all those in favor of the motion signify by saying aye. Those opposed, say nay. Nay. So Mike Barber did slap my wrist earlier today and said that whenever we have a non-unanimous vote we need a roll call. So Mike, could you call the roll? Yep. Member Holmes. Yes. Member Lunge. Yes. Member Yousefer. Yes. Member Cullen. No. Mr. Chair. Yes. Thanks. So let the record indicate that it was a 4-1 vote. Is there any other business to come before the board? We often open it up at the end in case Jeff Thiemann wishes to make any statements. I know last year he declined and just went with his opening statements. Jeff, did you wish to say anything this year? No, Mr. Chairman, thank you. I appreciate the board's careful evaluation of all these budgets. And obviously as a couple of you have said, we'll need to continue to stay in close dialogue during the monthly meetings and elsewhere to make sure that we're monitoring this and from my standpoint and a statewide standpoint to make sure that we're constantly ready for the next wave if we have one and that COVID is still with us and our hospitals are at the center of that. So we must always keep that in mind. And certainly that's most true for the academic medical center which has been such a leader here. Thank you. Thank you, Jeff. Very well said. Nobody has a crystal ball. We don't know what's gonna happen, but Vermonters have to continue their demonstrated efforts at safety. And with that, we'll get the best outcomes that we possibly can get. And hopefully there's some encouraging news on both treatments and vaccines coming down the pike. Although never fast enough for any of us who would like them here yesterday. Is there a motion to adjourn? Still moved. Is there a second? All those in favor of the motion signify by saying aye. Aye. Aye. Opposed? Thank you, everyone. I know it's been a long and trying process. And hopefully there are not major reconsiderations that will have to be revisited in the future. But again, 2020 is the year of uncertainty and we will plot along. Have a great rest of the day. Thanks.