 At this point, we're going to turn it over to the hospital budget team. We would like to go over overall what we're going to be presenting today. This is a recap of the FY20 budget guidance. I mean, we will be presenting that. We will also show you the budget requests for the Fiscal Year 20 budget considerations, the summary of the results that we saw, the net patient revenue and fixed perspective payment, the change in charges, rates and prices, and this also would include any changes to Medicaid and Medicare and commercial reimbursement. We have key financial indicators, operating margin, bad debt and free care, disproportionate share, payments and provider tax, and the 340B revenue because the legislature liked to see that particular slide a lot and this is included in the other operating revenue. We're showing you ACO participation and then we'll be showing you the timeline of budgets and hearings and the next steps and then final discussion. We will also be showing you system-wide summaries of net patient revenue fixed perspective payment increase of 4.5% or $117.8 million over the 19 budget. We're also showing the operating expenses increase of 5.7% or $155.5 million over 19. Operating margin budgeted at 2.5% and increase over the 19 budget of 2.4%. Just $193.2 million in capital expenditures, those includes the CONs also. Then we have system-wide estimated weighted average of change in charge is 3.2%. We also wanted to show you just a kind of quick look at the income statement system-wide and I wanted to make note that 340B is included in the other operating revenue just below net patient care and fixed perspective payment and reserves. A lot of the hospitals are reliant on that extra income when the net patient revenue doesn't quite meet their expenses so that they get a positive operating margin. Then we would like to show you what went into the budget guide and we'll have Agatha show you this one. Thanks, Lori. So we just want to review the budget guidance because it kind of sets the stage for the budget you're about to see. So you released or established the budget guidance in March 2019. It was sent to all the hospitals and the most important pieces for the presentation you're going to see today are these three items right here. Number one is the 3.5% maximum growth rate target that was set for all the hospitals. Number two, and this was new for this year, is kind of a secondary cap that was set for hospitals that are underperforming. So for hospitals whose FY19 projection shows a minus 2% or greater variance from budget, they would be limited to 5% growth and you don't have to do the math in your head because we have slides that have done all the math for you, but those are two kind of limits that have been set in the budget guidance. And then the third point is just to kind of remind, re-emphasize that the budget guidance, although it didn't set forth a limit for FY21, it did consider FY21. It considered FY20 and FY21 together in terms of if revenues seem to be in line with the all-payer model target, then the Green Mountain Care Board has also established tentatively a 3.5% growth for FY21. So when you're looking at today's figures, remember that FY21 figure is out there as a two-year target. We did some housekeeping with some board-designated assets. We clarified some terminology. This next slide is pretty much just a summary of what was in the guidance and there's no need to go through it now, but just to remind you that this is, because a lot of work goes into the budget guidance this year and this is what the results were from the difference from last year. So once we received all of the hospital's budgets, staff goes through individual hospitals and puts questions against their budgets, comparisons, or we like to know what should we ask every hospital the same questions and then we have individual questions. In this particular round, we asked the hospitals to give us, were their fiscal year 19 projections valid? And if not, give us an update. We ask that every single year. This year, we're asking the question on ACO reserves and other reform payments. We're also asking the hospitals, because it was in their budget orders, if they have connectivity with the V-High through VITAL. Then the next question we asked is, what departments in the projected 19 budget were the expenses exceeding their revenues? Another question was, how can we understand the utilization or census in the hospitals? Give us some kind of statistic that we can start monitoring that type of information. We asked the hospitals, what's the value of one day of day's cash on hand? We're asking some of them for that particular hospital, but also for their parent, so that we have something to compare. The charge-related questions, this one is where we're asking, what is your increase in charge, or it used to be called rate? We're also asking to give it by Medicaid, Medicare, and commercial, and what are your assumptions? Then we have additional specific hospital questions, like for instance, if they had any changes in FTEs, if they had changes in their balance sheet. So every hospital's questions are unique. These analysis will be sent to the hospitals late today or early tomorrow, and we will have them on the web also. The considerations that we were reviewing these budgets is, or you should consider this report, preliminary. We've been talking to the hospitals and found that some of the information in the submissions are incorrect, so we have to inform you of that, they will have that in their responses so that we'll have the correct information when you make your decisions. So usually the board based their decisions on NPR and their rate or change in charge, but there's other items in each of the hospitals that need to be taken into consideration. We review, we are not done reviewing, we're going to continue to do more analysis after this meeting and so that we'll be having tools for the board for their decisions. And then we'll have more analysis at that time. So like I said, this report is definitely preliminary, and it helps the board with their decision making. To Lori's point, through our conversations with the hospitals, we've already identified a couple areas where hospitals submitted something that they didn't mean to submit or it was the wrong number or maybe they missed a key stroke. So part of what we think we feel our job is is to review the budgets and make sure that what's in adaptive is what the hospital meant to put in adaptive. So that's on top of all the analysis we do, we are also trying to make sure that the data is correct. So this is another slide on considerations. So as you go through, this is a slide on FY19 amended budget orders, even though we're talking about FY20. The FY19 budget is the basis for the FY20 budget. So just a reminder that there were four amended budget orders in FY19, two were related to provider transfers and two were related to a change in charge. So just briefly a reminder about that. In FY20, we are seeing some provider transfers and acquisitions being requested, just a reminder that the board and their guidance puts a May 1st deadline on requesting an amended budget order in FY19. For example, the deadline was May 1st. And so if anything happened to the hospital between May 1st and October 1st, we asked them to submit it in their annual submission. So we're seeing some provider transfers and acquisitions and accounting changes that affect both FY19 and FY20. And we have calculations throughout that will help you see what the impact those were. In addition, there are requests for consideration for, this is coming from the UVM Health Network for unique patients and case mix index. And we have slides on that further on. Is this me? Oh, still me. This is just kind of a basic summary slide. This format is familiar to you. The only thing that's different in this than what you normally see is the column that shows participation in the all payer model. We've titled that column budgeted FPP. This is because contracts for FY20 have not yet been signed. But we can see in their budgets that these are the hospitals that are budgeting for FPP. On the right hand column is the hospital's request for MPR FPP and then a percentage of the total. This slide is showing you the percentage changes between the years of net patient revenue fixed perspective payments and the operating expenses. And we also wanted to let you know about the dollar amounts. So the NPR was an increase of 117.8 million over 19. And we found that the largest drivers of that were utilization, change in charge, and provider transfers. But that is not limited to what the changes are, but those are the largest ones. The operating expenses, they increased 5.7% or 155.5 million over the fiscal year 19. The largest drivers of operating expenses were inflation, workforce. We heard that a lot on every single hospital and drugs, which some of them get reimbursement in the 340B. That's in the operating revenue. We also review the capital budgets and they proposed $193.2 million in capital budgets, which are planned and ongoing. So that total for CONs was $94.4 million. There was going to be probably 16 CONs. We wanted to show you the system-wide payer revenue for FPP and NPR growth in fiscal year 20. Commercial increase 6.6% or 92.7 million. Medicaid increase 0.5% or 1.5 million. Medicare increase 2.6% or 23.2 million. And disproportionate share didn't change too much. It's 1.8% or 0.4 million. We also wanted to show you the charge assumptions, which is the estimated weight average of charges 3.2%. That is taking the rates that the hospital submitted, applying that to the previous year's gross revenue and get a weighted average. Most hospitals assume zero increase for Medicare and Medicaid. So we also wanted to show you in these pie charts what's the poor portions of fixed perspective payments by payer and NPR, the NPR and FPP portion. How much is that FPP? And then of FPP payments, what's the percentage by payer? And then on that pie chart, there's a little disclaimer. I don't know if anyone can see it, that this is FPP as reported to us as the payments, does not include reserves. So that would be, if you're looking at an income statement, that would be the fixed perspective payment line. We wanted you to see the operating margins for the system from fiscal year 14 through fiscal year 20. And we are estimating a five-year average of 0.8% or $53.8 million. We also wanted to show you buy the type of hospitals, so perspective payment hospitals and critical access hospitals. We also noticed that fiscal year 18 was where both types of hospitals had quite a dip in their operating margins. And after that dip, there is an increase, but that's the FY19 budget, just so you know that this is actuals all the way up until you get to FY19, and that turns to a budget here. So the next couple slides are going to have lots of numbers on them. This is where we're getting into our system-wide looks. We're moving away from sort of high-level observations, and you'll start to see information on a hospital level. So here we are, MPRFPP as a dollar value. The next slide we'll show it to you as a percentage change. Quickly go through the columns. FY18 actually actually ended the year. Their budget as of FY19, so this includes those amended budget orders that we saw, those four amended budget orders, their projection for the rest of the year, and then their budget for FY20. And then this next slide shows those same numbers, but as a percentage change with the column in bold is really the column that's part of the discussion is the budget-to-budget percentage change from last year to this year. And that's where you see the 4.5% as a system total. So this slide has a lot going on, and we're gonna spend a couple minutes here. And we kind of consider this slide to be a reference slide, a tool that a board member of the board could use during the budget season. So it's the MPR percentage growth by hospital and I'll just go through from left to right. This first column here, budget-to-projection variance. This is important to consider because it's hitting on one of those criteria in the budget guidance. This is for the hospitals that underperformed in FY19 and whether or not they would be subject to the 5% cap. So the figures in red in this column is any hospital that dipped below the minus 2.0, but also exceeded that 5% gap. So you'll see that there's a 5% limit. You'll see that there's hospitals in that row that definitely went below the minus 2%, but they're not in red because they satisfied the 5% limit. Any questions about that? Excellent, all right, the next column. This line divides the variances with percentage growth. So this line is as submitted and adaptive the percentage growth from last year to this year by hospital. So any hospital whose figure is in red is a hospital that exceeded the 3.5% cap and also that minus, I'm sorry, the 5% limit for the underperforming hospitals. So those are all the red numbers in that column. And then the last column is their percentage change from year to year when you factor in provider transfers and acquisitions and accounting adjustments. So these are the things that happened between May 1st and now that the hospital is bringing to our attention as a transaction or a transfer or an accounting change that affected their budget. And a breakdown of this column to be specific is down below. These are the hospitals that are requesting provider transfers, accounting adjustments, and then specifically accounting adjustments related to ACO accounting. And specifically for ACO accounting, it's bad debt collection fees moved to expenses. So they're coming out of revenue and payment reform investments moved into deductions. One other thing that's worth noting here is that Northwestern Medical Center, they had a dermatology practice, leave their practice in FY 19. And although we're not talking about hospitals specifically, you need this information in order to interpret the chart. So that happened at the beginning of FY 19. If that had been considered for their budget to projection variance, they would go from having a red number here. Am I looking at the right hospital? It would go from a minus 2.1% to a minus 1.4%. I'm sorry, from where I'm sitting, I thought I was pointing at Porter, but so they would go from a minus 2.1% variance to a minus 1.4 variance. So they would not trigger the cap if you factor in the loss of their dermatology practice. Did I make that clear or did I make it less clear? There's a footnote that makes it clear. All right. Next slide. So this slide is specifically about the UVM Health Network. So in addition to requesting consideration for provider transfers and accounting adjustments, the network has also requested consideration for changes in what they refer to as unique patients and case mix index, a change in their case mix index. The network attributes these changes to a population that is sicker and older across the network. So the dollar value and the percentage impact there, NPR is in the chart below, but we don't plan on getting into detail about that today. But are there any questions about this chart and how to interpret it? So my question is, was there substantial supporting documentation that it's different than other hospitals? I mean, all of New England is older demographics like that, it's just curious. No, and we didn't ask for it. We are kind of, we do analysis on the income, all the financial documents, but we learn a lot in the hospital presentations. So we're expecting that UVM, because this is where the budget guidance says unless justified. So this is where the health network would have to come in their budget presentation and justify. Yeah, I think when you read their commentary, that's what they're trying to do, is explain their overall growth at 6.6% of the network and then calling out these two pieces as contributors and then what's left. So I think they're trying to use it to just explain why they're exceeding the cap. Yeah, right, exactly. Okay, more numbers. This is a breakdown of, again, this is a reference, no one has to understand this just by looking at it right away. This is just a reference for, you start to ask yourself, well, what exactly did the provider transfer due to the budget? And sometimes, for example, in Northwestern's case it's a minus because they lost a practice and a positive and it's netting out to a positive number. So this is just a list of everything that came in. We would like to point out that our analysis is not complete. We're following up with the hospitals to make sure that they fulfill the requirements that forth to notify patients when a practice is acquired. We need a little more clarification, at least on a couple practices, whether or not the projections we were given were a partial year impact or a full year impact. And we need more clarification on whether or not these acquisitions were independent providers in the community that were acquired by the hospital or whether they were there expand or whether they were expansions of the hospital's existing services. So still more work to do on this. This chart is showing the preliminary look of the change in charges. We used to call it the price or rate increases. But this year for 2020, we specifically gave the hospitals the definition of what we were looking for and we wanted to know what is your change in charges? But we also wanted to point out that there was on the UVM networks narrative the effective rate of commercial. So that's why you're also seeing that on the far right. This is where you will be making decisions on reducing their change in charge. And how much is that going to affect their net patient revenue? This chart is showing you just that same information on a system look of how the board or past hospital budget commissions affected the rates submitted versus approved through the last decade or more, last two decades. And then we wanted to show you the history of the NPR and FPP from fiscal year 14 through the current budget and all the changes in between. So that you have some history of the growth this one is the percentage change between those particular years. Just real quickly, you'll notice that at the bottom of FY 18, it says 2.9 and there's an asterisk. This is to call out the fact that the year end report that we produced in March at that time that reported the results of FY 18, North country's data was still preliminary. And at that time, the system total was a 3.1% growth since North country has resubmitted and it brings it from 3.1 down to 2.9. So we wanted to call that attention because this could potentially be the first time that we're updating that number in a public setting. And this is the operating margin in dollars from fiscal year 17 to the budget 18. And we wanted to try and give you a five year average for each hospital and then the system total. The next slide is we were, as we've mentioned, this is preliminary. We found out that the five year average for the operating margin percent is incorrect. So we need to correct to make an adjustment on that and repost this slide on the web. But this is the operating mind percentage for each hospital. So this next slide is a summary of utilization and staffing levels. We collect information about utilization on many levels, but the one that we bring to this report is adjusted admissions. So we have the adjusted admissions listed with the total. We also report on staffing levels for non-MD FTEs, for MD physician FTEs and travelers and the system totals are at the bottom. On the right hand side of this chart are the percentage change from last year to this year by hospital and as a system as well. So an interesting note on travelers is that a lot of hospitals budget for zero travelers and then project that they will have travelers. So you'll notice that there's a lot of zeros there for the budget. And you'll notice that there's a lot of zeros over here for the change. But in between is a projection that has travelers in there. So we would encourage board members to look at the, in each staff analysis there's a page for utilization and staff. And that's where you can see more detail. Because we do hear a lot about the use of travelers but we don't see it in the budgets. And we have questions for hospitals about that. The other thing we wanted to mention is like we keep on saying this is preliminary and we already know some of these numbers have to change. Yeah, hospitals detected some issues. So just kind of generally we report on adjusted admissions. It shows an increase of 3% over FY19. Staffing levels are increasing 360 positions which is 2.4% above last year. And we will say that looking at 360 may or may not sound like a lot but a lot of those positions have already been staffed in FY19. So they're building these off of their projection. If you break down that 350 or I'm sorry 360 it's 351 non-physician fteens, 14.6 physician fteens and a drop in travelers. But as Laurie stated we know of at least one hospital that needs to revise their staffing numbers. All right, so we are including these sorts of charts in our standard reporting to the board. These are a handful of key financial indicators that you're familiar with shown from last year's budget the projection and this year's budget. So we will not go over these in detail except to note that we're still falling up with Southwestern. They have a parent company and we are we're asking them about their day's cash on hand with when you include their parent company operating margin and total margin. And then days payable, days receivable and debt service coverage ratio. Every year also asked to show charts on bad debt and how much it's increasing or decreasing per hospital. And we wanted to bring that to light. Last year I had combined bad debt and free care but we'll separate it in this presentation. Again, it's preliminary because these hospitals will probably changing their numbers. We never know. So do you want to mention the height of all the hands? Yeah, because of bad debt and free care it's your high deductible health plans. Bad debt is where people have insurance but they can't pay or refuse to pay, excuse me. And some of it is the high deductible health plans. And all the hospitals seem to have like some kind of collection agent to try and collect some of the bad debt. The free care is where people can't pay for their care. And so this is also where I believe some of the dish payments are also supposed to help some of the hospitals on some of this. So then there's the dish payments and what's happened year to year. This particular slide does not show when it was for the system total over $37 million. Now it's down to 22 million for fiscal year 20. And Grace Cottage does not receive a dish payment. Provider taxes, and I believe this is correct is it's 6% of their net patient rather than fixed perspective payment that they pay to the state. And what we do when we receive these dish payment and provider tax calculations from the budgets we also compare that to what Diva has given us just to see if we should be notifying the board that we should make adjustments or not. Oh, and so for Laura gave me this one because I love the 340B program. I'm fascinated by it. So because it comes up over and over in the hospital budgets narratives that they are increasingly relying on other operating revenue as a way to produce positive operating margins. So this shows history of the short history of the program. And you can see from these numbers how much it grew even from last year. We include this slide even if we don't include it in our preliminary presentations the legislators always want to see this information. The other thing is the reason why Copley and Springfield are at zero is because they don't qualify. Right, and the reason Porter shows zero on FY18 is because they were previously recording that in a different in non-operating revenue. So, okay. Moving on. We wanted to show you the ACO participation and this is based on the fixed perspective payments alone not necessarily reserve. And so you can see the changes from year to year for each hospital. So as expected it's growing into the fiscal year 20. The contracts have not been signed yet for fiscal year 20. They're still trying to gather data from OneCare. And then these maps may look familiar. This was Marissa, one of our colleagues back at the office put this together that shows participation in all payer model from performance year zero up to performance year two. And you can see how the participation is growing from year to year. So that concludes the data portion of the presentation. This next part is procedural. So we should probably pause and see if there are any questions. Questions? Tom. I do. So if we could go to five to 15. Yes. 15 you said? No. Okay. Okay. I'm just thinking that the medicating rates might have 1% if the vat is what hospitals have submitted a cost regulation on that and I'm just going to be able to say that the growth might be in. No. Not to compare to this particular process. Because you know it's just a number that is always striking to me that 22% of remoders are insured by Medicaid. And then as last year in the budget process such a small amount is dedicated for that population with the cost shift goes up and that's a relationship I think that we need to be very explicit about so that policy makers can understand either change it or understand it basically. So for those Medicaid numbers include the dish payment reductions in 2017, the amount of dish was I think $35 million. This is all based on what the hospitals are budgeting. If you looked at the number for dish, we could go to slide where the dish is. 33, thank you. Does anybody need slide 15 anymore? No, because it won't make everyone see say. In our calculations usually the dish payment, we try to have it pulled out so you can get a, just a look of the regular payer and then we pull out dish. So presentation included. So it depends on the presentation but in there would not be included. But when you're talking about the dish being reduced that would be on this slide. And like I mentioned, it was the previous years it was at 37 million and now it's down to 22 million based on what the hospitals budgeted. And we take that like I mentioned the budgeted amount compared to what Diva said. And it is a little different for each hospital. Most of hospitals got the most current data from May. But Tom, if your question was does the Medicaid increase of 0.5% or 1.5 million include dish, it does not. That's reported as a separate line item. So actually what that means is that the 1.5 to 1% could even be less if you're gonna get out the dish and you get production if there are any. If there's reductions. So if it's worthwhile just checking in with Diva on the actual hospital, bottom up, seeing if those two tie out after the appropriation process during the last session might indicate that Medicaid might be bumped up a bit. We can do that, but we also want, we'd like you to know that we give them through the year the year to date actual slide fiscal year 19, information to Diva so they can keep their projections up to date. When we get actual data coming in like this fiscal year 18, we give that to Diva. They're also gonna want to see these budgets. So they're gonna constantly update their data. But for us to go back and compare, we don't usually. Starting on page 16, page 16 you have a, I'm just looking at the actuals now, so this money is, it's done, it's fixed. And so if you have the numbers from fiscal year 14 to fiscal year 18, the total amount of that margin is 300, not too low, it's 390, 326 here, but I've done it and the medical center's total margin for that period comes to 316 behind the U.S., so we know that's the number. And so that's 80.4% of all the margin over that five year period. And then here on page 26 you can see that projected margin total is 42 million, 42.5 million. And the UDM medical center shared that as $39.4 million which is 92% of all the margin projected for 2019. And I'm just wondering if you'd make a special look at as to what might be thriving that, because it is out of sync with the medical center's 49% share of NDR that in terms of what's broken through their system is significantly higher than that. And I don't know if that's driven by case mix or what might be thriving it, but I think it's because we're talking tens of millions of dollars here, it's something to understand as to whether or not it's something we should be concerned about or not. We did ask the question for the hospitals to give us their operating margin total, operating margin and total margin, their assumptions in their budget. So it could be addressed in their narratives, like we can, I don't know if you saw that or not but we can, but that would only be for the current years. As you notice as I look at these graphs now over the past year, you see when huge positive and then a whole bunch of negatives for the remaining, among the groups that remain positive. If you look at the bottom line on a gross basis, they owe us $290 million for the operating margin. Great, that's a big number, but it's the distribution of that across all 14 hospitals that issue and as we see, you know, on target and target, there's a lot of hospitals that are on the spectrum in terms of their operating margins. Okay, right, that is something that we're observing and tracking is budgets have, at least in the recent history, have all been for the hospitals, positive operating margins. They budget positively, most of them end positively, but in, what side is this, the next slide? You can see in the next slide how hospitals are ending. There's a lot more in the negative than there used to be and this year in FY20, two hospitals actually are starting off the year they're budgeting with a negative operating margin. Other questions? I have a few questions for you. Okay, if you can go to age 18, and this really just some observations, so when, first of all, great job, it's very, I hope that you guys can get together and really help us as we go through all the upcoming presentations. When we look at the second column in the budget projection change for 19, it's important to note that 10 of the hospitals are missing their numbers this year. Overall, we're getting to about the same place because UDM is about 1.9% and the rest of, well, everyone else is down. But that goes then in context with the requests in the next column on the budget to budget where six of those hospitals that are down are asking for increases significantly above the guidance. So that would be something obviously we're tracking because they're missing, some of these hospitals have repeatedly missed forecasts and really just want to be focusing on making sure we're not looking at some what I call aspirational budgeting because if we're budgeting to define the expense load gets budgeted at that rate and if, in fact, the top line doesn't come in on the normal course of business, not because of any changes that the board imposes, it's very hard to correct that and that's where we only go to page seven, that operating margin page you were just looking at before. It really highlights how many hospitals that have moved in the projection to negative and I appreciate what you were talking about Tom, but I also would look more at the overall rates and being 2.7% for UDM, I mean, what is the right rate to be at and we want it to be positive, obviously. So I mean, I don't look at a 2.7 operating margin as high necessarily the problem is all of the hospitals that are negative, many of which didn't budget to be negative, obviously. So it's missing that top line and we've seen repeatedly where hospitals won't come back in assuming they're gonna get back to the number that they were at before or compared to their budget and then when they miss they are losing money. And so that's a big area of concern and so I would just kind of point out that try that the hospitals are missing and yet overall for the system we're looking at a 4.5% per class when the guidance was 3.5% so something to look at there. When we go to the page 19, maybe there the comments are right, we'll show you what the actual requests are and do I look at these adjustments that we put through here as bringing things really on an apples to apples basis. So if somebody made an accounting change, it wasn't in one year and then put it in the other year, if they had a decision to transfer, that makes an adjustment. So there we're looking at overall 4.7 with one, two, three, four, five, six, half of the hospitals exceeding the guidance. Some of them are pretty significant. So obviously those big things we're looking at and then if we flip to the next page on the commentaries by the new network they've brought up two different factors that it looks like they'd like the board to consider that they're meeting the numbers to exclude these factors. And just a couple of comments on this, this is the first time we're really seeing this and that could have been something that maybe presented to the board earlier because what we don't know is I think many of the hospitals have case mix index issues where the population is sicker and therefore it's costing more to take care of them. And none of the other hospitals have given kind of case mix in it. So what I do, the way I do look at it though is I'd say UVM overall network came in at 6.6 and that's the number they're requesting as a 6.6. Within that these two things do contribute to that and so we'll have to look at how that impacts. The difficult part is we're not seeing that offset elsewhere. Well, the unique patients are contributing three point, you know, we've got about $50 million of adjustments to the numbers but we're not seeing that offset elsewhere. So we'll just be, things we'll have to look at when we're going through the presentations. And one other on page 25, just to ground a little in the history in the past several years, 16 was, or the outlier was 4.4, 17 was 2.8, 18 was 2.9, system-wide, 19 looks like it's gonna be about 3.8 and then again going to 4.5. You know, one of the concerns, the reason we have the 3.5% guidance was to be looking at welfare model and try to look at that two years of how do we look at that? You know, in that context. The other page, you know, just to comment on from the UVM network piece, I would look at it a little more that in the 2019 forecast for UVM it was low, there was no request, I think it was 1.6. Now they're coming in at 3.5 and then next year it was 4.1. Not to say we would accept that, but I looked at it a little differently, like the 19 budget, the request is much lower than what the guidance had been. I think that's that. I think we're all going to be moving into the budget hearings and dig in a lot deeper. There's sort of a lot of hospitals still struggling and one of the variables we did see is if you go to the commercial increase, some of them are very high on the commercial requests and some of the hospitals spoke to the way they got to that number was just getting to 3.5% and then plugging the difference and we'll all want to make sure we're looking at all opportunities for cost savings and things to offset some of the pretty significant commercial asks that both the system and the board are not right, but thanks for all the information and the hard work, you know, putting this together. The one thing we also heard from some of the hospitals when you mentioned cost savings is the cost savings affect their Medicare cost report settlement, so the less cost, the less of a settlement because they're not going to necessarily get the charge increase that they're requesting instead they have to get it through their costs from Medicare. We heard that quite a few hospitals this last week. I guess the challenge on that would be if in fact they're accurately getting everything they should be for Medicaid and Medicare is these are the hospitals that are losing money and so making sure their cost reports they're getting everything in there that they can. I know they're trying to, I'm not saying that, it's just when you're losing, you know, five or six percent and whether it's plus one or minus one, if you get reimbursed, if they have an operating margin less than that, there's concerns with that. Right. For the questions or comments from the board, at this point I'll open it up to public comments or questions. Kevin, did you want us to finish with the procedural part in case there's a public comment on the process from here on out? It would make sense. Okay. All right. So the timeline, right now we're in the July, August time period where we do staff analysis and we also forward budget materials from the healthcare advocate. We examine all of the hospitals narratives, all the supporting documents they sent to us. We also do statistical analysis and review their budget submissions against the compliance or we'll say the budget guidance and then we have our analysis ready. We've also talked to the hospitals last weekend this week. We have our analysis ready the late this afternoon, tomorrow, final and then we're asking the hospitals to respond by August 9th. Also on this timeline is what we're talking about today is this preliminary presentation. And then we will be asking the hospitals to send their presentations into Abigail or to us by August 14th. So all of them are in at the same time before hearings. And then these are the dates for the hearings August 19th, 21st and 23rd, and then the 26th and 28th. You- You know, I'm a bad guy that is going to make sure that everybody hears to that. Okay. I know that somebody's already requested a change but it won't be granted. Then we go into deliberation August 29th, right after the budget hearings through August 14th, August 14th. And well, actually the 14th and 13th is when we have to have a final decision. And then we formally start writing the budget orders between that time and September 30th. So what we plan to do with staff is to, as Lori said, finalize our questions and send them out today and continue to analyze, listen to the hospital, budget hearings themselves, and then we'll prepare some recommendations. We're also gonna look at the submissions to make sure they're in compliance with the budget orders from last year. So we'll just make sure that everything's kind of, we're following up from the things we asked them to do last year. From the board's perspective, what you'll be doing the next few weeks is to review and evaluate individual hospitals independently. Go to the hearings, review the public comments that come in from the public, any comments that are coming from the Office of the Healthcare Advocate. And as Lori stated, approving the budgets by September 13th. So now we'll look at the questions. Yes, ma'am. I just got a question from Maureen. First, you said that the overall budgets don't show any new volume to UVM, did you say that? No. Or you didn't say that? No. Hold on. Exceeds the caps, but they're different. Well, I understand that, but the question here is whether you're getting redistribution of the patient load across the state. It's from one hospital to another, okay? And if that is true, then that's one thing. You've suggested that in the front end, by saying that at least I forgave another of the spending of 10 of these budgets for aspiration. No, that's it. Okay, 10 of the hospitals for 2019 are missing the top-line rejection that's now in every forecast. On the flip side, the total request for all of the budgets is four and a half percent, which exceeds the three and a half percent. So it doesn't seem like it's showing us the swaying of patients from one application out of that. You know, yeah, that's one thing. Rejection to rejection has been 10 months of missing and it's starting to be, for those of us that if you look at their operating margins, their operating margins are numbered. And so the caution is to really test and you can see that some of the hospitals they're down this year and they're asking for a 12 percent increase next year. If that doesn't happen, they go over expenses, if you've got a problem with many of them are fixed, they can't adjust to their idea and then they lose money. So, you know, a lot of the focus that I've done in the past hasn't just been on the hospitals that exceed the cap, but those that are underperforming and losing money. We don't want to have situations where hospitals continue to go over this money and can't break up an ends and can't sustain that. I was also saying that we've lived through a rebasing discussion not that long ago and it's not something that I think the board has receptive to doing every single year. Other questions or comments? Sure Bob. Thanks. I just, I'm curious, on slide 14 is a reference to the 16 CLA's and the one going from St. Helene Rose. How does that impact the budget consideration versus the board point of point of not? So, I was quickly changing pages but I thought I heard you ask how the CON's. Yeah, it's on slide 14, good morning. Yep, the capital budgets, yep. Do you want to jump on that, Lori? Sure, the CON's are planned. They are not in the operating budgets unless they've been approved. And like if we mentioned an ongoing CON, that means that it had already been approved previously so that would be in the budget. But if it's like UVM's Epic or their Miller Building that's already in the operating budgets. But if it's something that they're like an MRI that a hospital is planning to have that would be one of the CON's. And it's just a mention that they plan to do it. So it gets approved during the course of the year? We will be amending the budget. Assuming that the CON doesn't have a condition that it not impact the budget, which a lot of them do. Right. The vast majority of them do. Well it would have, it could have depreciation impacts but a lot of times that's lagged till later. Correct. And it's gonna have cash flow impacts. So usually when hospitals are looking at their budgets they're assuming in their cash flow that there will be capital expense and they'll make some such depreciation but the actual rules would be there. It typically is not supposed to increase commercial rates to offset CONs to make the numbers stable. Oh. The last note is this year we had a definition of what change in charge was. Previous years we called it increasing rates or prices. Basically now we wanna know what are you changing your charges to Medicare, Medicaid and commercial payers? And what is your overall increase in your change in charges? So this information was on the budget guidance and we also had the hospitals fill out in appendix. Okay, I'm just wondering though what did I actually get with the fixed payment perspective? That would have. So each of these are different terminology changes. So the first is that it clarified that net patient revenue is that addition of the fee-for-service revenue and the fixed perspective payment. So that's one terminology change. A second terminology change was a great increase to change in charge that's unrelated to the NPR FPP. We declared part of the more so the hospitals will say they charge us some rate to everybody. So if the charge is $100, they take a five which that increase goes to $105. But the actual then the change in deductions and actually what passes through would be five percent for commercial that zero for Medicaid or zero for Medicare. So we wanna make sure we're understanding by payer type what the actual change in the charges versus the rate may affect the gross cost at the top. Thank you for the presentation. I want to spend the team even though we've been down in half hour. I want to. That you've been ahead of schedule the whole way and that's really great to see. Keep up a great work. Thank you. The staff analysis will be on the web also this week, later this week. And there's also a lot of other summary documents that people can access on our web. Like we have what is called the trends report that takes all the different statistics and rates it by hospitals. That's a really good report. It'll take some of these measures and you can rate them like UVM and how they measure up against the rest of the hospitals who's number one, who's number 14 and things like that. Thank you.