 Alright, we're back after break and this morning we're going to hear a little bit about the hospital finances, sort of an update and an overview and we've asked the Green Mountain Care Board in to do that as well as the Hospital Association and we're all hearing different things from our own hospitals and also from the bigger, larger organization. So I think this is important for us to understand especially now, still still still pandemic time. So Susan Barrett is here and Laurie Perry I don't know that you've been Laurie I don't know that you've been in our committee before I presented the expenditure analysis a couple years ago. Yeah, I do remember that. Okay, so welcome back. Thank you. Some new faces. Senator Hooker from Rutland County. Senator Hardy from Addison County. Senator Taranzini from Rutland County. And then Senator Cummings is unable to be with us today. So the Susan I'm going to turn it over to you and let you introduce yourselves for the record. And then we do have something from you on our webpage. Great. Good morning, Madam Chair and Senate Health and Welfare Committee. My name is Susan Barrett. I'm the executive director of the Green Mountain Care Board. I'm joined today by my colleague Laurie Perry and Laurie, why don't you just go ahead and introduce yourself for the record. Hi, I'm Laurie Perry. I've been with the Green Mountain Care Board since inception and before that I was with Fisca. And Laurie is going to drive the slides as she's putting those up. I want to extend apologies from Chair Mullen this morning. We had a board meeting scheduled this morning to discuss hospital budget guidance for FY 22. So he is there with the rest of the board and with the director of our health systems finance. So I was lucky enough to snag Laurie to come along with me to give all of you an update on the financials. What we're going to do today is I'm going to have a little bit of background, but then I think it's going to be very helpful for Laurie to go through those numbers with you. And then I know we're going, you're going to hear afterwards from Vaz and Devin. I know, Laurie, you're having a hard time getting the. Yes. Wait up. Okay. Sorry. That's okay. We use teams over at the Green Mountain Care Board, not Zoom, so it's a new system. And I can just start while Laurie. Yeah, that's great. Thank you. Great. So let me just close this up. Look at what, why don't you, why don't you begin? And we do have the slides on our iPads. I actually preferred to have them up on the screen, but we'll be able to follow along a few. Great. Great. So on the overview of what I'll share today, we're going to talk about our statutory charge that is in statute and you've given us as it relates to hospital budget oversight. We're going to talk about the hospital budget guidance, which is currently happening right now in our board meeting. And look at how we've been able to adjust that guidance per Act 91 over the last year and this year. And then we'll get into some of the timelines just to give you, I know there are some newer members to the committee, just a high level overview of what our summer will look like. It's very exciting when you have a very busy regulatory summer. Because that's a good thing and a bad thing when there's like three weeks of Vermont summer. And then we'll turn it over to Lori and she can get into the FY20 system-wide performance and go through some of the numbers and lastly, we'll round out with an interactive visualization. I want to check in on time, Madam Chair. We should get through these slides fairly quickly, but I want to make sure that I wasn't clear how much time I had. Well, we have you and we have Vaz for the next hour. OK, so we want to make sure that you each have enough time, I think. I think that's reasonable and we'll get through these and be available for questions as we go. So one second, Susan, I'm frozen. I'm going to have to try and get back into the meeting. It's completely frozen. I'll be right back. OK, thanks, Lori. I got it covered for now. And sorry, Lori, before you go, would it be helpful for Nellie to try and put your slides up on the screen? That'd be good. I just I still can't even use my mouse or anything to get out. Well, let's do that. Nellie, do you mind? Can you do that, please? Nellie. OK, great. Thank you. I'll be right back. All right, perfect. All right, let's go. So now that we have so we can go to the next slide, Nellie, if you wouldn't mind. Great. So our our statutory charge is annually by October 1. The board has the responsibility to review and establish hospital budgets in the review. The board looks at local health care needs and resources, utilization and quality data, as well as hospital administrative costs and other data. We hear presentations from hospitals. We receive input from the health care advocate and we do everything in a public form as it as you all know in our public meeting. And we of course accept comments from the public. All of this is what we usually do when we don't have covid with covid. We have adjusted our process, which I will go through in the next slides. So Nellie, the next slide, please. So hospital budget guidance off for a quick overview. I won't go in detail on this, but it really starts over several months before we start talking about the guidance at the board meeting. We work with VAZ and with CFOs. First, we look at the the finance and the health of the hospitals. We look at our internal regulatory alignment and then look at the scheduling. And we use our data to drive our analytics. Then, as I said, we work with VAZ and with some CFOs from the hospitals, as well as the health care advocate in meetings. And when I say we should specify this is just the staff, the board obviously cannot meet as a whole with any of these entities unless it's a public meeting. So we do this at the staff level and then internally working with our value based care teams and then start this public process, which we're going through right now, hopefully finalizing our guidance today. And then we issue that guidance and then we update the information from that process into the narrative for the for the hospitals to follow. So next slide when I see Lori's back, that's great. So this is just an overview of our timeline. I don't have to go through this now, but just so you know, we're right at the very beginning. The guidance will be issued at the end of this month to the hospitals. The summer will be reviewing those budgets that come to us July 1st. As I said, our hearings are also this summer in August. So everyone knows they will be virtual again this year. We didn't want to take a chance of trying to have folks come together. And they actually worked out really well. I think the hospitals appreciated the flexibility in terms of travel time that they didn't have to take. And then in September, we issue the decisions. They are due in statute by September 15th. OK, now the next slide. So just to summarize last year per Act 91, thank you to all of you for your flexibility in terms of our regulation. And I know I got the hospitals and our other regulated entities appreciated that fast work from all of you so that we had the ability to streamline our processes. And these are just a summary of what we did last year. And then on the next slide. So we changed the date from July 1st to July 31st. So gave folks an extra month to get the get their submissions ready. We abbreviated many of the Excel templates that were used by each hospital. We eliminated non financial reporting. And I'll go into a few more details on that on the next slide. We limited questions from the board and the health care advocate also limited their questions. And then we added information that would help identify and highlight the impact of COVID, which is pretty obvious. You'll see it in Lori's slides. Next slide, this slide. I won't go through all of it, but I wanted to highlight it because you can see on the left side is the items that are in the many of these are in the non financial reporting section of the hospital budget guidance. And you can see the recommendation and the result was that we removed or combined many of these items like quality reporting, capital investment cycle. We were able to, if the last part, the appendices remove many of those tables that we really felt were, you know, this year, last year and likely this year, just burdensome for the hospitals to provide to us. With that said, we obviously have the statutory duty to review these budgets and to make sure that we are receiving critical information at this time. But I just really did want to highlight that we made a tremendous effort and thanks to all of you for the ability to do that through our Act 91 flexibility. So the next slide is looking at the guidance that we're reviewing at this moment. And again, this year we changed the date back to July 1st and the hospitals were fine with that. But we are doing this very similar things that we did last year in terms of removing those non financial reporting requirements, looking at quality, looking at white times, really important things. But we just these two years, we recognize have been really unlike any other for the hospital. So we are streamlining our efforts. Again, we're limiting our questions to those of a technical and clarifying nature. One other thing that is under consideration, again, as we speak is the exemption from the public hearing policy and that criteria and and hopefully we'll have a final vote on that today. But again, that Act 91 flexibility allowed us to do that. OK, next slide. I'm going to turn it over to Lori now, madam chair. Do you should I stop for questions now or have Lori get into the numbers? I have a bunch of questions that I'm going to I'm going to hold them for now and and maybe even till after the hospitals have testified. So we'll just keep going, I think. Great, thank you, Lori. OK, we wanted to show you what happened with the hospitals for last year, their first year of the pandemic. So the next slide we're going to go into fiscal year 2020. And we require the hospitals to send to us in our adaptive software. They're operating results for fiscal year 2020. We ask for it for all of their years. But we also ask them to send us their audited financial statements and also if they have parent organizations, the audited financial statements for those two. And if you are interested, we have all this information on our website under hospital budget review actual 2020. And you can see the individual hospitals, reports and audited financial statements and things like that. We also like to make note that Springfield was not able to give us their audited financials for 2020. So we use their preliminary data that they had sent to us last fall for their fiscal year 2020. And you'll see notes on all the slides pretty much about Springfield. Next slide, please. And we also we were doing the hospital budget guidance last year in May, the last day, the board waived the enforcement for 2020 because of the COVID pandemic. And this is the language of the motion that happened on the 27th board meeting. Next slide, please. So we're going to show you what the hospital Vermont hospital system has looked like for 2020. And of course, that's Vermont Community Hospitals. It does not include Ratabar Retreat or the Vermont Psychiatric Hospital on the left hand side is the Vermont Hospital System net patient revenue and fixed perspective payments. The actual results to their budget. And if you compare it to budget, they were just shy of three hundred million dollars from their budget, which is pretty significant. And then what their operating expenses were twelve thousand twelve million two hundred over their budget for 2020. This other chart on the other to the right is showing fiscal year 19 to fiscal year 20. And their net patient revenue fixed perspective payment was less by one hundred sixty three million dollars, but their operating expenses were eighty five million dollars higher in nineteen. Again, this is all of their pandemic type expenses, PPE, testing, things like that. And very significant. We also show it all throughout any presentations that we do, we show operating margins. And this is from 2015 through 2020. And they, as you can see, they've been declining and twenty twenty was hit very high because of the pandemic, but also twenty twenty has the stimulus funds included. And we want to emphasize that this number might change based on federal guidance on the stimulus funds. Can you just stop there for a second? So I mean you you hit a question I was going to ask, but this is a good time. So the stimulus funds are included in the twenty twenty data that we thought that they've had so far. That's true. And it's also based on their auditor's guidance. Some are recording it in their profiting loss or income statements. So are we showing up in the operating margins and some have been told not to. So it's all over the board. And so expect this to probably change. OK. All right. Thank you. You're welcome. So we can go to the next slide and the top slide is showing fiscal year twenty twenty quarterly operating margins. And we would like to see the margins with all the hospitals showing just UVM Medical Center and then without UVM Medical Center. And there's quite the difference in these particular graphs. We also like to show that because UVM Medical Center has about fifty percent of the hospital system. And then the bottom slide is showing for two thousand fifteen to the two twenty. Again, operating margins with UVM Medical Center without UVM Medical Center than all the hospitals. It's a very telling slide. Next slide please. We also when we're looking at the hospitals, we look at their pair mix. Of course, commercial Medicare and Medicaid. And in this slide, we're showing two thousand eighteen, nineteen and twenty. And for system wide, we haven't seen too much change from payers. But when you look at individual hospitals, you will see that they have a different pair mix. Some might be sixty three percent commercial. Some might be again, fifty percent commercial and things like that. So but this is the system. And it's it's been consistent for the last few years, even with the COVID. So next slide, please. With the pandemic, the hospitals were having to rely more and more on their other operating revenue. And this is where the COVID funds were reported. So we wanted to show you from year to year, their net patient revenue and fixed perspective payment. And then their other operating revenue and what the other operating revenue percentage is as a total of of total operating revenue. So the total graph or bar is their total operating revenue. The light blue is their net patient revenue, fixed perspective payment and a little bit darker blue is the other operating revenue. And for twenty twenty, that is, like I mentioned, where their CARES Act funding is showing up. And so as we're showing, it's fifteen point nine percent of their total operating revenue. And a lot of the what a few of the hospitals credited the CARES Act funding was critical to the sustainability of their hospitals. The next slide, please. Another look at the other operating revenue to slide on the left is just showing the growth in other operating revenue from two thousand sixteen to two thousand twenty. Just about double in two thousand twenty. But then the other slide on the right hand slide, we wanted right hand side, excuse me, wanted to show the different categories that the hospitals have that are in their other operating revenues that help support the hospitals. And some of this is like outpatient pharmacy revenue for our UVM specialty pharmacy. There's the three forty B retail pharmacy programs and then the one with just the one bar for covid stimulus and other grant funding. How much that was for fiscal year twenty twenty. We also want to mention that not all the hospitals were able to record all the stimulus funds that they receive this last calendar year because this is their fiscal year, which ended in September. So some of the hospitals receive some funds like in November or December of twenty twenty. And you will see that show up in their fiscal year twenty twenty one. So, Lori, I just want to ask a quick question. You have specialty farm pharmacy and then you also have the three forty B. So if we if we added those two together with that show total pharmacy. No, there is outpatient pharmacy specialty pharmacy there. Three forty B put all of the pharmacy revenues together then, including the outpatient. I forgot to mention that one. This would be the majority. Yes, but I think that we've been hearing in the past that sometimes there's pharmacy revenues that are accounted for netted against expenses based on their program for three forty B. We have to really tease that out and we haven't done that very well in the last few years. OK, so the appearance of this as revenue is not. This is not the revenue that's going in flowing through the hospital in the net patient revenue. Like, for instance, if you're an inpatient. If you have if you're patient in the hospital and need to have pharmacy drugs will say or administrative, it might not be included in these particular categories. OK, thank you. These are non claims, I believe. These are. Arrangements that they also might have with the pharmacies in the area. And even as of the other day, we're learning more about three forty B from one of the hospitals. OK, thank you. Next slide, please. This slide is showing the operating margins again. And this is the dollar amount. But we wanted to show you each hospital what happened in their fiscal year 19, what they budgeted for in 20, and then what their actuals came out to be in 20. So you can see the drastic changes from fiscal year 19. They were having a twenty million dollar operating margin, which was mainly UVM Medical Center. But in twenty twenty, they only realized three million dollars because of COVID. So the and if you're wondering about the percentage variances, those are basically just comparing budget to budget budget to actual or actual to actual and some of the calculations don't look the greatest, but that is what they came out to be. So like if you're using Montesquotney and you're starting with a negative number to a positive, it doesn't always come out that great. Like, for instance, actual is a negative one thousand three hundred fifty five percent, which is so unusual. And then also for budget to actual, it doesn't even want to calculate it. So if you're wondering about some of those figures. Next slide, please. We also look at key indicators for the hospitals, not just operating margins. We look at days cash on hand and we want to see that particular indicator growing or increasing every year. We want to see days receivable and we just want to see that indicator decreasing so that they're collecting on their accounts receivable timely. The days payable, you want that to be a decreasing so that they're paying their bills timely and that that service coverage ratio. You want that to be increasing so that they have more assets and cash available to pay off their debts, mortgages and things like that. And then you don't want their age of plant to be growing that much. So for instance, you're seeing Grace Cottage at 20 years. You want that to be much less. And the days cash on hand we wanted to point out is for fiscal year 2020 includes that stimulus fund. So that might be inflated artificially. And that might I mean again that might be changing again based on what the federal guidelines are. Next slide please. This is we're happy to announce that we have an interactive visualization that was just launched this last week. You're going to be the first outside of the B-mount care board to see this. And we're very proud of our team for launching this with our we call it A-Team Analytics Team. And hopefully this Oh, you've got to drive on. Nellie, could you click on that link please? Thank you. It should be able to go to the Green Mountain Care Board. I think I think we can do it on our iPads or our computers. So it may be going up. But we have it. So we recommend trying it out. Sure. There's different radio dials and you'll get a different look. The look that I pasted into this PowerPoint is the system income highlights and you're able to select on different indicators. You can select on different hospitals, you can select on the different. Do you want to look at balance sheets? Do you want to look at income statements? So play around with it. We want your feedback. And we're very proud of this information and we'll be updating it with the second quarter of 2021. Probably in May, April or May. Terrific. We will we'll we'll we'll spend a little bit of time ourselves just looking at what you've done. It does look pretty impressive to say the least. So if you go to the operating margins, if you do see that as some of its drop down menus and some of its radio dials, you will see like for UVM Medical Center, their operating margin increased in 2021. They received additional stimulus funds. That were not recorded in their fiscal year 2020. So things like that you'll see. Right. How do you how do you how does the board adjust his thinking around that? The the CARES funding, the additional federal dollars relative to the budget and maybe what appears to be a lower operating margin. How is that considered? Is that the CARES funding theoretically is to cover the needs during the pandemic? But then we're seeing some significant effect of the pandemic on margin. So the circular question. Yes, yes. And we are emphasizing that type of look and that the CARES Act funds is, you know, it's not necessarily going to be flowing into the continuing into 2021. It's not going to continue maybe into 2022. And we have to it's a fine line where we're being very careful on our guidance based on that. All right. Thank you. I believe we are at the end of our. Oh, there's a couple more slides, maybe. I think there's just a summary of what's next. Thank you, Lori. That was great. And I'll just take through these quickly. Sustainability planning is coming up. We have an update due to you April 1st. So you will see that next week. We just so everyone knows we have taken that work in-house. Really, the hospitals as you've heard and you will hurt here, I'm sure is, you know, they're still really bogged down with COVID and now the vaccines. So stay tuned on that. Continue to move towards value based care and part of the sustainability planning looks at that. We will work, as I said, and Lori said, with the hospitals as they move through the COVID-19 impacts through the next years. This will continue to have impact. We have transparency work we're doing. We have a workgroup with our data team and VAS is involved in that. And then also health equity is and that is related to our transparency work. I did not say this at the beginning. I will just close in saying that we want to recognize the work that the hospitals and all of their workers from the cleaners to the nurses to the doctors. Everyone in between has done over the last year and it continues. As I said, the vaccines are they are in the forefront of rolling that out. So thank you and we can open it up to questions now or would you like to go to the next presentation? We're open to whatever you'd like. Yeah, so we'll stop here for just a couple of minutes for questions and then we'll move on. But thank you. This is extremely helpful. I can tell you doing a lot of work on the budget process during the pandemic. And one of the questions that we're going to be asking, of course, and one of the reasons that we're looking at this now is to determine if there are any improvements that might be made in the process. Just knowing that, A, we've got a reform process that's going on that does include quality improvement as well as financial metrics. And then B, the process that the hospitals go through every year for budget review, I think, is of concern. It is, I mean, it begins, let's say, it begins on March 31st and then it goes through till September 15th. And it's a one-year process with a lot of input submission dates, clarification information. And then this year, obviously, with the pandemic or last year and then going forward, there will be some modifications to that you've demonstrated to us, one of which is on the, it's not the elimination of the need for quality, but at least not reporting quality, which sort of counterintuitive when you're thinking about what are we trying to do? So I have a thousand questions, but I guess the one general question would be, how is it that quality metrics will be included on the dashboard for budget evaluation? So as we highlighted last year and the guidance has not been voted on this year, unless it has as we have sat here, but it looks, you know, it looked like the recommendations from staff were to remove, for instance, we would ask waiting times, how long are folks waiting to see a provider? We eliminated that. We will continue to work on a way forward. I think the sustainability planning will also be integral to this work and recommendations out of that work in terms of how we may look at the hospital budget process so that it is getting the board the correct information and the right information at the time that we need it in the back of my mind. And it's always that Goldilocks point, you know, that sweet spot, like what's too much, what's enough, you know, not too long ago, pre-pandemic, you know, Kevin and I were in here talking about Springfield and what happened. I looked at the chart that Lori showed on the indicators, those arrows, which I love, that was a result of the Springfield experience. And so now we track those. So, yeah, Madam Chair, absolutely, we will continue to work through this process to make sure that we're doing our due diligence per our statute, but also recognizing that the hospitals acutely are in pandemic mode still. And our way forward is to allow them to thrive and sustain in a value-based world. So, yes, thank you. I think we all want that to happen. The hospitals are critically important to our healthcare system. One of the things that we talked about this morning with Commissioner Levine was he brought up the Health Improvement Plan and I was glad to hear about it because, and I think I've mentioned this to you previously is how the Health Improvement Plan may actually inform the quality metrics for Green Mountain Care Board. And not to mention the ACO, but just sticking with Green Mountain Care Board. So we may be circling back to that as a basis for quality improvement. Absolutely, and we worked very closely. This, again, was pre-pandemic when we had the luxury of meeting with our colleagues over at the Department of Health. But you look at that, the SHIP, as they call it, State Health Improvement Plan, they were so forward thinking, they were thinking about health equity issues way back when nobody else was talking about it, right? So now that we look forward to continuing to work with them and we'll take your lead as you point us. Yeah, so, you know, and I think we'll hear from, we're gonna hear from the hospitals in just a minute, but just the hospitals are doing work to help link with community services to allow and to provide care management services to link primary care, medical home services. So there's a lot going on and we don't wanna lose sight of that, I think. Questions for Green Mountain Care Board on the hospital data, Ruth, Senator Hardy. Sure, thank you, Madam Chair. And thanks, Susan and Lori, for being here with us. I had two questions and one is sort of for you and also for Devin when she comes on, but I'm looking at the slide. This is my specific question on Vermont Hospital System. It's the slide about the margins, the operating margins and the declining operating margins from FY 15 to FY 20. And I'm gonna tell you how I'm reading it and see if I'm missing something here. On one hand, we want hospitals or any business to have an operating margin so that they have a cushion to carry forward, but you don't want them to have too much of an operating margin because then their revenues, they're maybe charging too much or their budgets are not accurate. So I see this as both a positive and a disturbing slide because we see the decline, but then it gets to be too low in FY 20 when the pandemic hit. And I'm just wondering, am I interpreting that correctly or am I missing something? So I'll start, and I think I said this to Lori, we were prepping to talk today. I said, Lori, can you expound on this slide a little bit? And I think I'll have her share what she said to me this morning, but I had the same questions. I think it's the sweet spot. Again, that Goldilocks, our job at the board is to reduce the cost of healthcare while maintaining access and quality. And if the hospitals don't have that margin to continue to do their good work, that's not where we wanna go. Lori, I think I'll let you share the bigger picture and what we've been discussing at the board around the expense side of things. So before, I wanna, this is a question that I've had and I did ask it of the hospitals the other day, but the question I would ask is what I think Senator Hardy is getting at is critically important. So what's the floor? What's the floor for the margin based on the, whether it's a critical care access hospital, whatever it is, and then what's the cap? What's too much and what's too little? So, and what do we know from our national, from national data? Is there data from hospital types that can help with that? And Lori, I don't know if that's something you can briefly touch on as you're answering Senator Hardy's question. I'll go first with your national information. We've been trying to find a lot of national information. We're still trying to find benchmarks. We're looking at maybe S&P. We're looking at Kauffman Hall. We wanna make it so that it also relates closer to Vermont because we're pretty unique. And we to also answer the other questions is that some of the operating margins are basically cause for those particular hospitals having to find their own efficiencies. And also we are constantly asking them to try and cut their costs as much as possible, but we also realize a critical access hospital has to get reimbursed from Medicare based on their costs. So like Susan said, there's a sweet spot and we're trying to get it exactly like you said, don't make too much revenue, but make enough to get a margin so that you can funnel the funds back into your organization, do improvements on your plant, do improvements on your workforce and things like that. But it's like we are struggling all the time. We're always trying to have it so that we're not having higher commercial rates for insurance to support the hospitals, but also we wanna have it so that they can survive. Some of these hospitals, it's we're seeing it's each individual and we're keeping an eye on each individual hospital to see what's been happening. Some of it is not necessarily just the hospital, it's their organization. Springfield was a good example because they were associated with their FQHC and having to help with their FQHC. We see other things like that. So it's not just the hospital, but that's why we're having a fine line to see just the hospital because that's what we're monitoring, but we also have to know what is the health system that they are supporting. I don't know if that answers the question enough. That very much answers the question. It begins to allow for us to look at it and I think it very much relates to the issue of reform that we're talking about where we're looking at care management systems, primary care clinics and then linkages all across the board. So, and how is that measured? So if it's simply measured based on the hospital budget, it doesn't actually measure the entire system of care associated with that hospital. So, and we're look at we're in the middle of the pandemic and we know that a lot of what we're, a lot of the reform goals that we have are not going to be met in the pandemic, but the pandemic is highlighting the need for some transition away from the purely hospital budget metric to something broader and more inclusive. So that's our job. I mean, we're going to have to look at that as a committee and perhaps make some improvements that will overall help, help overall. If you are interested in, and it's on our website as if the hospitals are part, are consolidated with like UVM health network. We don't just have UVM. So we have their audited financial statements on our website and you can see the linkages if you were wanting to. So, or other hospitals. Thank you. That's good. Go ahead, Senator. And just real quickly, Madam Chair, next, no, this week. I forget which day, one in day this week. Friday. Hearing, yeah, thank you. You'll be hearing about second floor equitable reimbursement report, which also touches on exactly what you're talking about. And I think Senator Hardy, these questions keep them in mind as you're looking at, at that report as well. Okay, great. Well, thank you for your, this information. I just, I find that slide just very interesting and one I will certainly keep an eye on. And the second question, and I'll ask Devin, or Devin can listen and answer it in her presentation too, is, you know, I talked to my hospital a couple of weeks ago, my hospital, hospital in my district, Porter Hospital. And, you know, their concerns with the sort of regulatory burdens during the pandemic and totally fair, I get it. And what I said to them, and is that I, you know, I understand the concerns about the regulatory burden. And it sounds like you all have been really sensitive to that and trying to reduce the amount of sort of reporting and things that they have to do for their process with you. But I said to them, I don't want two years from now to find out that the hospital's in the same situation as the Springfield Hospital. So it's sort of like your constant Goldilocks. I love the Goldilocks thing. Every time I think about Green Mountain Care Board, the G is now going to be Goldilocks, I think. So that sort of balance to make sure that there's not too much burden during a pandemic on hospitals and that there's enough oversight to make sure that we're catching the problems because the very last thing I want is in two years to hear that quarter is going under. So we have monthly monitor, excuse me, monitoring of these hospitals. We were doing this before the Springfield bankruptcy, but it's definitely emphasized now so that exactly like you said, we're not surprised. And we bring any issues forward to the board if we think that there's any problems. Of course, the pandemic is completely different, but we're still reporting. And so you've got a quick look on our interactive visualization of the first quarter of 2021. Okay, so that's sort of an ongoing thing that's outside of the budget process that you're doing. Okay, that's helpful to know. Great, thank you very much. That's great. So this is good and this is all extremely helpful. The other thing that, of course, the margin graph that you gave us, slide graph, that you gave us is very informative. It's also informative that the Medical Center of Vermont has actually held up some hospitals. It looks like that given the participation in the ACO, we've seen some benefit to some of the smaller hospitals from that larger hospital. And it does call into question how that gets balanced at the Green Mountain Care Board. So maybe we'll circle back to that at some point. Any other questions for Susan Barrett or Lori Perry? Okay, well, there are a thousand more questions. You're not escaping that easily. But thank you, thanks both, don't go away. But Devin Green is here from Vaz and Devin, you have sent us some information. Why don't you go right ahead? Great, thank you. Devin Green from the Vermont Association of Hospitals and the Health Systems. And I wanna make sure that you're seeing my Word document. Okay, great. And just my Word document, okay. Beautiful, we can see on our screen, we see half of what you have. It goes down just, yep. And then the graph is down below, okay, got it. Okay, great, thanks. So I would be remiss if I didn't take you all to the sort of ground level to give you a sense of where we are with COVID and what hospitals have been doing and how we've gotten to this place. So I just wanted to highlight over this past year, the COVID hospital care for communities and everything that had to be done there, the hospitals were an integral part to the care during the COVID crisis. And what they were doing was they were creating capacity for negative pressure rooms, they were building spaces in their hospitals, they were redeploying staff, they opened new treatment areas, they invested in screening devices, they had labs investing in testing equipment and testing supplies, they test staff and patients on a regular basis. They stood up new monoclonal antibody infusion units, so whole new units to provide that outpatient treatment for folks so that they wouldn't need hospital care. And they prepared for and managed surges of COVID positive patients, including assisting nursing homes. So that was the hospital response in terms of caring for their patients. But in addition to that, there was also a major public health partnership with hospitals throughout Vermont. And I think that really contributed to Vermont's success, but they assisted the state with the supply chain for PPE and testing supplies. I don't know if folks remember, but at the beginning of the pandemic, we had maybe a few days of testing supplies before we were going to run out and the University of Vermont Medical Center came in and helped procure more testing supplies. They partnered on community testing, so those CIC sites that folks go to, a lot of those are staffed by hospital staff. They stood up vaccination clinics for their communities as well. So they started with the vaccination process, which was not how it was done in other states necessarily. Some other states had their Department of Health starting it with the running population. The hospitals stepped up and jumped right into the vaccination process, which was not easy. But they made it look pretty easy. This has all been fairly seamless. It's all gone really well, but it's certainly come at a cost. So right now with the hospitals, there's a lot of uncertainty. It's unclear what patient volumes will look like in the future. Workforce, as I've heard talked about previously, and I appreciate that. It's stretched to the absolute limit. Healthcare employees have been working beyond their FTE for a year. There's no way to recruit new employees right now, and we are dealing with very high temporary staff and costs. So workforce is really an issue. We also have the uncertainty of COVID-19 variants out there and what their effects may be. And deferred healthcare too. We've heard from our emergency departments that they're seeing an increase in people in more severe mental health crisis or more severe physical crisis. And they're coming into emergency departments later so that it merits a larger response, which is taking up resources. When the Green Mountain Care Board talked about this margin that you see at the bottom here, where we're at 3.219 million, that does take into account 180 million in the federal COVID-19 relief funds. So that goes to the hospital's income statement. And even with that, we have just a 3.2 million margin on a 2.4 billion statewide hospital system. So that gives us virtually nothing to reinvest into our hospital system. What I hear now is I heard a very impassioned plea from our chief medical officers on Monday that they need breathing room. They are feeling like they have stepped up. Their hospitals have turned on a dime, provided services when needed, have procured testing supplies and testing platforms as needed. They've done what they can to respond to this pandemic, but they do feel constricted by the current growth rate of the Green Mountain Care Board. So a growth rate of 3.5% does not meet the inflationary challenges of workforce, pharmacy inflation, investing in infrastructure and new technology. When I talked to our chief medical officers, they were saying, if you don't invest in new technology now, the way advancements are happening and innovation is happening, you basically lose three years in advancement because it's just all happening so quickly in the medical industry. So what we're really looking for is, the Green Mountain Care Board has responded to us. They have been flexible. We appreciate that. But we still really need to be able to have some flexibility with that margin so that we can reinvest, make sure that we're still, we have that room to have our emergency response and preparedness. We can reinvest in our aging facilities and also the latest technology and healthcare reform. So that's where we are. We have been, as Lori pointed out, which I was glad she did. We're not asking for no regulation. We're recording monthly. We've been working very closely with the Green Mountain Care Board, but we are at a unique point, which you see at the bottom there, where we are getting dangerously close to not having any breathing room, not being able to have the resources to have the response that we need. And so we are looking for flexibility in that growth rate and in that growth rate to at least get up to medical inflation so that we have a little more room to reinvest in our hospitals and be care for our communities. Okay, why don't you unshare and so we can ask questions. So when we're looking, when you're talking about a 3.5% growth rate, is that the growth rate that has been utilized in the budget process over the past several years by the board? It's changed. I'll let the board respond, but typically it's lower than that. I say 3.5% because that is what they are looking at today is the 3 to 3.5%. And so that's why I'm saying that today. Okay, and so Susan, just so for the, so the committee understands what that growth rate percentage means. Sure. So I think Devin is referring to the net patient revenue growth rates. And that has varied. The board initially had a target back when the board took over hospital budgets of I believe 3.8% and then it went down year over year. And it has hovered near that, but as Devin said, it has fluctuated. The one thing about the net patient revenue growth rate is it's a, I'm going to be careful with my words. It's because we're deciding this now. I don't know if the other meeting has ended, but this was an option. There are several options on the table to have it as a ceiling, but traditionally NPR targets are, we used to say jokingly, like what if there was a pandemic or a flu pandemic and everyone ended up at the hospital, you'd blow through your NPR target. So that is where enforcement comes in, which we likely will put aside again this year again. It hasn't been decided yet, but we do monitor, as Lori pointed out monthly, we recognize that we are in a very unique time. And I can't speak for the board per se. We will see where they end up, but I know there are varying views from board members on this issue. I don't know if I really answered your question, but... No, you did, you gave us some insight into the thinking around that. So that is helpful and we understand the hospital association's position on that. I just want to say that historically that growth rate has been eight percent. And so it's come down significantly from there. And Susan was talking about the sweet spot and I would just say eight percent clearly is not right. We've really reduced our expenses, but a 3.2 million margin on a 2.4 billion industry is also not the right place we want to be. So we're not the regulatory agency here, but we're stuck in that position pretty quickly. But I think it's important for us to understand, it's also important for us to understand the work that you have done. And I very much appreciate the work that the hospitals have done. My hospital in particular has been done an outstanding job of supporting our long-term care facilities, our nursing homes in the beginning of the pandemic and then establishing a vaccine clinics, very large vaccine clinic in particular at the Champlain Valley fairgrounds. So I think, and it has, I would just say this and I'll ask a couple of questions, but it has been seamless. Nobody knew and nobody knows all the work that's gone on literally behind the scenes. So it is extremely, very much appreciated. But then the, I have one little question. The antibody infusion is how available is the antibody for patients coming in? Pretty big deal. Yeah, that's a great question. And there's been, it's gone back and forth in terms of the effectiveness of it. And now with the variants that have come in, I think we have at least five hospitals providing it, but I just got a notification this morning that said, doing BAM-lanivimab and do this other cocktail and because of the variants and the effect on it. So it's new information every day. And, but there are at least five hospitals that are providing the monoclonal antibody cocktail. Amazing. All right. So then I'm gonna go to the question that I've been asking right along. And that is now with knowing of course that the hospital concerns right now are focused so much on the pandemic and moving out of the pandemic. But during our healthcare reform process, hospitals have had an eye to expansion for care management, supporting folks getting to community services. You did mention mental health issues and needs and how that is being handled A, during the pandemic and B, how you're gonna be looking at it going forward. And just knowing that there is always a bottom line, but it's a bottom line for our DAs, our SSAs and our primary care folks. So the thinking about that and the thinking about how that fits into your budget review, your regulatory review. Yeah, well, I think as you can see there's not a whole lot of room to put resources into the healthcare reform direction that we want to go. We think the pandemic more than ever has shown us the importance of moving in this direction in terms of the payment methodology and allowing healthcare providers to stay in business. Obviously, having greater primary care wouldn't necessarily have prevented COVID or anything like that, but there is a real mental health crisis brewing and we know that we're gonna have to put resources into there and into the community. I think member Holmes last week when you were doing her confirmation hearing suggested maybe some federal funding that could go towards things like mental health and healthcare reform. You know, Senator Lyons about, I always harp on the federal funding that never came with our all-pair model effort. And so now would be a great time to invest in those healthcare forms in that care management and in mental health. Thank you. Yeah, it's a big issue. We get it. This is where Devin and I agree. Thank you. Let's start there. That's where we're gonna begin. Okay, committee questions. We have a couple of minutes left. Comments. You know, I just, I wanna thank both the Green Mountain Care Board and VOS for the work that you're doing during the pandemic. It is always difficult for us when we hear from any of our constituents including our hospitals about the dire straits that they're in and the pandemic has certainly taken hospitals to the brink. So just thank you for your work. We'll just leave it there. And we'll, don't worry, we're coming back. We will be back to a lot of the information that we have here. I think that, you know, I'm one of these literalists. So when you talk about Goldilocks, it always takes me a while to get there, but I talk about the cap and the floor for the margin and you talk about the comfortable chair. So I'm, we'll all go for the comfortable chair. But thank you. Well, I think we're good. I think we'll be good. We always end early and this is another example of that.