 members and Mr. McCracken and Dr. Lindbergh. So I'll turn it back to well turn it to Brattleboro sorry Mr. McCracken to swear in the witnesses and then we'll get going. Thank you Chair Foster for the Brattleboro team. Who could you let us know who's going to be presenting and answering questions. Hi. Yes. Thank you. Thank you. I'm Chris Stardy. I'm the president and CEO. Next to me is Jodi Stack. Sorry we can't hear you if you're speaking. Oh I'm sorry. Is this better. I can hear them. OK. So I'm Chris Stardy the president and CEO. I'll be speaking today. Jodi Stack Chief Operating Officer Chief Nursing Officer. Dr. Kat McGraw Chief Medical Officer and Chief Medical Information Officer. Rhonda Calhoun Board Chair. Jennifer Griffey Chief Financial Officer. Can you hear now Mr. McCracken. Can you now. We can hear you now. Can Mr. McCracken hear us. Yeah we can hear. If it's no trouble if Mr. Doherty could you spell the names of each of those that you listed for me. Sure. No problem. So Rhonda Calhoun our board chair is R-H-O-N-D-A-C-A-L-H-O-U-N. Jennifer Griffey our Chief Financial Officer is J-A-N-N-I-F-E-R-G-R-I-F-F-E-Y. Dr. Kat McGraw is actually Kathleen K-A-T-H-L-E-E-N. McGraw M Small C Capital G-R-A-W and she's an M-D. Jody Stack is our Chief Nursing and Chief Operating Officer. J-O-D-I-S-T-A-C-K and she's an R-N. And I'm Chris Dardi C-H-R-I-S-D-O-U-G-H-E-R-T-Y. Thank you. You bet. Thank you. Great. Thanks very much. If the Brattleboro team could raise their right hands, I'll swear you in. Do you solemnly swear that the evidence you shall give relative to the cost, no under consideration shall be the whole truth and nothing but the truth shall help you God? I do. Great. Thanks very much. And I think the floor is yours. All yours. Good afternoon. As I said earlier, I'm Rhonda Calhoun. I'm Chair of the Board of Directors of Brattleboro Memorial Hospital. And I'd like to thank you for your time and the opportunity to present our 2024 budget. We are proud to present this budget to you for our entire board finds it reasonable, responsible, and most importantly responsible to the needs of the community that we serve. Many of us are looking at COVID in a rear view mirror. However, health care is still recovering and faces continuing challenges. This budget has been thoroughly reviewed rigorously and including our Finance Committee of the Board working closely with staff to develop the budget, our entire board review, which is comprised of community leaders, and finally a review with our legislative delegation so that we could obtain their feedback as well. All parties have found this budget to be reasonable and directed to quality care and sustainability in our future. Now, I would like to introduce a couple of other people that are here in the room. Our controller Laura Bruno is here. Our Chief Information Officer, Steve Cummings is here, as well as our Director of Development and Marketing, Gina Patterson. And I would also like to put the table back over to you, Chris. I think you have a brief opening statement. I do. Thank you. Well, we'd like to thank you, Chair Foster, and members of the Green Mountain Care Board for your time, your guidance, and your service. I'd also be very remiss, I understand, if I didn't thank Director Sarah Lindberg. I understand she's been sensational to work with throughout this process. And I'd actually like to give an enormous thank you to Rhonda for being our Board Chair and her great leadership. This is a very difficult time to chair a health system board, especially in Brattleboro, Vermont. We're about to celebrate our 120th anniversary of service to this community. In those 120 years, there's been a heightened sense of dependency, expectation of service, expectation for improvement, and expectations for us being responsive to the needs of our community. These have intensified over these 120 years, and Rhonda is in that glorious situation of getting to be here right now, when they're probably at the highest they've ever been. Somehow, Rhonda and our Board keep us focused on our high calling of making lives and health better for our entire community. Our Board pushes us to serve our community with excellence, and they do so through a balanced scorecard approach. This approach actually tracks our progress on seven key strategic priorities. Today, we'll probably hit on three of them that are key to our budget presentation, and they include elevating the health of the community, recruiting, retaining, and caring for our phenomenal team, and of course, exercising wise financial stewardship. Now these three play a prominent role in the development of our reasonable, responsible budget that is responsive to our community's needs. I'd like to quickly highlight that our budget has a major uniqueness to it. I'm sure you're going to hear this 14 times, but this one really is unique. We are the only Medicare-designated dependent hospital in the state of Vermont. In 1987, the U.S. Congress established this program to help support small, rural hospitals for which Medicare patients make up a significant percentage of patient days or discharges. That's us. This was put in place because a federal government acknowledged that Medicare on average only pays about 84% of hospital actual inpatient costs, and I believe Director Lindbergh actually has some graphics that support that. We actually get a somewhat more robust payment from Medicare since we have very limited opportunities to make up costs anywhere else. This program is in place through September 30th, 2024, and there is actually a bipartisan bill in the U.S. Senate that would make this designation permanent, and we are hoping that that comes through. This is all very important in helping us achieve our goal of being the enduring hub of hope, health, and healing for our entire community. We realize we cannot do this alone and that we must work in and with our community, so now we're going to ask Dr. Kat McGraw to talk about some of the work that we do with and in our community. Thank you. So, BMH is not just a hospital, though we are that, and we're not just an independent medical system, though we are that too, but also an integral part of the Browderboro community, and we're dedicated to improving the health of our community, and we start doing that by providing the foundation of health, which is primary care. We have five practices with a total of 15 clinicians providing primary care services. Each of these is a level three patient-centered medical home, reflecting our commitment to ensuring excellent primary care that includes care coordination, access to services, and continuous improvements in each of these areas, and it's working. We hear it from our patients. Here's one recent example. Hi, my doctor called me at home and told me to get ready and have the ambulance come get me and get me to the hospital, and if he wouldn't have done that, I probably would have died. So, I ain't got nothing but good things to say for saving my life about my doctors, about my heart doctor. Thank you. We build on this work through collaborations to provide the right care delivered in the right location, keeping it as local as is appropriate, collaborating with Dartmouth, Cheshire, UVM, and community organizations to ensure this. For example, our Dartmouth and Cheshire collaborations ensure that we have board-certified ED providers delivering high-acuity care that our primary care cannot and tele-ED coverage to help support unexpected surges in volume for acuity because there really can't be anything unexpected in an ED, and we know that our community depends on this. We lift the health of our youngest community members with our birthing center. Last year, we delivered 273 babies in what would otherwise be a maternity desert. It is more than 60 miles to the nearest NICU nursery, so our tele-NICU collaboration ensures that babies who need NICU care can get it before their transfer has even begun. These are but a few of our essential clinical collaborations providing necessary care in an affordable and sustainable way. We are here every day ready to treat whatever is presented. We're prepared to treat the persistent heartburn that might turn out to be a heart attack or gallstones or an esophageal rupture or maybe just heartburn. It's what we are set up to do. Vermont is not well set up to deal with mental health crises right now. Mental health resources across the state are not sufficient, and the number of patients in crisis in our ED is increasing, and unfortunately, so is their length of stay. The ED is not a good place for these adults or children in crises who sometimes spend days or even weeks in our ED because there are no appropriate psychiatric beds available. We have invested in numerous unreimbursed services to assist in improving this from constructing a calmer space to providing tele-psychic consults to hiring an ED-specific social worker. We have recently stepped even further into this space as leaders creating HealthWorks ACT, a new program intended to be a replicable model for other Vermont communities. It brings a data validated approach to mental health treatment with medical care, homeless services, and peer support on a 24-7 basis for adults with mental health diagnoses and housing instability. Our goal is to treat these patients before they need the ED or inpatient services. It costs less on a per person per month basis than one day in the ED or one day at the retreat. We know we're having an impact on the health of our community. We focus on creative solutions that address the issues in ways that are not just responsive but preventative. And our budget for FY24 follows this philosophy. Jodi? I'm Jodi Sack, Chief Operating Officer and Chief Nursing Officer. In order to serve the community in all of the ways Dr. McGraw mentioned, we need to recruit, develop, and care for the people who work here. We pride ourselves on providing many pathways to a career in healthcare and to removing the barriers to getting there. In less than five years, we've raised our minimum wage from $12 to $15 and eventually $17 an hour. We provide scholarships for certified medical assistance, licensed nursing assistance, LPNs, environmental services, and most recently, phlebotomy. We have on-the-job training programs for entry-level care providers, such as medical and patient care assistance. We offer significant financial support for professional development and higher education through scholarships, tuition reimbursement, and other professional programming. We host clinical rotations for nursing, pharmacy, and other technical programs. During the pandemic, we work closely with our affiliated nursing schools, specifically Greenfield Community College and Vermont Technical College, to keep those programs running safely throughout. In 2019, we created a new RN graduate nurse residency to ensure a safe and rewarding transition to practice for new graduate RNs. Last month, kicked off the 2023 residency program with nine nurse residents in our progressive care unit and emergency department. I wanted to share a reflection from one of our nurses, who was the recipient of one of our VTC LPN scholarships. This year marks 10 years for me at BMH. I started working in our coffee shop and from there landed a position as a unit secretary and LNA. I gained experience over the years in many departments, including SCU, PCU, Short Stay, and MS2. My experience on MS2 sparked an interest in orthopedics, and after graduating from Vermont Tech one year ago, I decided to try the outpatient setting. Our department is very busy, and working here so far has been a new and exciting experience. When providing care, no matter how difficult the situation, I always ask myself, what if this was my family member? What can I do that will make this patient remember me in a positive way? I wanted to share this as just one small example of the difference it makes when we invest in the members of our community, both as employer and as a provider of healthcare. Thank you. My name is Jennifer Griffey. I'm the Chief Financial Officer at Brattleborough Memorial Hospital. I just wanted to start with giving you a landscape of where we started at the end of fiscal year 22, which was from a very fragile financial position. Brattleborough was hit strongly with the Omicron variant of COVID, taking out approximately 10% of our staff being unable to work, causing us to reduce our patient services, including the closing of our ORs. We ended up in fiscal year 22 with approximately $4 million operating loss. Fortunately, fiscal year 23 has proven to be a different story. This has been a story of a turnaround for us. Services is stabilized as a result of the loss services and closed services from Omicron, including the opening up of all of our ORs. We're seeing a trend of a $736,000 loss as of our June financial statement closing. While that may be a loss, that represents approximately a $3 million turnaround from fiscal year 22. We feel that we're on the right trajectory from a financial perspective. However, we do know that more work needs to be done from this fragile financial position, which is the reason why we approach this budget from a reasonable perspective, a responsible perspective, while keeping an eye on providing first rate health care to the community of Brattleborough. To walk you through a little bit of how we approach this budget, and I know Director Limburg will get more into the details, but I do want to set the stage. We do have a reliance on the IPPS increase for Medicare. If you remember what Mr. Doherty talked about, we are a Medicare dependent hospital, meaning that the majority of our patients are Medicare or Medicare Advantage. We needed to rely on that increase. As a result of Medicare not supporting all of our operating expenses, we are reliant upon the Medicare dependent hospital status, which provides an enhanced reimbursement to support that shortfall. We do have a small utilization increase of 1.6% for next year, fiscal year 24, which results in a very, very small and modest commercial rate increase of 1.5%. We approached our expenses from a very responsible and fiscally conservative manner. We asked each one of our directors to approach us with a 1% challenge. Can we do 1% better on finding more creative and fiscally responsible ways to our administrative costs? We intend to rely less on contract labor filling our open vacancies. We also have participated in yellow belt lean training for every one of our managers and directors, so next year we can focus on finding and implementing workflow optimization, causing us to have less reliance on administrative costs. We're looking at using augmented intelligence to automate manual tasks, thereby reducing the need for FTEs for these manual tasks on the administrative side. We are also anticipating less use of energy and becoming more fuel efficient with the replacement of our boilers and plant services with the Ron Reid Pavilion that was open this year. All of that results in a very, very modest gain of 0.7% on the operating margin or $845,000. All of this we need to support, continue support of our community. We need to ensure compliance with our debt covenants. We need to replace end-of-life patient equipment, our IT infrastructure, and of course maintaining our facilities. We also keep an eye on our investment to the community. My esteemed colleagues have addressed some of the things that we do as a health system to support our community, including supporting a labor and delivery, allowing Vermonters to be able to deliver their children in their home state of Vermont. With that, Chris, do you have anything else before we kick it over to you? Thanks, Jennifer. No, it's all yours. That's our opening. Thank you for the time. You're maybe muted. Can you hear me now? Yes. All right. Double mute. Okay. So, when we look at Prattle Borough compared to other perspective payment hospitals, we see that their MPR growth is among the highest. We also know from their opening remarks that this is almost entirely Medicare-based reimbursements and utilization. We do see on the expense growth side operating expense growth from fiscal year 22 of under 9%, just under 9%. So, that is very close to what we're looking for on a benchmark for expense growth. So, that is where they stand in relation to their peers. And so, that 19.9, we said, is all NPR, all payers, all the time. So, the commercial price, if we go back, I'm sorry, for a moment, is estimated to net 1.1% from fiscal year 23 to 24 based on 1.5 on the charge master. So, very small increases from 23 to 24 for price. As far as operating expenses, again, we don't have that benchmark, but very close to what we are hoping to see for revenue growth. And then the labor expenses, so these are per FTE rates. What we would expect to see based on the employment cost index is a range between 0.8% and 9.7%. So, very close to that. And when we look at that, we see the impact of those inflationary pressures to increase salaries between fiscal year 21 and 22 and seeing the decline in FTEs, which I assume is part of the why the reliance on traveling nurses and locums has been necessary. But I'd be interested to hear kind of how you approach the labor challenges in your budget and what adjustments, if any, to positions you were considering as you built this budget. Sure. Would you like to start without the nursing side? Right. So, are you referring to the programs that fill the FTEs? So, right now we have about 18 contract temps. Most of those are in nursing. I think 13 of those are in nursing. So, those new graduate RNs by first quarter should be filling the majority of those nursing. Holes. We still are recruiting for experienced nurses into open positions and we're finding people who left about the 2021 mark for clinical positions are returning to the workforce. And so, as we fill those throughout the summer and early fall, the hope is that by the end of calendar year 2023, we'll have most of those filled. Sarah, also from the financial side of it, we had a $3 million budget last year for contract labor. We ended up reducing the contract labor to $1 million on the financial statements moving the difference into salary wages and benefits as we're seeing the less reduction on the contract labor filling those vacancies as Jody talked about. So, just wanted to point that out there when you see the increase year over year. And just a practical thing as well, Sarah. While we did not implement a hiring freeze this year, we actually have implemented a more structured position control system that looks at vacancies and we've had a lot of attrition. And with that attrition, a lot of those positions have not been filled nor budgeted for the coming year. Thank you. And in terms of the rate for contracted labor, what are the assumptions for fiscal year 24 as compared to 23 level up down? What's your best guess? We use level from fiscal year 22 to fiscal year 23. There's still some volatility on the rates. Although I am happy to say over the last few months, we are seeing those rates actually go down incrementally. Every little bit counts, right? And so... I'm sorry to interrupt. Was that Ms. Jennifer Griffey speaking just now? I think you're off camera, so I'm having a hard time seeing you. It is Jennifer. Yes. Thank you. Wonderful. So those are the main questions that staff had related to labor. Do board members have any questions on this area? All right. This is Dave Merman and I must just say hi to Kat McGraw. We worked together 11 or 12 years ago in Greenfield and haven't seen each other since. So nice to see you. And I've been hearing your name since then. So the one question I have is actually on the report one. The physician fees and salaries are not in the FY24 submitted budget, but they were in the FY23 budget. And I was just wondering if that was an error in this submission form in this way or if there actually is there's been a change? There's been no change. The contracts positions are budgeted at their... Sorry. I have to stop for a second. We have the answer. So when we look at one, we put it in the hospital budget. They were all budgeted in-house. We can provide more clarification and more details if that would help the board. That would be great. Thanks. Just noting the follow-up here. Well, you're doing that Sarah. I'll just jump in really quickly. It sounds like... So prior to the pandemic, BMH had some very robust programs for growing your own as people sometimes call it. And it sounds like those are coming back online and getting rejuvenated. So that was good to hear. I just wanted to confirm that my understanding is right. Yes, absolutely. Great. Thank you. That's all I had on labor. All right. Any questions from the advocate on this topic? No, thank you. Wonderful. So turning our attention to utilization. So I think you're not the only ones, but the exhibit 10 was a real bear for folks. Sorry. It was designed to be simpler, but I think I made it more difficult. So just back of the envelope, can you help me understand from fiscal year 22 to 24 kind of how much of your budget is being driven by utilization? I think you said it in your opening remarks, but I wasn't fast enough to write it down. No worries. So as I mentioned in the opening remarks, fiscal year 22, because of the Omicron variant and our staff needed to stay home as a result of that, we ended up closing our ORs, which is our largest service line. So there was a significant decrease in our utilization in fiscal year 22. We are seeing a bounce back. When we look at our overall net patient revenue increase, 17.24% of that is driven by the change between 22 and 23. 23, of course, as I mentioned in the opening statements, we have been able to reopen and stabilize all of our services, including the reopening of the OR. So that was strictly driven by the utilization. Thank you. That tracks. And then the other notable utilization trend, and perhaps you can speak to some of the local challenges that might be behind some of this, but the significant increase in emergency department utilization. Just curious, what's driving that? How you're looking at that? If any of that, how you think about that in terms of potentially avoidable utilization and just trying to wrap our minds around that significant trend? I can start and if anybody else here wants to add anything up, I'll start by saying that we have scenes and increases. We know mental health is a part of that. As I mentioned, the length of state is growing there and we have put some additional position hours in the emergency department to really assist with that and to turn around the smaller problems more quickly. We've also started staffing one of our primary care clinics with a acute care option so that folks can come in for any of those kinds of things that aren't necessarily emergency level and get in and seen the same day. So we're not entirely sure of what's driving it specifically, but we're putting in place things to help kind of decant it as it were. The only thing I would, this is Jodi, the only thing I would add to that is there's a lot of work being done not necessarily on the specific to avoidable ED visits, but with multiple ED visits. So doing an analysis, people who are going back frequently and making sure they have outreach from primary care, that they have primary care first, but they have outreach and if necessary, they have a multidisciplinary care plan in place. Wonderful. And I don't know how closely you had a chance to look at these, but we see, and you mentioned in your narrative that a substantial amount of business comes across straight lines into Vermont for you all. And I was just wondering if kind of the magnitude in the share for your in migration looked like you would expect for the facility claims. And similarly, you're not the only hospital in your HSA by far, but you know, if these kind of out migration dollars seem in line with what you would expect or if you're scratching your head, just a kind of basic data quality check. So when we look at the, first of all, we are a border state, we border with Massachusetts and New Hampshire and we have this year been looking at, you know, from, from a commercial revenue perspective of what's being driven from that out of state. I can share with you of our gross revenue for fiscal year 23, approximately 21 to 22% of our gross revenue is derived from Massachusetts and New Hampshire. So it is a, it is an interesting landscape. When you look at the outward migration, they'll come in for services of the need to go out to other places like Cheshire, state down in Massachusetts. Does that answer your question director Limburg? Absolutely. And would you say that you noticed any differences in the rate changes between the in state and out of state payers? Are they pretty comparable or are they different? That's a really, really good question. We haven't, I haven't dove into that, that level of detail with the, with the out of state payers can compare to the in state payers. Okay. And okay, yeah, I think that would be really interesting. And I think, you know, as the board thinks about building its data model, we might think about ways to capture that in, as administratively on bird, bird of some way as possible. So those are my utilization questions. What questions do the board have related to utilization? I'm so sorry to interrupt again. Can I just verify who that was just speaking before Ms. Sarah? I'm losing y'all's visual every once in a while. My apologies. That was Jennifer Griffey. I'll try and make sure I introduce myself next time. My apologies. Thank you so much. And here in the cream shirt in the middle, what's your name? Dr. McGraw. Got y'all. Thank you. Thank you. Related to utilization for Brandenburg Memorial Hospital. Okay. This is Dave Herman. I could chuck in on a quick question just to try to further dive, like dig down into the ED utilization. I think it was like a 14% increase from 22 to 23 and a 5% budget increase from 23 to 24. And Kat, you mentioned the increase of the, having a available clinician at a primary care clinic. Do you have any idea of, of what that volume is annualized? If, if, if, how that's going to affect ED volume? Or if you think it's affecting ED volume? And if there's any other discussion of trying to expand more cost-effective care options for patients. Yeah. I think that we look forward to it being very helpful, but it is an initiative that we just started. We have some clinicians who are providing those services. Really, it's only been a couple of months that it's really been rolling. So I don't think we have enough information to annualize it out yet, but clearly it's the right thing to do. And we'll, you know, we'll direct the usage in, in positive ways, but the way that we're aiming. And do you know if any of that availability is maybe my air quotes off hours other than Monday through Friday, nine to five timeframe? At the moment, it's not, but we are, you know, we're open to considering a, you know, a lot of different options that allow us to, you know, in, in essence, decant that ED volume. We have, I've also been tracking our next available appointments to be able to ensure that, you know, folks can get into any of their primary appointments and don't necessarily have to utilize those acute care appointments if they don't need it to be done that way. Okay. The other utilization related question I had, actually Sarah shed light on a few of them, which was an exhibit 10, but on the out of state patients, do you have any idea of the pair mix of people that are coming across the border to seek care at Bradabara? The majority of that of the 20, 21% that I had referred or indicated a few minutes ago over 14% is commercial. So as we come through the border, Medicaid, Medicaid, the states want the Medicaid to stay in their own states, a few of them Medicare, but the majority is going to be commercial payers coming over from over the state bounds. Okay. Thank you. And I think you addressed some of these again, it's faster than I could write in your opening statements. But the only other question that I wanted to make sure that we asked was just, you know, as you are onboarding folks and expanding folks, how do you fold that into your utilization assumptions? Like the expect kind of a exponential growth for them to get onboarded? Or is it a more gradual kind of experience? I don't, would you, I'm not understanding the question. Oh, yeah. I'm sorry. As you, you're talking about adding some providers, homegrown, if you will, does that affect your utilization assumptions? Or is it doesn't matter who is actually providing the services? So when you say I'm growing, are you talking about nursing? No, provide. Yeah. Yeah. So the contracted versus salaried utilization, does that affect your budgeting at all? No, no, no, because those are filling budgeted positions. So it's an okay. Okay. And so the productivity expectations are equal. No matter. Okay. Okay. Just those are. Yeah, those are nurses, not physicians or nurse practitioners. So it's sort of a one to one FTE. We're not adding volume with that. Yeah. Okay. Thank you. And sorry to jump back in. Any other board or advocate questions related to utilization? I just have one. Thank you so much so far. I think in order for us to understand access issues across the state, but also to really put some of the utilization assumptions into some context, it's really helpful to know the referral times and the referral lags and visit lags and wait time information. And we had requested it by practice and by specialty area. But BMH submitted a very just summary measure across all their practices or all your practice areas. And I'm wondering if you might be willing to break it down and resubmit the wait times information by practice specialty area. Yeah, I don't have it with today, but we can certainly submit that we've, we've made some progress with primary care and specialties as varied so we can send those. That'd be wonderful. Thank you so much. Okay. And I think I neglected to ask sooner, but what sort of ACO participation are you expecting to do for fiscal year 24? Again, we, we intend to participate in one care on the Medicare Medicaid side. Okay. Sorry if I missed that. Just so I'm moving cases today. All right. Advocate, any questions related to utilization? We don't have any questions. Thank you. Okay. Wonderful. So I think really appreciate that your cost inflation assumptions are within the benchmark. I was wondering if you could give us a little bit more understanding of kind of how those numbers break out for different categories. So, for instance, you know, what's fuel versus drugs versus medical supplies? Just wondering kind of the range that gets you to that 6% overall. Right. So on average, it's about 5% across the board. We are seeing a little bit of an upward trend of 8%. We factored in for supplies themselves as we see year over year growth on the supply, the supply at cost inflation. But when we look at salaries, when we look at benefits, when we look at drugs, 5% and then most of the other are contract services. With the exception of labor, there are three or four year contracts where they're pretty flat year over year with the actual cost assumptions. So probably have more dramatic jumps in between those three to four year periods. That makes sense. And I think you addressed that question. The other question I had was related to, I think we talked about this quite a bit this morning. But as people kind of are unwinding from Medicaid to QHPs or potentially losing coverage, just curious how you approach those assumptions in your budgeting. Right. Thank you for that question. It was difficult to put a good number with the Medicaid online for the last two years during the pandemic. There hasn't been any redetermination issues, obviously. So we just didn't have a good data source for that. And anecdotally speaking to our director of patient financial services, what we've seen over the last couple of months are those that are unwinding from Medicaid are really coming more into a self-pay and charity or bad debt perspective. So we are optimistic that we'll be able to not have as a dramatic impact on the Medicaid unwind, but we do anticipate it going more to a charity care or bad debt. Okay. And I'm sure you've got reasons why you made those assumptions. Can you share some of those with us? Again, it was difficult to make those assumptions and not having a long data set. What we had just didn't seem to be reliable for future predictions of behavior. Again, anecdotally, what we find are those as we try to to read up on the Medicaid tend to come down into the charity and self-pay. It's again based strictly on and on antidote. When you look at our overall budget, the net payer revenue to what we have for charity and bad debt, we did keep that about 2.6%, which is what we've been seeing on charity bad debt aggregated over the past three years. Great. Thank you. And you mentioned in your budget a few additional expenses that you took on related to security, to address some staffing issues in your emergency department, as well as some unforeseen repairs. Just wondering kind of like what that did to your budget, to your best estimate for 24. For the budget, we just pulled forward what we were actually realizing in fiscal year 23. Those unforeseen expenses were actually realized in fiscal year 23. So when we look at the actual expenditures to the budget, we ended up negative in some of those areas specifically due to these unforeseen. So we just pulled these assumptions directly into the fiscal year 24 budget. Okay. Yeah, I didn't quite follow that in the narrative. Apologies. And then in terms of like you mentioned quite a few initiatives in terms of avoidable costs, what are kind of maybe the top three to five initiatives that you're targeting to address in 24 and maybe speak to some of the risks that you feel about those? Right. So when we look at some of those initiatives, one of the big ones, and I'll turn it over to my colleagues in a second, but from the administrative side, we were really looking at how can we take some of the tasks and I'll give you an example of cash postings where we have an FTE doing those cash postings. Are they really working to the highest level of their skill set where we can automate some of those look for opportunities to automate through augmented, augmented intelligence to automate those tasks allowing the FTEs that we have to actually work to their highest level. We did have one FTE that was open for fiscal year 23 and our patient financial services because of this anticipated cost savings measure in fiscal year 24. We did not budget for that open vacancy. We ended up reducing it through attrition. I think a couple of other things, Sarah, that we're working on and actually one of them is in the room with us. We've created a shared service agreement with the Bridal Bureau Retreat, which is about 1.6 miles away from us and we actually share a chief information officer right now. Something that neither of us could probably afford on our own, but we've gone out and done that. We're looking at other opportunities. We're working with Springfield Hospital, potentially sharing our cardiology program with them and finding ways to reduce costs that way. We also believe that care transformation is the best way to ultimately reduce costs. Talk about your avoidable emergency room visits, et cetera. Most states have been able to utilize community paramedics to actually make a big difference in these types of costs that are avoidable. We are about to do a demonstration project with Rescue Inc. in the state. It will be specific to our joint replacement surgeries. This will help us get to a same-day ambulatory surgery for all joint replacement surgeries. We'll do it in a safe way and we'll do it in a high-quality way, but this is just to break the ice in the state of Vermont, which does not allow for paramedics to go into homes unless it's an emergency situation. Again, New Hampshire, Massachusetts, Connecticut are having great success with mobile integrated health community paramedicine. We are investing in this to break the ice so that we can start to do this. For us, we're paid on a global payment for these total joint replacements, so we'll be reducing our costs. Ultimately, we'll be able to demonstrate to insurance companies that we're going to be able to reduce their overall cost. I would also add that, as I mentioned in my early remarks, HealthWorks ACT, which is our innovative project in conjunction with the route of our retreat, GroundWorks, which is our local homeless services organization, as well as HCRS, which is our designated agency. That particular project is designed to really alleviate some of the need for folks to end up in our EDs and using those resources, which isn't the right place for them anyway when they're in a psychiatric crisis. That is intended not just to be a program for here, but we're working very carefully in that program to ensure that it can be a model for replication elsewhere. Also, that's really getting ahead of the curve in that way. Then I would just finally add, unless somebody else has something else they want to jump in, but we have put a real increase in our emphasis on quality, which we have not spent a lot of time talking about today. But over the past couple of years, we have had a really significant increased focus on that. As part of that, we've been working on getting lean training for folks here in the organization. Our leadership is getting yellow belt training. Many of them are already at this point. We have been doing that not just with the clinical folks, but with the administrative side of the house as well, so that we can look for ways, look for ways to streamline things on the clinical side, the workflows, but also within the administrative side and the workflows that are part of that as well. Thank you very much. I would take a moment here. We are again here to learn about the limitations and strengths of these data sources. For your peer group, you're with other small rural hospitals, and Browderboro actually is a very small, small rural hospital. It's closer to a size that we might expect for a critical access hospital, which again echoes back to that Medicare-dependent designation. According to calendar year 22, we see the case index a bit above the median. Again, this line would be the 50th percentile. We see that within the range of between 50 and 75th, but a bit higher acuity than some of your peers. We see a lower ratio within the 25th to 75th percentile compared to the other two Vermont hospitals in this bucket. Again, this is going to be the spending on basically line five. I think it is on the cost report compared to the salaries associated with lines 30 through, I think, it's 110 or 20. See that in the lower range than the other Vermont hospitals. Then for cash on hand, again, knowing that this is going to include donor restricted funds and other good stuff to 36 million, I think a lot of people's cash position in fiscal year 22 has changed. Don't not hang in my hand on this number, but relatively speaking, it was at the 75th percentile compared to other hospitals in this peer group. As far as profitability goes, that's a tough number to see. Always not fun to see a negative number, but obviously, you can see that that has been a real struggle when we look at the EBITR purchase adjusted discharge for you all, so that it would be below the 25th percentile. Those are some tough operating results. Then when we look at the cost per adjusted discharge here, just above the median at $10,000 per adjusted discharge. What do you think we're missing in this look? Do you have any concerns about the way that we've summarized the cost report or local conditions that we maybe haven't factored in in looking at this? If I take from the cost report perspective, this was nicely summarized. I have to be honest, it was a little challenging for me to read with those little dots so we could blow that up for my old eyes. That would be fantastic next year. I do also want to point out on the cost or the earnings of the EBITR for adjusted discharge. It is below, but as we said in our opening statement, fiscal year 22 was tough. It was a real, real tough year for us with close to a $4 million operating loss, so taking that into perspective. Very important point. When we look at the cost coverage, so we'll see overall, Brattleboro is, so again, this would be the Medicare allowable cost at 58%, getting 58% of the allowable cost for Medicaid, 50% of the allowable cost for Medicare. Now, that one makes me scratch my head a little bit because I would expect that to be a little bit more favorable. I'm just curious if maybe some of the enhancements aren't flowing through claims or if that number feels right to you. Again, this is blended inpatient and outpatient and then overall seeing 200% of the allowable cost from the commercial book in total. I was very surprised to see the outpatient cost coverage for Medicare being as low as it was and again, seeing a common trend in that kind of erosion of cost coverage from Vermont Medicaid. So just any thing you want to come on on or ways we, yeah. So Sarah, for Medicare, the Medicare-dependent hospitals do not get the OPPS bump and so we do have a disadvantage quite candidly. They cut professional fee rates last year, bumped up OPPS. We did not get a bump in OPPS as a Medicare-dependent hospital. It's being fought out vehemently. They do it for sole community hospitals, but they have not done it for Medicare-dependent hospitals. So we're always at risk there that we actually typically take a cut in OPPS each year. Thank you so much. That's why these conversations are so important. I absolutely see that differential between inpatient and outpatient that you mentioned here. So that's a helpful context. And then finally, related to these standardized prices. So let me actually, for whatever reason, I can't get these to pop as much as I'd like. So we see quite low at the 25th percentile at 16,000 per price per inpatient stay. So this would again be the commercial payment. And we see that kind of flip towards the 75th percentile for outpatient rate. So I don't know if you feel like you're getting relatively better reimbursement on the outpatient versus inpatient side on commercial side, bearing in mind that this is data from 2018 to 2020. That's a good question, Director. Again, because it was data between 2018 and 2020, in full disclosure, I didn't dive that deeply into it. It's two years prior to the pandemic, the entire financial world of hospitals really were turned upside down from fiscal year 22 forward. But if you'd like us to dive into it, we would be more than happy to and provide a response. Yeah, I think you just want to make sure that we're measuring the signal and not noise as much as we can. So not something that can just spend a ton of time on, but just a sniff test, I think would be really helpful. And so all that is translating again to a commercial ask, if you will, of a little over one percent. So it just shows your alliance on Medicare specifically as a payer, I think. So with that staff are done, curious what questions board members have at this juncture? I will jump in. I'm wondering, you had mentioned in your narrative that you are having some impacts from the Medicare advantage changes that you're saying. I wonder if you could elaborate a little bit more on that. Sure. From a financial perspective, Medicare Advantage, we are seeing a shift from traditional Medicare into Medicare Advantage. The challenge we've been having with Medicare Advantage on the financial side are increased denials. It's causing additional administrative burden. We've actually shifted from one FTE to almost two FTEs to manage the denials and the collections on the Medicare Advantage. Dr. McGraw, anything on the access side with Medicare Advantage that you're saying? I don't think so. And most of those denials, again, prior authorizations that need to happen. It also feels, and this again is anecdotally, just those denials keep going up. I hear it's a trend across the country, but we are seeing not an experiencing that here at Brattleboro. Thank you. And just to add to that, Robin, an enormous increase in the percentage of Medicare Advantage compared to traditional Medicare as well. It's been as high as 67% growth. And may I interject just to confirm that they would not necessarily respect the Medicare dependent pricing? Well, they, we still get the Medicare dependent up for that. So we do get that because that's federally legislated. And since they're working for the federal government, they do have to, Director Lumberg. Okay. It is an odd thing. The Medicare dependent up is not a perfect tool. We love it, but it's not a perfect tool. They're still working off a base year of 2012 of Medicare rates. And we get about a 75% to the inflationary factor payment for all the work we do with Medicare patients. So it's still not really coming close to covering our costs. I think that bore out in the cost coverage information. Yeah. Okay. Thank you. Could I thank you back? Okay. Go ahead, Dave. Go ahead, please. All right. Just a quick Medicare Advantage related question that anecdotally I've been hearing of patients being denied coverage for ambulance transfers. If it's not deemed to be emergent, meaning being within six hours of presentation to the emergency department, that would be transfers from Prattable Memorial to other hospitals. Is that something you guys have experienced there with your patients or that you know about at all? We're not hearing about it. That's terrible. I mean, just stay for the record. We're not hearing about it, but it's very concerning because we know that access to tertiary care and beds, it can be very, very limited at times. And, you know, we over the past year or two have had to really search excessive distances to find appropriate beds available for tertiary care for our patients. So not familiar with that particular phenomena, but maybe a harbinger of something much worse. Yeah. Thanks. I want to follow up on the question about the denials, the increased denials. What are you comparing that to, just that the Medicare Advantage denials are increasing or versus denials in other carriers for other types of coverage? And then, second question to that is, can you give us a sense of scope of how much larger the percentage of denials are? That's a really, really good question. We've been comparing it to the same time last year. While we're our denials the same time last year, and we've been seeing a trend up when we see the trend up, we start drilling down into the pair mix. What we're finding is that pair mix of that's causing our trend up is Medicare Advantage. As to the scope, we can get those numbers for you and if you're interested in seeing those compare last year's data to this year's, but overall, that's what we're comparing it to. Does that answer your question? It does. Thank you. And I would certainly be in the year-over-year denial increase. You can get it to us. I'll stop there, but thank you. Can I hop in on this Medicare Advantage questions? I think it is likely not appropriate to answer this question here, but I would be very interested to know whether all Medicare Advantage is the same here. And what I mean more specifically is we, of course, have no regulatory power. Nobody here in this room has any regulatory power over any Medicare Advantage, but there are some more local plans that I think arguably we could have some influence on. And if this trend of increased denied claims and the challenges to you is indeed the local carriers, I think it would be interesting to know that. I'm not understanding that. Is it like MVP or is it, do we know which Medicare Advantage or so dive into the actual contracts? We actually don't have that detail. We have it more of our financial class, which is Medicare Advantage. Okay. Sorry, it's for you to see my multitask. All right. Any other board questions related to finance? Yeah. So related to the cost, inflation, pharmaceutical expenses, and or commercial price that we want to cover at this point. So, Sarah, can you hear me? I was considering whether or not we could move to an executive session, but maybe it makes sense to do it at the end of the presentation. Yeah, we can certainly. Yeah. Thanks. Goodness, Rastis-Anne. Okay. I'm happy to jump in if that is appropriate. I think the question, so I think if the board has a question that may or may not be more appropriately answered in executive session, that question could be asked and put out there now in a broad way. And perhaps we could defer to the hospital as to whether that question could be answered publicly or whether that implicates some confidential information. And if it does implicate some confidential information, knowing that would help provide the board a basis to move to executive session. Okay. So I'll ask the question in a broad general way and we'll see where it goes. And yeah. So my question is whether or not Brattleboro has received rate increases from insurance companies that exceed, sorry, let me ask you a different way. Does Brattleboro receive different levels of rate increases from different insurers? Different level of rate increases from different insurers. Would you mind elaborating on that? I'm not quite sure. For example, you know, the answer would be yes. If Brattleboro receives a 5% increase from United but a 15% increase from Blue Cross, but I'm getting as trying to understand whether or not the rates that you're negotiating with insurance companies are different. So essentially it would be based on individual contract? Correct. So yeah, I apologize for not quite understanding where we're going with the question. I mean each contract is individually negotiated on the commercial side, but again on the Medicare it's based on the fee schedule. Right. I'm going to the commercial side. In those contracts, I presume that you have different rate increases each year from the different insurers. Is that fair or no? I think what would be more comfortable discussing the rates in an executive session if that's okay with the board? Fine with me. Mr. McCracken, I don't know if you think this should be answered publicly or not. I'll defer to your guidance. I think the board could address this in an executive session if and so the way to do that under the open meeting law is the process in section 313a1. It requires two findings of the board. The first is that premature general public knowledge would place a BMH at a substantial disadvantage with respect to the negotiation of a contract. So I think that that's the finding that the board needs to make as the first step of this. And then the second step would be to go into an executive session to discuss that particular material. Mr. McCracken, why don't we keep going because I don't think we actually have an executive session line set up. So it might make more sense to just continue and then come back to this at a more convenient time. Okay. Okay. Yeah. We can finish this up. And if there's someone who could help us get that link ready in case it's needed, that would be helpful. Thank you, Susan. And the other question I think that came up when we were reviewing the budget was understanding. Brattleboro definitely seems like a lot of hospitals is in a place where they're trying to figure out the new normal. And I think that it's hard to predict anything these days. But just curious as you are thinking through kind of the sustainability of your hospital, you talked about a permanent designation and some important care transformation, just like kind of what key metrics that you're tracking for the next, say, two to four years to see which win the win, how Brattleboro will be successful in meeting its community needs. Well, I think it was Abraham Lincoln who once said the best way to predict the future is to create it. And so what we do know, Sarah, is that value-based payments are going to grow. And we fully embrace that. What we believe is going to be key to the success of any, whatever the value-based payment may be, is truly doing more outside of the hospital and being less hospital-centric than we have historically been. So really beefing up our medical group practice to care for patients in the medical group. We fervently believe that patients are always cared for best as close to home as possible. So trying to do things more in the community, like our health works ACT, having that as a model for other services, hopefully being able to actually have a community paramedicine program, or actually caring for patients in the home, keeping them healthy in the home. We have seven key strategic priorities. So we do look to say, how are we elevating the health of the community? It's not just about what happens when they cross the threshold of coming into a hospital. We prefer that they don't come into the hospital. So really transforming our system so that we are really much more focused on what takes place in the community, working with community partners, finding shared service agreements where we can. We track the seven key strategic priorities. We have smart goals for each one of those. Our board reviews them every month. And that for right now is our key. We know we need to be much more of an agile, integrated delivery system than a hospital. And I think that's where our attention is at this point in time, is how do we build this integrated delivery system so that overall costs are going down, not just the cost of operations, but really the cost of what it takes to care for people. Thank you. Any other board questions or those from the health care advocate? Yes. Sorry, Sam, you go. I just want to steer, so San Paes health policy analyst at the health care advocate's office. I just want to steer folks to page nine of the narrative where there was a breakdown of FTEs. This is in the administrative costs section. One thing that stood out to me at least was that your average median C-suite salaries seem to exceed physician salaries and the nonclinical admin salaries seem to be higher than nursing salaries. So I was wondering if you could elaborate on that and maybe explain that a bit more. Sorry, I'm just pulling that. Yeah. Right. The C-suite, if you could repeat your question, I was pulling the document while you were referring the C-suite exceeding the physician salaries. Yeah, yeah. It just seems a bit higher. I'm just wondering if that's a deliberate thing or more of an incidental finding. No, I think one of the things to remember on the physicians, these are the FTE employee physicians. We also use locum physicians in our emergency room and other areas. So this number isn't fully representative of what we pay out for physician costs. Got it. And would you mind, I'm not listening everything out, but I'm just curious what falls in that other admin bucket because it's a pretty large salary chunk. Right. That is the, if you remember in our narrative, we discussed the fact that we do have a company by the name of Southern Vermont Health Services, which the hospital reports under. Those are the intercompany transfers of administrative costs and salaries. Got it. I'll turn it over to Mike. I'm sorry. I believe I may have misstated. I thought you were referring to the administrative costs that were on page eight of the, or excuse me, page nine of the narrative. Is that what you were referring to or are you referring back to page 10 on the actual FTE breakout of the other administrative? At the bottom where it's in underneath the FTE tab, Sarah, yeah, where it says other administrative and then the 286 FTEs. I was just curious about what, yeah. Right. So Jennifer, the median salary for physician, does that include nurse practitioners and PAs as well? And is that driving the median down? It is going to drive the median down, but the other thing that's driving the median down is this just for employee position, which referring to the question of the other administrative, that is going to be every other administrative physician that doesn't fit within a physician, mid-level nursing, C-suite, directors or managers. So it's everybody else in the hospital. Okay. Thank you. And then Mike has a couple of questions. Thank you. I'll steer back to our traditional question now about ratio of pre-cared to bad debt. I just want to recognize that your projection for 23 is that you'll have for every dollar of bad debt, $6.5, I'm sorry, for every dollar of free care, $6.5 of bad debt. And 22 was similar, one to 5.1. Your budget projection, what you're budgeting for next year is a one to two for every dollar of free care, $2 above bad debt. That's going in the right direction from our perspective. What do you have to do to accomplish that? Well, first of all, it comes down to data. Traditionally, Brattleboro Memorial Hospital has aggregated both bad debt and charity care. So to try and tease it out from prior years has been very, very challenging. What we want to do next year is actually be more data-centric and be able to prove out the difference between the charity care and bad debt. So that's what we really need to do is be able to look at it from a more data-centric place, so we have better numbers as to the charity, the dollars per charity care versus bad debt. So the reason for my question, I think it may be it's obvious, but we're saying that we think that having as close to a one to one, a better ratio between bad debt and free care would be a sign of hospitals doing a good job of reaching people, whatever that effort takes. I fully understand why one hospital may have more uncompensated care than another hospital. Paramix is complicated, but I don't understand why hospitals would vary in this ratio. I don't know what would be different about the people in Gretelboro versus Rutland who owe the hospital money other than the hospital's effectiveness at reaching those people. Right, and so we are looking at that one. We do have a community services liaison that attempts to reach those individuals for them to fill out their charity care applications as well as trying to get them on to Medicaid and their reach determination. We also know that we have one across our entire continuum care. We've been exploring options of how can we bring outreach to our community for the charity care applications and Medicaid determination, including speaking to another non-profit in the area this week of how can we branch and partner with them to get this message out that there are resources available for care? That's great to hear. I don't mean to make this sound like it's easy. I know it's hard work, hard to engage with people who might not want to be engaged with. I appreciate that answer. I'm sure it's correct that it's going to take multiple approaches to reach people. I think that's my only question. Thank you. Thank you very much. Thank you. Any other questions from the board before we turn back to the potential executive session? Okay, I think the question that we have for you is if BMH believes that sharing their negotiated commercial insurers would cause them any disadvantage. Is that right, Russ? Or maybe I'll let you talk. Thanks. I can address it right here. I can do it because then I'll just move. It's fine. So my question for you, Brattleboro folks, is whether or not you believe that publicly sharing the rate increases or fee from specific commercial insurers would disadvantage Brattleboro and its negotiations with commercial insurers? Yes, Chair Foster. We do believe that. We actually don't do our own negotiations that comes through a shared service agreement, and we have a company that does that for us. So we'd also not like to put them in a difficult situation, Chair Foster. Understood. Great. Well, given that the testimony is this would publicly disadvantage Brattleboro, I moved to find that premature general public knowledge of the rate increases received by Brattleboro from different commercial insurers would clearly place Brattleboro at a substantial disadvantage with respect to its negotiations of contracts with commercial insurers. Hi, second. All those in favor, please say. Hi. And then second. Oh, I'm sorry. Go ahead, Sarah. It's a logistical question that should wait till after the next vote. Okay. Second, I move that we go into executive session under one VSA 313A1 to consider Brattleboro's commercial payer contracts, specifically the rate increases received by Brattleboro from different commercial insurers. Second. And all those in favor, please say. Hi. Motion carries. Hello. I have two questions. I'm not sure if we have an executive session line that we have a link and I need to know who I should send it to at Brattleboro for you all. So, I want to be clear on who was attending the executive session. So, I believe it is the board members, board staff, so Sarah Lindberg and team, Susan executive director myself and maybe other of the board legal staff, the Brattleboro team, the healthcare advocate, Mr. Fisher, Mr. Payesh, anyone else from your office who would join? And then I think if it's possible, we'd like to ask Ms. Holland to join and do a separate confidential transcript for that. Of course, no trouble. That's okay. Just say that we're not, we don't have the information right in front of us. We may need to set up an even separate time to do this where we can have that information right in front of us. We don't have it right in front of us here today. I don't want to waste your time with that if we don't really know what the rate differential is between what's been negotiated between the commercial insurance company. Sorry about that. I mean, I think it makes sense to probably try some of the questions and if you don't have the information, we take that as the answers and we can see if it's appropriate to reconvene. I think at least some direction may have a sense, but if not, then that'll, we'll deal with that. Fantastic. Well, we will do our best. Great. And who shall I email this link to so that we can get you on the right link? Ah, sir, it will go to E-ingraham. So it's E-I-N-V-R-A-H-A-M at bmhbt.org. Anybody asked who that was speaking just now? That's Laura Brunner. Thank you. Okay, so I think it should be all set. We'll send this over. Why don't we take just a quick four-minute break and we'll jump into the executive session at 2.30. And for those that are not going into the executive session but participating, we can, I don't anticipate, will be very long. I think under 20 minutes would be my guess. So we can adjourn this and we'll go back at 2.30 into the executive session. Thank you. Okay. All right. Great. So we will resume the Green Mountain Care Boards hearing with Brattleboro. So Ms. Lindberg, Director Lindberg, take it away. Thanks. Sure. I think this is a good time to offer a chance for a public comment. Are there any comments from the public? Please use the raise your hand function if so. Okay. Hearing none, I'll give Brattleboro an opportunity to have the last word here. Anything you want to make sure that it comes across before we adjourn? I just have one quick thing to say. Director Lindberg, thank you so much for your patience and help with this Green Mountain Care Board budget process. Being the first-year CFO here in Vermont, I do appreciate the partnership that you've offered us. So thank you. And with that, I'll kick it over to Chris. Well, I would just add to that. We didn't say it as we were going through the budget tool. I know that it was a little wonky, but it was great. This is great data. It's great to have benchmarks. It's great to have these comparisons and we're very excited about that. And I guess just the final thing I'd say is, yeah, next year we'll mark our 120th anniversary of caring for this community and providing great service to this community. We look forward to working with the Green Mountain Care Board in assuring that there is a community health system in Brattleboro for at least the next 120 years. We look forward to that. We exist for no other reason, but to improve the health and lives of this wonderful community. And we thank you for anything you can do to help us in that endeavor. So thank you for your time and for a great discussion today. Thank you. We will work on a few follow-up items. And I believe that's it for the hearing for Brattleboro. I know the board has other business, but thanks for your time. All day today. Thank you. Thank you. Thank you. Thank you all. Thank you, Sarah. All right. Great job, Sarah, leading us through this maiden voyage through this process and for this process is your brainchild and your work. So I thought it went exceedingly well. So thank you so much. You should be really proud of the effort. That's great. Matt, Flora, Russ, Jeff, they are the ones that deserve the kudos, honestly. So it takes a village. So and thank you to the advocate for your participation. Great. So we'll turn to the next agenda item, which I think is the one care potential vote. I don't have the agenda, but I think that was next. All right. Great. Okay. All right. Wonderful. I'm Michelle Sawyer, a health policy project director with the Green Mountain Care Board, and I'm joined by staff attorney, Russ McCracken, to walk through the FY23 one care revised budget condition reconsideration and potential vote. This came up last week under new business during the board meeting, and we had a week to collect public comment and consideration. We did receive two public comments during this time. One encouraged the expansion of the compensation cap to the director level leadership of one care, and the other public comment noted that they disagreed with the procedural fairness and the regulatory authority being put forth by the Green Mountain Care Board. I will pass it to Russ McCracken to walk us through the motion language as it stands, and then how we may move to modify. Thank you, Michelle. As Michelle noted there, we did get a comment from one care around this, and so this is to kind of go through, again, I think what we just introduced briefly last week. What you're looking at here are the three conditions that were part of the Board's June 16th approval of one cares amended FY23 budget. Specifically, we're looking at the second condition, and there is on the next slide some potential motion language here that modifies the second condition to clarify how that condition is calculated and enforced, and the modification is to have it on an aggregate basis, so aggregating all of the VP level and above executives rather than on an individual basis, and marking and capping that aggregate amount against the aggregate of the 50th percentile of the benchmark that's used by one care for the compensation of those executives. No other changes to the condition that was approved on June 14th. This change is, I would note, sort of aligned with the only information that we've been able to get so far from one care about the benchmark used for these salaries. So I would turn it over to Board questions, comments, discussion, and any public comment. I'll go first. I made this motion last week. I think it's an improvement so that there's greater clarity in what we were ordering, and so that one care has greater discretion to decide how to use its compensation to further the goals, while at the same time providing the same amount of money to be reallocated to the population health programs. So I support the motion and that's it. I support the motion as well. Mr. Kraken, do I need to go ahead and move still? Yeah, so just for clarity, the motion wasn't actually made last week. We introduced the topic and had a little talk about it, but the motion would need to be made seconded voted on or any public comment taken and then voted on. So then I'll let other board members speak and then we can do public comment and then I'll move after that. Any other board comments or discussion? Okay, and I'll open it up to public comment. I'm sorry, Mr. Price, I should have called on you first. Please go ahead. No, that's okay. Thanks to the board for turning to this topic. We support the motion. I think it's quite, we believe it's quite clear that the board has regulatory authority in this area. We do recommend that you consider a minor edit to it, just to clearly specify what benchmark is going to be used. The reason why we're, I raise that as a concern is in the response of the subpoena, one care submitted a number of different benchmarks that they used and it was unclear which one would be used. So in the interest of fulfilling the intent of the motion, we think it makes sense to specify which one would be used. Thanks. Any other public comment? I think Mr. Price's point is well made, but I'm not going to modify it in that regard because we don't know what benchmark was used. And so I think for purposes of this motion, we'll use the benchmark or benchmarks that they had used previously. I don't think we have sufficient information right now based on the subpoena response to identify any particular benchmark. But I think the point is a good one and I think that was in part why this pino was issued. So hopefully we'll get that information and we can consider it next time. So I moved to modify the second condition in the Green Mountain Care Board's June 14th approval of one care's revised budget so that the cap on executive compensation established in the condition shall be calculated and enforced on an aggregated basis, capping the total combined compensation for one care's executives VP level and above in one care's fiscal year 23 budget at the total combined amount of the median 50th percentile of the benchmark used by one care to establish the compensation for those executives. The condition is otherwise unchanged. Second. And I think we had a split vote last time so we might need a roll call Mr. McCracken. Might be the best way to proceed. Sure. I'll take the roll in alphabetical order. So board member Holmes. I'll abstain. Board member Lunge. I will also abstain. Board member Merman. I support the motion. We'll take that as a yes. Yes. Board member Walsh. Yes. And chair Foster. Yes. So with three votes the motion carries. Okay. I think that was the last item on our agenda today. Let me just check. Is there any other older new business to come before the board? And is there a motion to adjourn? So moved. Second. All those in favor. Aye. Aye. Aye. Thank you very much everyone and thank you to the hospitals and Ms. Holland for their work today. Have a good day. Thank you and.