 Good afternoon. Good afternoon. I'm going to welcome the Greenbottom Care Board. The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you, Mr. Chair. I have some reminders and some suggestions. A reminder that we have an open public comment period in place from May 13th until July 24th, 2019 for the 2020 Mod Help Connect exchange filing. And as a preview to our July schedule, which is posted on our website online, I want to announce that on July 3rd, we will not be having a board meeting. We have all of our board members here in light of Independence Day. And then also, it's a busy month for July. We have a primary, in addition to our regular, regularly scheduled board meetings, we have a primary care advisory group on Wednesday, July 17th that takes place at our offices at 144 State Street, open to the public, from 5 to 7 p.m. And then on Tuesday, July 23rd, we have the Blue Cross Gouchier Rate Review Period starting at 8 a.m. And that's at room 11 at the State House. And then on July 23rd, we have MVP, oh, sorry, let me back up. We have MVP on the 22nd. We have Blue Cross Gouchiers on the 23rd. And then the night of the 23rd starting at 4.30 to 6.30, we're going to have a rate reviews public comment forum. And that will be held in the council chambers at Memorial Room at City Hall in Montpelier. And then on the 24th, we do not have a board meeting. So those are the updates. These consult our website for all of our meetings are posted. And that's all I have to report. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, June 12th. Is there a motion? Okay, thank you. It's been moved and seconded to approve the minutes of Wednesday, June 12th without any additions, deletions or corrections or any discussion. Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Thank you. So at this point, we're going to invite Dr. Bromsted to come down and really just give us an update on how things are going at this point in the year. And we welcome you, John. Thank you. Thank you for the opportunity. And it is, I think an opportunity just to check in. We'll be back together again at your invitation. I think later in August to talk about the specifics of our budget. Okay, I'm going to keep this pretty high level, although I do have some financial information that I'll be presenting. And really can, however you want to handle this to be conversational, which is what I'd really appreciate. So I'll encourage the board members if you have questions on any particular slide, just to jump in at that time and go back to that. I really would appreciate, you know, I want to be very open with the financial slides, but I'd really like to get past the financial check-in to the other parts of the conversation. If we do end up with a non-CDO level deep dive, I do have our secret weapon, Professor Stanislaus, in the audience, so Mark, stay awake to come down. You know, I really want to thank you for your approach to trying to understand what's going on out there in the broader healthcare environment, particularly in rural healthcare. We had a great panel. It was nice to hear the gentleman, the pundit, from Stroudwater talk about a lot of the things that we believe and we've been trying to implement over the past five or six years. And there's just no question that there are storm clouds on the horizon, particularly as it relates to delivering healthcare and maintaining access in rural environments. The economics and the financial models based on the prior approach are pretty dismal to do that. But we actually see a clear road ahead and what we're really all about is preserving access to high quality care in our region and we believe that we can do that using the existing backbone of our regional delivery system. And we don't need to bring in new players, the business disruptors, you know, kill me if people are getting their primary care of Walmart. You know, what we really need to do is on the backbone of the delivery system that people in our region have depended on, have trusted, have gone to for decades and decades, we believe that we can bring those organizations, those providers, those communities together and preserve that access to healthcare services that's critical. But we also know that we're gonna have to be innovative in doing that, some of the innovations that you heard from the Stroudwater folks were really all about doing the hard work of really integrating the care, changing sort of what's being done where and putting intentionality into how services are distributed and really shift more towards a wellness approach while still providing the sick care that everybody needs. And you know, you've heard me talk about connecting that to the reimbursement models that we've been, I hope you agree, have been 150% in on as we've gone down that path. And for our leadership teams, anything that we're going to invest in dollars or human resources or energy or engaging others to understand really are gonna be run through a filter on the impact that those investments would make for our patients and our families, the impact it would have on our communities and particularly, and I'll come back around and talk about workforce, the impact that the size and scope of our initiatives, the pacing of our initiatives have on our people. So our patients and families, our communities and our people is really sort of anything we're gonna do, we're gonna judge the impact in those areas. And so we as a leadership team feel that really the more granular approach to our road ahead is to really maximize the clinical operational and financial performance of each one of our units. So we can't just sort of hide that local performance behind a cloud of work network now. We really need to make progress on shared administrative services. Believe it or not, those administrative services are only 12.7% of the cost structure of our broad network. But there is perception beef in going there because it really shows that we can, as a network collaborate and share, you heard me say I view one care, one step removed as a shared service among all providers, that we really need to focus on the provision of high value care, quality, cost, outcomes. And the other place that many, many evolving integrated delivery systems haven't gone is looking at ways with great innovation that we can look across our organizations and see if there are ways to integrate services that you wouldn't think of. Why, with our seven hospitals, do we have seven pharmacies? And depending upon how you count it, between seven and 10 different formulators. So that's an area as well that we're really gonna work on. So we see a road ahead. We've sort of defined the lens through which we look at big time projects. And we have some general areas that this would drop down to a granular level. We're focusing all of our teams and all of our organizations around. So I'll jump into this. I realize it's small, but you have this, I'm assuming right in front of you, you all have this so you can see the numbers. First thing, the green sign to the right is team projected. I just wanna emphasize projected. This is through April performance. We just got NAE, it really doesn't change much. And this is annualized with some seasonality and with the CFOs of each one of our organizations taking a look at this, but it's a projection. And you're almost certainly will see different numbers when the year is actually closed. I go down to about a third or half a way down total net patient service revenue, fixed prospective payment and one care revenue. And we believe that when we finish the year on the revenue side will be about 1.4% over. Now come back to that. And this spreadsheet is for the University of Vermont Health Network, Vermont Hospital. So Medical Center in Burlington, Porter and Center of Vermont. And I would take a moment to emphasize that I believe going forward more and more you all are gonna have to regulate the University of Vermont Health Network at least at the Vermont level and not at the individual entity level. I realize that causes some change and some difficulty, but you've heard the gentleman from Stroudwater talk about the value that comes from these entities coming together. And the value that we create there is by functioning not as individual three hospitals with their providers, but in the collective figuring that out. So having each one of the organizations get the same common metrics I think is difficulty and that we're not getting the value out of that collaboration and that affiliation coming together in that context. The other thing that sort of jumps out to me if you go above in the 2019 variance amount, there's the fixed prospective payments that are $67 million off. And that's really because when we budgeted, we believed that Blue Cross Blue Shield would be providing fixed prospective payments in 2019. And we didn't quite get there. We do believe we'll get there in 2020. But so the fixed prospective payments are that much light because that's in the fee for service bucket. And on the expense side, we do have total salaries that have risen. I'll show you the medical center in a minute. And the total non-salary expenses, some of that is volume related. Seeing more patients again, I'll come back to that in a minute. But also the 340B and the pharmacy and other pharmaceutical expenses are part of that close to 5% growth. So take away from this slide, revenue slightly ahead, expenses over. And so it's gonna be tight. We'd like to think that we're gonna make the projected margin, but I think this is gonna be a tough year. And as an aside, we told all the rating agencies that going into 1920 and 18 through 21, our margins were gonna be stressed because of the investments that we've made. And then we had a great plan to come back out of that. Cash would stay strong. Even with that, Moody's based on our 18 performance was chomping in the bit to give us a negative outlook. So we're very focused on our margin for 19. Just wanna make sure that on the other revenue that's up 32 million, is that the 340B of commercialized expenses? A lot of them are offsetting that? That's exactly. That's the 340B. And I have a slide in a little bit, just like a huge chunk of not-for-profit healthcare in this country right now, but for the 340B program, it would be very, very little margin anywhere to be reinvesting in people programs. So that's exactly what that is. Let's switch this. So at the Medical Center, really that's, again, the driver for our network. You can see that same thing with the fixed prospective payment being lied. And we think on the revenue side, and again, I'll get to this 1.9% greater than the original budget. And that, again, the dominance of other revenue with close to 30 million dollars, and greater than budget, we've had people because this is one of the areas that there is funding available. We've gone after that significantly. And then you go down in the total salaries and for the Medical Center, this is related to the organized labor activity in our contracts. We're taking along above what we ordinarily would consider inflation, although I challenged that going forward. I think the salary, the workforce inflation is going to be significantly higher than 3% in healthcare, but 4.1%. And again, the folks at the Medical Center, because they want to close the door, it'll be great. At the Medical Center, the team believes that there's a chance of getting the margin target. May was another couple million dollars off of budget, made money off of budget. So if we added that in, it makes the hill in the last quarter of the year a little bit steeper decline. We just have to see where we end up with the dynamics of that. So, I understand that... You see the long-term growth in that wage inflation to be... I'm certainly not an expert, but I expect it to be 30 to 50% above what the rest of inflation is running at. I just think we've got nationally some catch-up to do. In all of those wages being suppressed for so long. And then you put on top of that healthcare with the aging population and the demands on the numbers of people being trained. And you put that we're in a rural environment and some consider us to be at the end of a long winding road. It is not like recruiting in Boston or one of those other urban environments. So I think we're really gonna have to invest appropriately significantly in our workforce. And I'll show you some programs towards the end that I think we have to increasingly grow our own and find very innovative ways to bring people into the healthcare workforce and support them. Now, I understand that if 19 ends up where we think it is that the revenue piece collectively will be above what we budgeted in your 50 basis points of leeway, I would bring forward that we're continuing to see in migration to our primary service area while the remote population remains relatively stagnant. The top bars that are all moving to the right are our primary catchment area. This is just a linear representation and pulling out just our UBM medical center. So I switched over to the medical center at this point. Our primary market, the population growth. And my favorite, since I'm right in there at this point, the percent change in the population over 65. You'll note that even Chittenden County down at the bottom that over this time period, 3% change the population over 65 while Chittenden County is the, I guess you'd say beneficiary of in migration from around the state with some of the young folks. So we're really seeing that we're having growth in revenues. Unfortunately, the growth in expenses are currently over and above that, which believe me, we're very, very focused on. And we're seeing age of the population, which would come out in case mix index or the acuity of the services that we're providing. And so another point, look at us as a constellation of organizations in Vermont. Another point, just to emphasize, is that we really need to collectively work on getting to a population-based metric. So this is CMI adjusted, so adjusts for the acuity of the cases, the demographics, with the revenue sources per unique patient. And our finance folks led by our really, really smart people have had and will continue to have conversations with the really, really smart staff people on the Green Mountain Care Board to make sure that we're sharing the methodology with which we would define unique patients. And you certainly could do this cost per unique patient. It would be essentially the same in this case. But if you look at the patient service revenue over years, if you don't put the population shifts and the demographics in, thank you very much for the discussion on rebasing last year, you miss the story. You know, what I'm laying out there for our teams as far as our targets are the cost per adjusted or per unit of service in a whole bunch of different ways. And we're watching the revenue growth that adjusted for acuity in the population that we're serving. More people are coming. We're not gonna turn them away. They're more acute. They need more services because they're older. So this or if we go back and forth and there's a better way to normalize per capita basis, we're all years. But this is, you can see the year over year growth well within what we're trying to do with the all pair model when you do adjust. In 19, even though the revenue looks like it went up 1.4, 1.9%, it's really not going up on a per capita basis. I had a question about this slide. And it's when you're obviously for your patients, you're gonna be getting a bunch of folks from New York and your New York hospitals transferring folks. So I assume that this includes every patient regardless of residency, is that? Yes, this is every patient, but just for the UDM Medical Center. And that's still New York patients on this book of business still are ticking along in the 15 to 18% range. I'll give you a thumbs up. So it's clearly a factor because those people are coming for tertiary and quaternary care. So they're going to pump the CMI out and maybe the cost of it would drive this in the other direction. So another important finding and I'm honestly not lobbying here. I can do that really, really well. I'm just explaining our internal thought processes and just to be really simplistic, if, and this is way simplistic, so Mark, plug your ears right now. But I just look at inflation 3%. Commercial business is about half of our business at the Medical Center to cover inflation since we ain't getting nothing from Medicare or Medicaid. We need about a 6% going in. You fine tune that and you go up and down. But if you look across the top, the commercial rate increases that we've had and then just calculate the value of a 1% increase, the difference between what we would get at 6% and what we actually got is that third row down. So in 19, it was $20 million was that difference. And where we're making that up is based to a significant degree, the 340B program. We're making that up some on that volume that's generating the revenue. But my concern is the bottom line that we're doing everything we can and believe me, I've got the throttle down all the way on expense control and we continue to work on that. But my concern is that with below inflation, commercial rates, our margins, particularly with the stress on the investments that we're making are slipping. And so we're watching that carefully. We have to push on the expense. We have to maximize 340B. Honestly, I don't know the specific number that we put into the budget filing. You'll find out from our narrative in 10 days. But this is something that we all have a tension to and we just have to be very thoughtful, I believe, on how we put our money into the system at this point, being appropriately frugal but also not blind to the ramifications. So- Comments on that? Because I think there are also ramifications for commercial increases that begin to price Vermont families out of the commercial insurance market, which is quite frankly a fear that I have that over time, what we're gonna see because of these dynamics that you were just talking about is that our uninsured rate is gonna go up and people can buy insurance, which then flows back to you all. That's where uninsured folks go is to the hospital because they can get coverage. So I think it's a tough market dynamic in a small rural state where the median family income is less than 60,000. So I think, I don't have an answer, obviously. It's just another part of the market dynamic. I couldn't agree more on the 30 or 35,000 folks that are on the exchange depending, you know, that there's obviously a sliding scale on subsidies for those folks. And I think that the real answer, in my mind, is in the all-pair model, bring those folks into a, even those that are self-insured not come back to this because I think there's some progress there, into the model where the providers are taking accountability for the utilization, taking utilization risk, and that the dollars, if that risk is appropriately managed, at least partially accrued to the delivery system, those providing the care. And so we can talk more about that, but I agree. This is very difficult in this, the pricing of traditional healthcare insurance in a small market like Vermont is difficult, bordering on it, possibly. Now, I would just piggyback onto that. The real need to try to keep pushing, even though we all believe that the all-pair model is the answer, Medicaid and other government programs should not give them a pass as to their obligations in the system. And what your chart very simply illustrates is the need that, in your particular case, commercial rate increase has to be double the inflation rate, but then you look at other areas of the state that have half as much commercial insurance as what you have, and then you've started to look at four times what the inflation rate is, and that's just obscene. And so, I know you're not wearing your lobbying hat today, but I just would say that nobody should be giving government a pass, and I guess I'll recognize two legislators since they're here, Representative Laurie Elton and Representative Carol Odie, but we can't just keep pushing it onto the commercial. That's the point I would make. You're not gonna get an argument from me, Jim Owen, on the cost shift, but there are some realities, and this really the point of this is how we, the levers that we have to pull to close this gap, whatever the genesis of it is, if it's not commercial rates, it's 340B, it's expense, control, and reduction, and if we can't pull those levers fast enough or dramatically enough without interfering with the access to services, we end up with erosion of the margin, which as you all know, we need to reinvest with. Yeah, I know what you said, I think you just touched on it, I mean, when I looked at this chart, I wrote a couple of things that could be added to it, because I imagine when I see it at budget time, and one of them was expense, control, and efficiencies, because we continue to push on where is their waste in the system and how do we get that out? And the other would be, it's kind of the offset of, because you're saying more people are moving into this area, into the Chittenden County area, and we get more patients, there should be some fixed leverage on the cost too. So I mean, when we're exceeding the top line, we would hope there would be some leverage on the fixed costs, it's not all variable, but I appreciate how you're looking at this, I would have just added, I think when we look at it at budget time, the other pressures would be what cost saving initiatives are helping to offset those inflationary drivers, and if we're getting more patients, how are we leveraging, because you talked about looking at US across the system, partially because you can get synergies, so. Couldn't, could not agree more, and although it's kind of inappropriate to say what I say to our management team, the speech that you just gave, I've given to our management team on a bottom weekly basis for the past 18 months, so. But it's, I can't overemphasize the difficulty of, and the grinding of gears when you get to a point where it's not just going to your book of what the top decile unit of service costs are for all the cost centers, you're in an academic medical center, which we do, and you sort of maximize all of that, and then you go, okay, where do we go now if it's not to just ratchet back on the services we're provided, and I believe strongly that there is the savings and efficiency in the actual way we're delivering care, replicate and duplicate only where absolutely necessary and make sure that you get it right the first time, every time, and what I alluded to before, I mean, taking a freestanding hospital, bringing it into an affiliation, and saying, oh, by the way, you're not going to have your own pharmacy anymore, we're going to have this sort of nice coalesced pharmacy. If it's a, I'm not making excuses of being defensive, it's what I, we are driving towards, it's just, it's a race against a lot of the rest of us, the easy stuff I believe long ago was captured, and it's a driver for doing this, it's a driver to have a global fixed payment as a real incentive for everybody inside of our tent and elsewhere to be driving towards those difficult to get efficiencies. So here's a happy story that I hope we can all revel in. I think it was summer fall of 14 when we came to you all to get a certificate of need, about $200 million to move towards single occupancy rooms at our state's Academic Medical Center, and that was on a backdrop of a new regulatory process and environment lack of trust based on the prior huge building project that had gone significantly sideways. So we appreciated the sort of the tension in the back and forth and the approval with the caveats, but we're there now, and this is an unbelievable resource for this region. So Saturday, June 1st, we moved close to 100 patients out of their double rooms into the Miller building named after Bob and Holly Miller, who were significant donors to this project. And this patient is the first patient that moved into the Miller building. So just as the move went along in our staff and tirelessly for several months, practiced how all this could go, each patient greeted essentially plugged in to the new room. You can see that this is the patient and provider section of the room and the technology, each one of these beds is telemonitored so we can expand up or down the acuity. They essentially all could be ICU beds, although they're certainly not used that way at this point. And you see in the background is something that I just can't tell you what it's done to the healing environment just in these few days to have towards the window, not only the light and the beauty of our environment, but you see a bed and a chair and that's the family space. So the family can be with their loved one when they're recovering and that couch there is fold out. So spouse, child, loved one can spend the time with the patient as they recover. And you can tell this nurse is pretty darn happy. And there is high tech in these rooms, that little iPad very much controls the environment and the patient or family really can do that all the way from getting Netflix and plugging into their Netflix account to more important things like educational information or even finding out the test results that go into my chart through this. And again, that's a real proud pleaser. Just from a patient, I was doing my infusions in Boston. The care was great, but no better than here. This is home. Another patient, I used to have a little slice of the sky, but now I have this view. Wow, this is amazing, incredible. This from a patient and family centered care advocate. Remember these rooms were largely designed not just with our architects or the providers, but with significant input from patients and families. And this advisor, this organization helped save my son's life. I feel honored and proud to participate in this profound time in our organization's history. And on the nursing side, we've been opening up curtains and windows now that our patients aren't sharing rooms. They've never experienced this before and it's incredible. So you all helped us do this process, helped us do this. And I'm incredibly proud that our organization was able to deliver on this complex project. And back to how these projects can be done with great transparency and get to a good result, we set up a process where for big projects in the health network, we have a trustee ad hoc oversight committee. We had one for this project. We have one for the epic project. We certainly will have one for the youth patient psych project should you give us a CO1 for that. And this is the spreadsheet that we took to the trustees on that ad hoc committee on a monthly basis. And the bottom line, the first number total project cost that you gave us a CO1 for 187 million at this point through May 31st, which is essentially complete, we're at essentially 180 million. So this project came in like we love to see it on time and under budget. And there might be a few contingency things that as we really get used to the building that we'll have to continue to use, but certainly it's not gonna be over budget. We also, the other huge investment that we're making that you've helped us with is the epic project. I'm certainly not gonna take it through this. I put it up there just to tell you the complexity of this and to remind you that on November 1st, wave one will go live and that will be everything epic at the UVM Medical Center. Inpatient, outpatient, ambulatory, business, revenue cycle, the whole enchilada. There's some key clinical areas that we didn't implement epic in 2008, 2009 that will go live. So this is everything epic. We'll also include in this wave one, so going live November 1st, the physician, ambulatory practices at Center Vermont, at Porter, and at Champlain Valley in Platspur. So our physicians and other clinicians at the ambulatory level are gonna be on the same record. So if you're seeing at Center Vermont, you have one of the primary care practices down the highway, up the highway to a specialist at the Medical Center in Burlington, same record. Okay, that's coming on November 1st. This is a monumental undertaking. And the sort of bringing this online in close proximity to the Miller opening at the Medical Center is a stressor on our people. And I'll take some ownership for those being close together. Maybe we didn't put in the right amount of planning time and whatnot. But this is gonna be a success just like the Miller building. About nine or 10 months after November 1st, the inpatient and rest of the business processes at Center Vermont and Porter go live. And then about 11 or 12 months after that go live, the rest of the inpatient and business at Champlain Valley goes live. And so this is set up as you remember from the CON to roll out and to minimize the expense, the expense largely being driven by the number of outside folks that we need to bring in to help us during the implementation phase. So doing this as one project, but in sequence with some overlap was the best way to minimize the implementation risk and at the same time minimize the expense. So mounting excitement, anxiety around this, my view is that the anxiety and tension is around the right level if there was none at the really, really worried that we were gonna not do this well. But I don't think that we're in a place where the anxiety is paralytic. People are really doing the work to get this done. At the same time, we're also implementing some other systems that are in the critical path of this. We put in the Axiom cost accounting budgeting system we're moving towards putting Premiere Connect in, which greatly does with this. It's a consistent GL and supply chain. And on the HR side, we're putting in work dates in the medical center. It's going in order and central as we speak. And having that implemented as a prerequisite to turning on Epic and getting off of Meditech. Because Meditech has the payroll system for those two organizations. So we can't just turn that off unless we have a work day or something else to do payroll in the other major functions. So some things looking forward, just some examples of ongoing work that I'd like to share or brag about. High value care really is achieving the triple aim, but think about it at the individual level. It's providing the absolute best patient experience, getting the best outcome for that individual and doing it as efficiently as possible. And we have some examples of how we would and are doing that, but wonderful primary tier doc, Natasha Withers, I'm sorry, in Addison County. And she's actually doing follow ups on FaceTime and iPad with those that have chronic conditions and great difficulty getting into her office, particularly during times when the weather's lousy. And that is providing the service when the patient needs it and wants it. It's as efficient as it gets if you look at the total view of efficiency and not just the charges. And the patients love it. You gotta go into that and say, maybe somebody would wanna get all dressed up and head out to the doctor. I don't know, it's kind of an outing, but being able to deliver this kind of service has done a real pleaser. Sort of in the same vein with home health and hospice, we've done a couple of things. They had this, and I'll forget the exact timing, but after an admission, you get home health reimbursement from Medicare, particularly on a set, I think it's 60 days. And for many of those patients who are home health and hospice are following, during that 45 or 60 days, they have home health monitoring. They got a scale, got a blood pressure cuff. They have a pulse oximeter that tells us what their oxygen levels are. And there's a nurse that calls them at a set time every day or every other day, depending upon their condition. And they just read off what their measures are. And you can tell if somebody's going off the rails, call the primary care doc, and so there's a connection function there. We've added that same FaceTime feature to the monitors that we've purchased for home health and hospice. We thought it's not expensive to have that monitoring equipment. It's actually about 15 minutes in an emergency room anywhere in the state with totally clips where it costs to have that equipment there. So we said, what the heck? We'll just keep the equipment in the patient's home. We won't call them as frequently, but after a couple of months, they're well trained that if something is going off the rails that they know to call in and give them a call in number, they will check in with them once. It's been a hugely successful pilot program and it looks like it really is very, very useful in reducing re-admissions and keeping people in the home where they want to be. One other example, and I know that Dr. Steve Leffler, I think talked to you about this at the session that you all arranged, the protocol for chest pain in the emergency rooms. I mean, that's just a classic example of how you work together, high value care, and if you're counting on fee for service for every single admission, although this would be the right thing to do from a moral ethical mission perspective, would be a dumb thing to do from a business perspective, but the admissions for chest pain using a standardized protocol have diminished to about a third of what they were before and there's still more room to go down at the individual provider level. So you can just, particularly with the epic implementation and the ability to really, almost with a keystroke, look at variations in these types of care, you can see more and more and more of those and they really relate to just the tip of the spear when you bring together the new reimbursements and what we're trying to do with population health. Workforce, we touched on this a little bit and we have been as an organization supporting for a couple of years the Vermont Business Roundtable in an effort to bring a national program here local. It's around developing the talent pipeline and they actually do it in different business sectors and we're supporting the program globally but one of the sectors is healthcare and it's really all about going out to the businesses in that sector, understand what they really need for the workforce and then going out to the educational system at various levels and bringing those needs, wants and desires together with those that can actually deliver the training and workforce. So it's actually most developed in the construction industry for the talent pipeline here in Vermont but there's been great work on the healthcare side as well so sort of top of the box where we're working on it. Central Vermont has launched some innovative programs both with LMA, Licensed Nursing Assistance and something called the Clinical Care Associate actually a new type of position, somebody that would put a patient from the waiting room into an exam room, take your blood pressure to vital science and take some early information and the approach that Central Vermont has taken is there are people out there that are stuck in relatively low paying jobs without a path forward that just can't take 10 weeks or three months, stop life and just come over and do a training program. So, and this is so simple, I thought it was brilliant, certainly not by idea, but we're paying those folks right from the get go, we're paying them saying that they're gonna be paid an entry level as an LNA or a Clinical Care Associate while they do the training with the proviso that they stay on for a period of time after. So that's really a way to grow our own and to work with VTC and CCV in that and also working with those organizations to improve the talent pipeline in nursing. Another great one, Kate Fitzpatrick who's the Chief Nursing Officer at UVM Medical Center for the last 18 months has worked with institutions of higher education on providing a pathway for nurses that are RNs to get their bachelor's and do it for free, essentially on the time of the Medical Center and in 18 months she's had 112 nurses accept that program and get their bachelor's which greatly takes the skill of the workforce up and decreases the pressure on those with higher degrees. On the physician side, we're working with the College of Medicine in March. We launched in Central Vermont the longitudinal integrated curriculum for third year medical students. We piloted this in Northern New York starting a couple of years ago and it takes a third year student that normally would do six weeks of OBGYN, 10 weeks of family medicine and do their clinical rotations sort of segmented like that and drops them for a year in a primary care setting and they get all of those experiences by following patients that come through that primary care conduit. Incredibly unique and innovative program in Northwest is really the only other places that's done that and we believe that that's gonna be a feeder to our rural primary care residency programs and that that's gonna help us keep those youngsters local. And you know that in Northern New York we started a family medicine residency out of the starting blocks graduating four residents a year. The first group graduates, actually graduated yesterday or today and three of the four are staying in the FQHC that serves our region in Northern New York. And this week our first core of emergency medicine physician residents are starting. They have rotations at the Medical Center in Burlington at Central Vermont and at Champlain Valley so they'll get experience in what it's like in a academic medical center in a rural and rural. So growing our own. And the last area to just chat about and then happy to answer the questions is around the eight all-payer model you know that we are totally in on that and you just have to know that a lot of my personal time allocation is going not only to just continuing to get very granular with one care of do everything I can, we can as organizations to make that work. Actually in Northern New York there is through the Department of Health in New York similar project that's moving down the tracks North Country Innovation Pilot that is going back and forth with CMMI to see if in that rural environment there isn't a pathway to a total cost of care model. So we still believe that there's work to do on growing scale. Chair Mullen was on the panel with Don George and myself and Kevin Stone last Thursday for the Vermont Business Roundtable and I think there's a good story to tell that one care at Blue Cross Blue Shield are really coming together around bringing a program forward for those employers that are self insured to be able to really bring value there and grow the attribution. So I think that's very positive and I think we're working with the last couple of organizations that aren't part of the Medicaid program and we think we can make progress there. Medicare is an issue in conversations about that. I think our approach would be get everybody but Medicare in and make it clear that there are things about the Medicare program that if we could adjust we could have the same sort of attribution built there but we'll see how it goes. And then the last area is in regulatory alignment I mentioned several of those areas that we can align our processes and efforts as we go through. I would make one other comment that there are BSR funds that there's potential to capture. I realize how difficult it is to bring state dollars forward to draw down those federal dollars but I believe that it's 20 and 21 are last two chances to take a bite at that federal apple and certainly wouldn't wanna leave federal dollars on the table if at all possible. And I think that there's ways that we might use those dollars in ways to begin tackling what I think is one of the most difficult issues still facing us and making this amount of work and that's developing reserves. And I understand where those reserves live is an issue how those reserves are generated. I will tell you that our latest latest thinking on that is that you have to stay true to the general principle that where the risk resides that's where you have to have the reserves to mitigate those risks. So there may be some risks that reside collectively at the ACO level so that there should be reserves there and we already know that I think for next year we need to have $10 million reserves at one care we have four and a half or something this year but there also are risks that are specific to the balance sheet of hospitals and we don't need any more Springfields. So we need to be very thoughtful about where the risk resides and if we can come to the principle of where the risk is that's where the reserves need to be. I think we can work through that, figure that out. Sorry I clapped going so much. I'm not happy to answer those questions. You're really keyed on some very important points. So I'll start off with the questions, Dr. Brumston. You laid out some great strategies that you're utilizing to grow your own important force. But just my question for you is what is the hardest area for you to recruit and to change the board today in giving everything that you're working on as far as strategies? What do you envision the hardest areas to recruit or train for in the future? You know, in various of that site by site I still believe that the most difficult are clinicians and technicians that are patient-facing. It's where we should have a leg up as an academic medical center and an academic integrated delivery system that we can find ways to train our own and hopefully to train our own and hopefully to train our own. To train our own and hopefully train enough so that we can serve others in the region outside. But I think it shifts over time as well. We see these national phenomena where there's a nurse shortage, it's a crisis and everybody jumps too and it seems to get better for a while and then it's nobody as anybody at the entry level. And so, you know, Central Vermont increases the pay for LNAs because literally they're all going to work for fast food chains and raises it a couple of bucks an hour and so we fill that gap. Now Woodridge seems to be fully staffed for a while so I think it's a moving target. You know, more globally and we do have people thoughtfully working on this. We have to do everything we can to be attractive, not just jump job to job. We have to recognize who we're trying to recruit. We have to pay attention to the what the hotspots in our various organizations are telling us about tensions or burnout or things that, you know, our own employees are telling us are problematic and so we have to fix those things. More flexible hours, you know, by step kids, friends, you know, work for Google or work for big software firms in Boston and big corporations and they have, they have gyms, they have, you know, free lunches. They, I mean, so competing for that stuff and not for public health care, we can't go crazy but we need to pay attention much more, I believe, to the work environment globally while we're doing these, you know, training, training our own. You spoke about the family medicine residency program in New York and I know you know that one of the hospitals in Southern Vermont is trying to create a model to do similar things. What do you think of those efforts? I think it's a great idea. Tom Dee, when his prior organization, he actually did start a family medicine residency, talked to Tom about it and offered any help that we can give. Lessons learned, it's incredibly, I don't know if this is a surprise, but it's incredibly Byzantine and arcane, how residency programs are funded through Medicare and essentially no funding unless you're in very specific areas, largely in primary care. I think they're trying to win their way through that. So we've offered help, but I'm sure Tom Dee can get it done if it's doable. Do you think they'll be successful in actually keeping some of these? The statistics are impossible to escape at how close to one's training the vast majority of people end up practicing. It's a formative time in people's lives and so if there's an opportunity, it's just almost seamless and comfortable to move into those roles. And it goes all the way, it's most demonstrable in primary care practices. My wonderful daughter-in-law is finishing her fellowship in pulmonary critical care at the Medical Center and she's accepted a job there, so it goes all the way to the specialty level as well. It's a great way. Emergency medicine, we have around the state significant expense from outside firms supplying the human resources for emergency rooms and some local tenants, not just in northern New York, but in Vermont, and so bringing good emergency medicine docs into the environment, I think actually are going to be considerable costs that are going forward. Any questions for the board? Thank you for this presentation. So it's nice to have a conversation rather than when it's time to something really at stake just to share ideas. One of the things that I'm growing of the more and more concerned as I move forward here is the impact of the cost shift in demographics. You mentioned both and I think that those are powerful forces that are a health care financing scenario and they affect hospitals or hospital service areas differentially. I'll just make a note here and connect the dots loosely, very loosely, but you referenced population growth which is happening in Chippin County. Certainly it's a younger population in Chippin County. There's a higher income relative to other counties and so the wind is a bit relatively at your back. And I worry that that gets embedded as we transition to a fixed prospective payment system. UVM Hospital has got a 4.6% advantage over other Vermont hospitals in terms of commercial payers. It's slightly less in terms of the Medicaid payers and 4% less in terms of Medicare payers. So here's where the dots get connected loosely. I'm going back to the enforcement period that we just went through and UVM had a 4.6.1 million dollar operating margin and collectively the rest of the hospitals were in the red. There were eight that were deeply in the red and kind of looking at total margin, UVM approved over 75% of the total margin among all the hospitals. So I'm just wondering, sometimes I wish that in our Medicaid program we had something like FMAT where at the federal level, Medicaid is distributed based on factors in the formula that way and these underlying economic demographic considerations and that where at Vermont procedure prices are set and they apply to everyone pretty much across the board. And I'm just wondering if you have any thoughts about how the playing field can be leveled as we move forward in the all bearer model as opposed to kind of embedding those differences through the actuarial work actuarial work that we do going forward. A couple of thoughts. If you go back to work by the Green Mountain Care Award that you chartered and even back further to work that Onurator Wallach did when her consulting firm, you'll see that for most of the sectors of healthcare delivery that the academic medical center in Vermont is the least expensive, particularly if you go to the procedure level or anything that borders on complex. And so you have to be careful of what you ask for because if you really did that leveling on the bundled payment, if you did that leveling on sort of bundling episodes of care, you will almost certainly sort of an untested hypothesis drive the smaller hospitals with the cost of providing those services is higher out of business. Now there may be, you know, as I think forward in the all bearer model and if you're really sitting at one care with your fiduciary at arm and you're taking a total payment for a population, at some point and I believe in the not do this in future, one care is going to have to say globally, all the reimbursements here we're going to only be able to pay X for this service and it has to be this quality measure and if you can do that, cost, quality and you can provide the access, go for it. That's going to, I think, force some of the issues around distribution of services and that's really where the rubber beats the road of going from fee for service with a little bit of cavitation to really the delivery system or a big chunk of it taking accountability for the use of X amount of resources. So, and preparing for that, the best way to do that is to take our current organizations and up front decide where you're going to do what's most efficient, where you can provide the highest quality, balancing that with how far somebody has to drive for a service. So, we're preparing for that, we being the UVM Health Network. Good question. Other questions? Yes? Thank you. So first of all I really appreciate this presentation with lots of helpful information in there and a lot of promises, I think. Relative to some of the workforce issues that you raise which I think are very important something we should all be thinking about. Access is obviously an issue in terms of, you know, seeing some weight patterns on specialty care and I'm wondering in your view what you see the role of technology in alleviating some of that and in particular your example of the FaceTime feature struck me as well as interesting. You know, with access, including access maybe making a provider time more efficient perhaps, I don't know if that is or is not increasing access, I don't know telemedicine. I also was thinking even just about Epic now that you have Epic or November, first you'll have Epic with the primary care practices at UVM, I mean at CBMC and Porter also with the network. Does that help with scheduling or referrals, screenlining that process and I'm just wondering what is the role for technology person just hiring more providers? How do you use technology? It's a great question. Particularly in rural environments telemedicine is important. We're actually piloting with senior housing having the caregiver there be able to bring to telemedicine unit individuals and have their primary care visit that way. When you, as long as you set up telemedicine consistent with the other schedules you don't have somebody that's trying to see a whole day of clinical activity and oh by the way the phone rang so they got to run that in. It can be a real enhancement. Call center technology and queuing theory comes to the last bastion of medicine. There's a whole science to how you can call Delta and book your flight and not wait to get moved right through. We're in the process of implementing a call center. It's very tech dependent and also very specific and how to set up the protocols. We actually have brought a consultant in by the name of Chartis and we expect by the end of this calendar year that a significant portion of the faculty practice in Burlington will have their schedules done through just one call which dramatically increases productivity. It's difficult to get professionals to give up their control of their schedule but once you get over that again everybody that's gone down that road really has done a crowd pleaser. The one that you buy the data will be most impactful of what I see and it's directly related to your question about Epic is the American Association of Medical Colleges, AAMC has launched a collaborative project that I think has gone through the three or four phases of organizations coming in and it's around developing the protocols and the processes to do e-consults. So I'm a primary care doc I have somebody who I really think needs to see a pulmonologist because they have shortness of breath and chronic cough and so for shortness of breath and chronic cough pulmonologists have developed a consult form what they need to know. AAMC is working on these providers how can you have a primary care doctor take five minutes or less to point and click that form send it off to the pulmonologist the pulmonologist can spend anywhere from five minutes to 20 or 30 minutes depending upon the complexity if they have to go look at images and stuff like that but there's a big portion just send back to the primary care doc do X, Y, and Z this is what I think it is go forth and prosper and so that interchange around the patient taking care of the specifics dramatically improves access and that's been shown in at the early roll up. Dartmouth is down the road on this a little bit of results we are in the next wave but we've got to get past November 1st it starts soon in the new year so that holds great promise without just throwing more providers that sounds fantastic and you can imagine it would cost them a lot of money and you know now there are RVUs associated with that activity and you can get paid for that activity of course we would want that for everybody that is under a global payment because we want that to be best for that and we want to be absolutely efficient with our time and I've said this a lot I mean it's been a couple of years since I've practiced but if I went and did a half day session and saw 15 patients if five of them traveling from all over our region really needed my expertise and my experience it was a great session. The other 10 I could have answered with a phone call or they could have with a little prompting seen their local OBGYN and gotten just as good service and so this cuts through all of that. I'll be anxious to hear the outcome from that but that's great. My last point, one of the things around your points about Population Road and the changing in acuity are really important and to the extent we need to be thinking about that when we do possible budgeting we definitely I appreciate that you brought that forefront there. We are I think maybe aware we're trying to do a little self-study ourselves on regulatory alignment and in that we're trying to think about how do we align our processes, our hospital budget process or ACO process, our insurance review process all of that to think about how does it align with each other how does it align with the goals that we all pay money. So I thought your chart on the risk-adjusted cost for unification was incredibly helpful. So I guess to throw out there, I would love to hear if this may be a future conversation with Professor Stanislas, I'm not sure, but the methodology behind making those calculations and the ease with which other hospitals who don't have the same IT software support cost accounting systems that the network has would be able to make those same competitions. So I recognize that that's a long question and it's probably for another time and maybe a phone a friend and I think I believe this has started to a certain extent but it would be great to have remodern care board staff and finance folks from around Vermont, all of the hospitals and probably the FQHCs just understanding is pretty basic if we moved to that kind of metric we all should agree on the methodology and I would think that most of the hospitals would be able to come up with the variables in calculating that everybody tracks CMI everybody tracks net patient service revenue. It's a matter of really the denominator and figuring out how you define a big patient. Do you agree with that Mark? Yes. Future conversation. Thank you. Any other questions? I'm not going to open it up to the public for public comment. Ken? Yes, listening to the presentation I thought it was a very good presentation made me think of my coach in college we had a very good team for a number of years and every time we won he'd come in and he'd say uneasy lies the head that wears the crown and I thought he made this up and I was really impressed with it it turns out I think it was Shakespeare who said that's the little story but the the issue is that I think it's you know, brief analysis to say and listening to the presentation that the UVM Medical Network wears the crown in Vermont in terms of health care it's obviously a service leader it's an incredible economic engine with amazingly strong financial record of the last five or six years I call it bountiful and perhaps even have been critical of the bounty. It's definitely an employment center and the UVM Medical Network is a very powerful political force and in turn it creates an interesting vacuum because it provides great negotiating power it's certainly a staffing workforce magnet that attracts people for some very good reasons and it's increasingly and again the presentation of the opening of new units increasingly becomes what we'd call the place to go when one needs health care, particularly more intensive health care the question that I have is, and it sort of relates to a panel of, I don't know, a month ago or a few weeks ago, you know, about the lamenting what to do about the smaller hospitals in Vermont and everybody was wringing their hands I was actually amazed that nobody on the panel offered the suggestion that I'll offer is that the very power and dominance of the UVM Medical Center is one of the reasons that many of the smaller hospitals are in jeopardy they simply can't compete in this environment and it's not necessarily to criticize UVM Network for being very successful although it does beg the question is there a responsibility that the network has to help some of these smaller hospitals that are increasingly I think going to have trouble competing so that's the essence of my question is it possible that the very bigger of the UVM Medical Network is one of the reasons that increasingly it appears small hospitals which really is everybody else but the University Network seem to be potentially in distress Interesting question I've been part of the UVM Medical Center and its progenitor organizations since 1981 and from the time that I actually got my head up and recognized where I was and what was going on which was definitely a few years after 1981 I've always been struck at the posture of the academic medical center being a very big fish in a small pond working hard to not take advantage of that to not replicate what happened with partners in Massachusetts and you know this is a an issue that I certainly would not expect anybody to just take face value from the obviously biased but if you went back and objectively looked at the track record and reach out that the resources of the academic medical center from the MCHV days how those resources have been allocated to support other organizations I think you'll find that at least nine times out of ten the academic medical center was functioning with in a very meganimous way supporting the blueprint all in totally all in all in it for support of primary care putting tens of millions of dollars into the formation of the ACL in a sea of large academic medical centers around the country being in a very small group that really have not just been willing to sort of go towards a change in reimbursement but going all in and those are just you know, off the top of my head, sharing clinicians having clinicians oncologists go up to Morrisville and do oncology clinic even though much more efficient to stay in the big office in Burlington I think if really anybody, again don't take it for me but objectively went through how this organization dysfunctioned over time couple of lips along the way and I'll admit but if you looked at how that organization our organization has functioned over time you'd be hard pressed to put it in the evil empire category other public comment just wanted to pick up on a comment that Robin made earlier about affording assurance in that no one can afford insurance now never mind in the future because of the systems inability to keep costs under control even though we're trying hard but our wages don't go up every time we see another figure on the board here about 6% or whatever increase I just wanted to thank Robin for that comment because we can barely afford it now we can afford it really other public comment I want to thank you Dr. Brumsted and we'll see you again in a couple of months thank you thank you for it's very easy to fall into keeping the status quo in leadership and I've always believed that organizations have to grow or die and I'm not saying that you have to expand of that but you have to continually innovate and challenge yourself I think you continue to do that I appreciate that thank you for that is there any old business to come before the board seeing none is there any new business to come before the board seeing none is there a motion to adjourn so moved it's been moved and seconded to adjourn all those in favor signify by saying aye thank you everyone and enjoy the rest of this glorious