 Okay, seeing it's one o'clock and there's five board members will call the order the green mountain care boards meeting of March 8, 2023. Today, we have three primary agenda items. First, we're going to hear from. Springfield hospitals, CEO and CFO on their fiscal year 23 Q one financial performance. We also have an update. We're going to address the UVM self-restricted funds from the 2017 enforcement action. And last we'll hear from Mike Barber and our actuaries at Lewis Ellis on cost share reduction draft policy. I'll turn it to Miss Barrett for the executive director's report. Chair Foster just a couple of minutes. First, I did want to point out that our agenda did flip from an earlier. The chair Foster just outlined the agenda items is how they are going to proceed today. And then I also wanted to say that there are no special public comment periods, but to thank everybody for ongoing we, we and the board really one and it really does help inform their decision making process. So I just wanted to thank everyone for that. And there is that ongoing period which I announce every meeting for a next potential all pair model. And we do share those comments with the agency of human services as they are model and a next potential model negotiation. So with that. Thank you. We had a board meeting just last Thursday, March 2nd. I'll take up those minutes. Is there a motion to approve the minutes from March 2nd 2023. So moved. Second. All those in favor, please say hi. Hi. Hi. Thank you. And the vote is unanimous. And the motion carries. And with that. Mr. Adcock and Miss Westcott, I'll turn it over to you for the Springfield presentation. Thank you guys for being here today. Thank you chair Foster. Appreciate being here today. Looking forward to presenting our first quarter FY 23 operating results with board. We are continuing to have a lot of headwinds in the marketplace, but we feel like we're off to a pretty good start for the fiscal year. So I'm going to ask who is screen sharing for us is that you Katie. Crystal is going to be sharing. Okay. I don't have that option to share only the organizer or the presenter can share. We just made that change. Oh, thank you. Thank you. So again, this is our first quarter operating review of FY 23, and it will be Katie and I presenting today, but I want to emphasize that we really represent our hospital family who has worked extremely hard, not only in the last quarter, but the last four or five years with the challenges that this hospital is faced both in the marketplace economically and with the pandemic. So can't start any meeting without praising our team in our hospital family here with the work that they have done to help us on our continued journey of moving towards sustainability for Springfield. So first slide please. Again, we're on. We're on our journey towards sustainability and we're continuing to make progress on that. Every day we work around three main provisions here are our patients come first that we're going to be flexible and nimble and we're going to adapt and transform to the marketplace and use that transformation to continually understand and meet the needs of our community so we can take better care of our community. And then finally is is our journey towards sustainability, which is everyone knows this hospital has had a very challenging five years. And we're in where we're the architects of moving the hospital towards sustainability. So we're doing that with a number of things one our culture is a culture where we have ongoing process improvement. We're looking at the things we do it every day at the hospital and how can we do those better. We have made a lot of progress to date, and I'm going to include in our presentation, our final audited FY 22 results, even though they're not part of the scope of this presentation, because we're so proud of where we ended up at the end of the fiscal year with a positive operating margin. Operationally we recognize that we still have work to do, and we're committed to doing that, and we're exercising due diligence every day to continue our journey towards sustainability for the hospital. Next slide please. I think everyone knows that the hospital environment across the nation is in a very difficult spot right now in Springfield is operating and continuing our progress towards sustainability with the backdrop of what's happening all across America and in Vermont with other hospitals here that are our colleagues. So what we know from national statistics is hospitals in FY 23 started off better than in 22. However, the performance still lag behind 21 and 20. And again, this is all hospitals nationwide that I'm talking about hospitals continue to increase lower volume in higher expenses. Clearly the headwinds of inflation have impacted us pre significantly in the first quarter. Operating margins and we focused in on the Northeast in middle mid Atlantic regions operating margins year over year have experienced a 28% decline from the previous year. And then finally for critical access hospitals, comparing ourselves to other critical access hospitals in America, we've seen discharges decline in all critical access hospitals. R's declined a little bit more. We also saw decline in ER visits. However, ours increased inpatient revenue has declined ours slightly more and outpatient has increased in ours only slightly less. Operating margins have improved by 12% year over year nationwide, but ours remain unchanged. Next slide please. Our situational overview for the environment that we're operating in continues to be very challenging. This is probably a familiar story to the board. We work in a very tight labor market. Lots of work for shortages. And we have also in addition to work for shortages and supply issues. We also from time to time have our shortage exacerbated by either employee illnesses are people that are quarantined with other family members who have illnesses. So that also affects us in a smaller hospital pretty much pretty greatly. We have made a lot of progress in travelers over the last couple of years, although those continue to be a high cost of ours. And as we go through our financial performance, you'll see one of the main drivers of our performance for the first quarter has been traveler cost in excess of our budget. So we've spent about a million dollars in the first quarter on traveler cost. Inflation continues to also be a problem. Many of the supplies that we bought a year ago have seen significant increases in cost, particularly in items that we use in the operating room. And the other area that we should highlight is energy cost. You know, because it costs more, more to heat the hospital this year, a lot more than it did last year. So we continue focused on our goal to maintain local access to care and to continue to understand and analyze what are the needs of our community and what are the things that can and should be done locally. And we'll talk more about that as we move through the presentation. And then we have a lot of environmental drivers. That are also affecting us. You know, and one of the things that you'll see in our presentation is we've had a lot of variability and volatility in our volume, which is very challenging to manage on a day-to-day basis when the census and patient demand is fluctuating like that. Tertiary bad challenges, we of course are committed to taking care of patients in Springfield and providing the care that's appropriate for us. We do see a significant number of patients who require tertiary care that mostly come through our emergency room. And our emergency room does a fantastic job taking care of those people and deciding which ones, which patients would be better served in a tertiary environment. And that has become a very difficult landscape for us now. Finding tertiary beds is a challenge every day. I was personally involved in a transfer a couple of days ago where the patient went to UMass. So the idea that tertiary care all goes to one or two places that are fairly close is not true anymore because we see lots of cases that have to go to Massachusetts or Connecticut or New York because there are no beds in New Hampshire or in Vermont. And then finally, I always want to highlight one of our handicaps. We feel very strongly that we qualified for PPP funding at Springfield and we did not. We ended up not being eligible for it because of the Chapter 11 proceeding that we had here. So we were blocked from receiving any PPP funding and we're pretty sure we would have received funding in both phases. So all of our cash numbers and reserve numbers. When you look at those, you have to take into consideration of the fact that we did not benefit from that program. Next slide please. Again, I wanted to very happy and very excited to announce how FY22 ended. And so we just recently complete, we brought our audited financial results to our board finance committee last week. And so these are these are new numbers. So we did receive a clean, unqualified opinion from our auditors for FY22. And we posted a $3.5 million positive operating margin for that year. And the going concern statement that's been present in our audit over the last few years was removed this year for the FY22 audit. Our net patient revenue improved from 50 million in the previous year, the 53 million in FY22. And keep in mind that in FY22, net patient revenue was affected pretty profoundly during the Delta and Omicron variants that we had. Those really hit us pretty hard, particularly starting around the holidays and into the early spring here. We did benefit from some federal grant funding with provider relief, ARPA. And also many of you may have seen in the media that we received some USDA funds as well, which will be used for plant and capital improvements. We continue to be very, very proactive at collaborating and building our community partnerships here. I mean, we partner with just about everybody around us for a whole variety of things, such as radiology, laboratory. We have a regional group that staffs our emergency room in hospital service. We have cardiology from Keen, urology from Concord, OB from Brattleboro. Dartmouth serves as our radiology group and UVM serves as our pathology group. So we work very closely with everybody in the marketplace, but we can work together to have the best services in the most cost-effective manner for our hospital and patients. Our biggest partner that we always have to talk about is our FQAC partner here in Springfield and in our market area. Now they're called North Star Health, but they were formerly known as Springfield Medical Care Systems. During the Chapter 11 process, the two organizations split. They were formerly one organization, actually the FQAC owned the hospital, and during the Chapter 11 process, the two organizations were split. But we continue to have a very close partnership with the FQAC and they are our primary care provider base in our marketplace. There are no independent primary care doctors in our market. They're all part of the FQAC. We also work very closely with our designated agency, HCRS, and with our community collaborative, which was formerly known as the community health team. From a population health standpoint, in accountable care, we are a one-care participant. And so we work very closely with them looking at our utilization and our cost to make sure that we're competitive with what we're doing in providing the right care to their patient group. And again, I want to stop and mention again about the tertiary referrals that we have a lot of headwinds due to capacity challenges at the various tertiary centers that we send our higher acuity patients to. And I think it makes it even more important that we focus on the care that we can provide here and do a good job taking care of the patients in Springfield that are appropriate to stay here. Because there just isn't capacity at the tertiary centers for us to transfer those patients. Next slide, please. So let's start in talking a little bit about the first quarter volume. So this slide represents how we do and keep in mind how this compares to the national statistics that we showed in the earlier slide. Of our primary services in the hospital, 14 of the 31 services exceeded budget for the period. Even stronger in our specialty physician clinics, 6 of the 8 exceeded budget for the period. The two that were down were general surgery. In general surgery, we have one full-time surgeon and we fill in with locum staff and we are aggressively recruiting a second full-time surgeon. And we're actually in discussions with a very promising candidate right now over for that position. In gynecology, a year ago, we had two part-time gynecologists at Springfield. They left and we used locums for a good part of last fiscal year. In September, we brought our first full-time gynecologist in who is building up per practice. And on Monday of this week, two days ago, our second full-time gynecologist started on our campus. We think that the continued availability of women's services in Springfield is very important and that it will reduce barriers for that patient population to seek and obtain the care that they need. Inpatient admissions, in the earlier slide, you could see that hospitals across America also were running below on inpatient admissions. And that was our experience as well. We were below budget on inpatient admissions for the quarter. Now, we work very closely every day with the patients that are at our hospital and our care team does a really good job determining which patients are appropriate to stay and which patients should be transferred to higher level of care. So that's an ongoing process that we're going to continue to prioritize and focus on. But this statistic will be important to our performance as we look at how it affected our net patient revenue for the quarter. ED visits, as I mentioned earlier, we were above budget for ED visits. Our outpatient specialties were above budget. In our observation days, we're 31% above budget. And perhaps some of the inpatient decline is also a reflection of the continued conversion of patients from inpatient to outpatient and observation stays. In any way, I would speculate that the rise in appropriate observation days is a positive metric, certainly. Next slide, please. We continue to have a number of operational challenges here. These will probably sound familiar to our colleague hospitals in Vermont. We are committed to very aggressive ongoing expense management, but we are living in a world of very high inflation. We have items that have increased multiple times over year over year and things like cost of labor, cost of supplies, pharmaceuticals. And another one that's really hit us hard has been energy and heating because we heat the hospital with fuel oil and we've seen significant price increases in that commodity. To manage our volatility and changes in volume, we do continue to use quite a few travelers, although we have a slide in the deck to show how our travelers have compared year over year. I think we've done a pretty good job managing it, but it continues to be one of our operational challenges. Primary care access, as I mentioned earlier, all of our primary care providers in our marketplace are part of our local FQHC. And I'm pleased and we have a great partnership with them. Our community health needs assessment shows that that is one of the primary concerns of our marketplace is access to primary care. I'm very pleased to report that they're now in the process of successfully recruiting eight positions and six of those are primary care providers. So we're very pleased with that and excited about that. We believe that will address some of the concerns in our marketplace around access to primary care. With the hospital's history, with our financial turmoil in our chapter 11, the hospital has had some confidence issues in our community and we're working to rebuild that confidence in the community. I think when we talk about our audited financials out in the public forum in the community, I think that's going to be very positive when we start rolling those numbers out here in Springfield and in our area. So we're excited to tell that story. Our adult daycare has always been a high quality contributing program for us. We were forced to downscale the operations in order to maintain social distancing during COVID and we have those social distancing requirements have now been lifted, but we and we are working to return that program to full capacity. We have founded a number of our patients are reluctant to come back and participate in those type of group activities still today, even though the for the social distancing has been lifted. So we're working hard to build that back because we think it's a real benefit for our community in the aging population in our community. And of course, again, another theme that you probably hear all over the state workforce challenges are very ongoing pressures of workforce challenges are very big for us. We did implement a 2% cost of living increase during the quarter, and we have also analyzed the market and implemented market adjustments in departments where we needed to do that to remain competitive. Next slide please. So, kind of the summary on our first quarter is we ended up with total revenue $1.4 million below budget. And again, that was driven primarily by the volatility and the declines we saw versus budget in our inpatient volume. Again, we are working on our process with that every day to make sure that appropriate patients are admitted and triaged in or at the appropriate level of care so that is an ongoing day to day hour to hour process that our team works very hard at and has been been very successful with not surprisingly with the outpatient numbers that we just talked about our outpatient gross revenue has exceeded budget. And so that leaves us with our gross and net revenue per day below budget. Now the good news in the quarter is we were very successful at managing our expenses. So we were $600,000 under budget for the quarter with the versus budget with the areas that were over were contracted services travelers and insurance increases with the vast majority of those being travelers. So, travelers were over about $281,000, which is pretty close to the margin difference of where we were for the month in terms of our overall margin, the travelers being over over budget would have closed almost all of that gap. So, with aggressive ineffective expense management we were able to operate with our expenses per day actually below budget. And so at the bottom we have just a little summary of our operating income by month. So you can see we had a favorable margin in October and negative margins in November and December. And while January is not a subject of this presentation, we were excited we closed the books last week, and we also posted a positive margin in the month of January. And for our last four months, we're batting 500 were positive two and negative two. Next slide please. So in the first quarter our expenses increased by 2.7%, which was an increase of $374,000 from the prior year of 22. The amount the traveler cost increase constituted 72% of that year over year increase. So that was about 270,000 of the 374,000 variants. So we feel like we've done a very good job managing expenses in the face of the headwinds we're seeing with the inflationary and labor pressures. It's just that the travelers continue to be a factor for us. Factoring out the travelers are expenses have only increased by 0.01% year over year. Next slide please. So I'm going to ask Kata to hear we'll go through our financial statements and it'll be in two parts one on the revenue side and then on the expense and margin side. Okay to please. Thanks Bob. This is the income statement, which is going to show a little bit more of the detail of the first quarter performance that Bob just spoke of. And this first slide is just on the revenue. If you go over to the right hand side towards the bottom that yellow highlighted the $1.4 million shortfall is our total operating revenue shortfall for the first quarter where we had an actual a 14.1 million versus a budget of 15.5 million for revenue and that's net patient revenue plus our other operating revenue sources. Going up to the top near that first red check mark that you see way over to the right, you can see that's a $1.7 million negative, which represents our inpatient revenue shortfall, which is driving primarily the shortfall for revenue as well as our negative operating margin for the first quarter. And then that second red check mark is showing the opera or the outpatient revenue is exceeding but budget by just over 400,000. So we had 23.8 million in outpatient revenue versus a budget of 23.3. The other operating revenue category, which is near the bottom, which is our other our nonpatient revenue sources, which is primarily a composed of our grant revenue, our mastered shared services agreement revenue with the FQHC. When we share staff with the FQHC, the revenue generated by that, as well as our adult daycare revenue. So we're here today for the first quarter. We have a $268,000 shortfall there, which it just primarily due to two reasons. One is the adult day program operating at half capacity that Bob spoke about and secondly is our grant income, which we believe we have conservatively budgeted for the year. We haven't realized any grant revenue yet so far. That grant revenue is budgeted evenly over the 12 months of the year. We do have 14 grants that are either in process of being applied for or have been filed. So we're waiting on on those right now and so working very diligently on getting some grant money into the organization. Next slide please actually before before that just looking at the gross revenue per day that Bob talked about on a per day basis. The gross revenue is 343,000 versus the budget of 364. So that's about a $21,000 shortfall per day on gross revenue, primarily on the inpatient side. And when you get down to net revenue, it's 148,000 per day versus 161, which is a $13,000 shortfall on a per day basis. We'll look at in a couple of slides of what that means. Next slide please. So this slide is the detail. This is the income statement, but it shows the expense detail, as well as our operating margin and bottom line. The looking at the way we're to the right the $600,000 that's a negative that's in the yellow highlighted that is the expenses that are under budget for the first quarter. As Bob mentioned, where our expenses came in at 14.4 million versus a budget of 15 million for the first quarter. If you look at that right hand column you can see that most of those numbers are negative, which is a good thing. Most of our expenses are have been under budget with the exception of the big one with the check mark next to it being the travelers, which were over by 281,000 for the first quarter in last year. We're up for this quarter comparatively for the first quarter of this year and last year by about $250,000 for travelers. Our expenses per day going down to that yellow highlighted are 157,000 per day actual versus a budget of 163. That delta is about 6000 per day where we're managing our expenses so that they've been under budget for the first quarter. Looking at the total operating expenses line by month, which is about two thirds of the way down. You could see in the month of October we had 4.6 million in expenses. Expenses in November and December that those total expenses crept up to 4.9 in November and in December almost 4.8. A lot of that increase is due to the other expenses line, which is right above the total expenses line where in October that was 4.32 jumped up to 4.88 in November and jumped up to 5.23 in December. And that's primarily driven by higher energy costs that we're experiencing in the winter months for the hospital. Our bottom line as Bob mentioned for the first quarter is a loss of 301,000. And then just reiterating what Bob had mentioned that by month in the October we had a positive margin of 50,000 and negative margin in November of 151 and then a negative margin in December of 200. And also with the travelers being up 281,000, if that variance hadn't existed, we would be pretty close to breaking even for the first quarter. Next slide, please. Thank you. We're going to talk about this one, Bob. This is a slide I mentioned previously. We manage our contract and traveler expenses very closely. So this is a graph showing the last few months of those expenses. And you can see they kind of reached a peak last year in the summer. And then we implemented some corrective programs, primarily our premium per DM program and our extra hours bonus program, which many of our own nurses picked up those extra shifts and allowed us to reduce the number of travelers shift that we were using. And so we're working very, very hard to recruit staff members. And we're also looking into the educational pipeline, looking to partner with our schools and education programs. So we can, you know, kind of grow our own team and keep our team here in Vermont taking care of their neighbors. So next slide, please. So this slide is kind of putting together what the revenue and expenses per day that I was just speaking about in the previous slides. And this slide heading is our goal is to close the gap. So the gap is our operating margin for the first quarter on a per day basis. And you can see this is broken down where we have total revenue per day, which is all revenue sources. It includes our net patient revenue of 149. This is the first quarter, plus our other operating revenue of 5000. And this is on a per day basis for a total revenue of 154. And our expenses for the first quarter on a per day basis were 157. And so that shortfall on a per day basis is 3000 a day, which we feel is demonstrating that it's really within reach of being able to close the gap with being under 3000 a day. And with our positive results in January, where our revenue on a per day basis was 165 versus our expenses of 163, we had a positive margin of 2000 a day. And if you net the two of these together really after the first four months of the fiscal year on a per day basis, we have a 1000 dollar a day shortfall, which we believe is attainable to be able to close that gap. Next slide. So just to cover a kind of our going forward strategies. So here we are after four months, looking to go forward and continue continue our process of moving towards, you know, sustainability. So we're going to continue to work through our community health needs assessment to make sure we identify the services that are needed and continue to collaborate with our FUAC partner. We're very excited with the success they're having right now with recruiting primary care providers into our marketplace, because it's been a pretty hard thing to do during COVID. So now we're starting to see that it is that recruitment is becoming more possible, both on the primary care side and over at the hospital on the specialty side. So we are we are having people express an interest in interviewing. So we do have opportunities there. We want to continue to increase the awareness of the local services that are available. Clearly now we're going to have a very competitive gynecology program with two full time surgeons here. I feel pretty good that we're going to recruit a a second full time general surgery surgeon and hopefully we will do that before the summer. And then we also have growth we're experiencing in other areas. We have we have increased our podiatry services from part time to full time. We've increased urology. They're still part time, but we have added a couple of days a month to their schedule so they're more available now. You know, so we have we have growth happening over on the physician clinic side that is that is starting to show up now in our numbers. And so it's we have to get that word out to the local community that we can provide those services here and they don't need to go out of the marketplace for those. One of our operational strategies that we are working on is our revenue cycle. We have actually retained an outside consultant to analyze our revenue cycle process and we are they have completed the field work and we are now waiting for their work product to see what opportunities are identified in that sector of our business. We believe that there are opportunities and improvements for us there as well. And again, again, we do have some inpatient capacity and some capacity in our psychiatric center. You know, we have seen a lot of variability in both of those programs with the census going up and down this morning at Wyndham. Our psych census was eight, but we have seen some variability with it going up and down. And again, as Kate mentioned, the adult daycare has been running at about 50% capacity and we're trying to get that more fully used as well. Last year, we were very successful with grant funding and it made a big difference to us in our year and we will continue that strategy. As Kate has said, we're right now working on approximately 14 different grants that we're working on right now that that has the huge opportunity to help us with our financial performance this year. And then we're proud of where we've been on the expense side so we will continue to aggressively manage our expenses. Understand that that's also in the face of the fact that we have quite a bit of things that, I mean, we have aging equipment, things that need to be repaired and those sort of things that are, but having to address many things that was not possible for the hospital to address over the last five years. Specialty recruitment. In some cases, like in general surgery, you know that that is actually a real positive because we're already paying for a locum's physician to cover call and be available after hours. So if we can convert that to a full time doctor that's part of our hospital family, that will be a win-win for everybody because we'll have another doctor that can grow a practice rather than just cover call. And again, of course, reducing travelers, we focus on that every day, making sure we have the right resources for the patients that we have. As I mentioned earlier, our extra hours bonus and our premium per diem programs have been effective for us. And then finally, recruitment and training. We are, we, we, recruitment's very hard right now. There's a real shortage of staff, not only in the clinical staff. I mean, everybody hears a lot about the nurses and the technical people in the hospital, but all positions in the hospital are very difficult to recruit for. In many cases, some of the fast food restaurants in our area may be paying higher starting salaries than we do. You know, so our benefits are a lot better, but you know, that's some place where we have to be competitive. All right, next slide, please. So I just want to conclude, you know, that we, again, we continue our journey towards sustainability. We are pretty proud of the progress we've made. Are we where we want to be? Not yet, not yet. But if you look at where we've been over the last five years with the management turnover that's happened here, the financial difficulties that have been experienced. Chapter 11, going through the split with the FQHC. Going through the pandemic and now our big headwind is kind of labor and traveler expenses. And again, I also say that, again, recruitment is loosening up now. We're having more success on the provider recruitment side. So I mean, I can't finish this presentation without thanking everybody that is a member of our hospital family and our hospital team that's helped us along on our journey to continued stability. And, you know, the staff out there or the ones that have done it and the confidence that community has in us is what is helping us continue to progress. Great. Well, thank you very much, Mr. Adcock and Miss Westcott. And I know you meet with the board monthly and I've had a chance to sit in on a couple of those. And so I appreciate you guys putting in all the effort when you go through that sort of more frequent check up with us and letting me sit in and learn about your experiences there. They've been some real challenges that you guys have taken on and are working towards and I appreciate you keeping us all informed. I have a couple little small questions, but first I'll turn it to my fellow board members for any questions or comments they may have. I just have a quick one, if that's all right. Thank you. And thank you for the presentation. I appreciate you coming back and all the efforts you're making to get Springfield on a sustainable path. I'm just wondering if you could talk a bit about days cash on hand and where that is. Sure, I'm going to ask Cated to do that, but we have made significant progress with our days of cash on hand. We're probably the lowest, we may be the lowest in the state, but it's significantly improved during the time I've been here. So Jessica, thanks for your question. We are at about 60 days cash on hand, which we know is probably lower than most all of the hospitals in Vermont, but we're proud of the progress that we've made from being at single digits just a couple of years ago when Bob came. So we're at 60 days cash right now that we've been averaging. Thank you. I had a couple of questions as well. So I'll go ahead and jump in. I was curious if you could speak a little bit more about your revenue revenue cycle process improvements and just give us some examples of what you are expecting might come out of that process that you're going through. Sure, I'll be glad to start that and Kate it can can fill in. Robin, what we are doing is looking at our whole process about all the clinical care that we provide, you know, how we document that. How does it get from the point of where that care is is provided to how does that get over on the patient accounting system and into the bill and then how do we work through that from a billing standpoint. And we believe that as we work through that we will find opportunities to modernize that process that we have in and make it more effective. I mean, we have some really great people that are working in our revenue cycle. They do a good job for us, but some of our processes, you know, are being looked at because we think there's opportunities to improve those and update those. I think we're looking to see, you know, we've had a lot of denials and stuff denied due to no authorizations stuff like that that they're going to be looking into that process. Also things that, you know, we think that we may not be charging for everything that we should be charging for so there may be revenue leakage because of that so we feel that there's many many opportunities in the revenue cycle because it's such a big. There's, you know, many parts to the cycle. So we feel that this is going to be a huge opportunity for us and we're excited to see what the results show. As Bob mentioned, the consultant came in about a couple of weeks ago three weeks ago I think now and they interviewed every single department and so they're going to be going back to the drive not to the drawing board but going back and kind of pulling all of those. You know, all those questions that they had for the different departments and kind of compiling on the information and coming up with some recommendations for us. And also they're going to be quantifying what those recommendations are to the extent that they can. And what's your overall timeframe for the project. As soon as we can do it. I know that I know that's kind of a tongue in cheek answer, but we're not. I mean I would say that we're not sure because we're not we don't know what what's going to be identified. And then the things that are identified will have to be prioritized and then we'll have to have a plan of how we will implement and roll out those changes. I know the whole overall process to you know the recommendations when are you expecting the recommendations. I think by the end of the month is that right. Okay. I think they they said either mid to end of the month for March. Yep. Okay, and then we had the second there's a second phase of this project, which is the implementation phase so this this first phase is just the assessment portion and then the second is the implementation which is hard to say how long. Great. Thank you. And then my second question was about what you're thinking about in terms of growing your own in the workforce area and also if you've talked with other hospitals who've successfully implemented those types of programs to get some lessons learned. Well, we are working in partnership with the local programs. I know our chief nursing officer is now teaching an LNA course. She goes in is actually instructing herself. So she's a fantastic, the hard talented and hardworking person for our team. We're also we are also implementing a program where we put in a nurse preceptor program in our emergency room so when new graduates come they can get the appropriate training. So we'll be able to hire new graduates and bring them through training process to get them fully trained and oriented to work in that area. So we're looking at any and all ways to collaborate on an educational side to grow the, you know, population of healthcare providers that are in the area. Yesterday, no, Monday. This week I greeted a group of health career high school students that were touring the hospital and actually I had a chance to talk to them about about what it's like to work in healthcare and why it's important to work in healthcare. And I know many of those students think about very traditional healthcare roles, you know, such as medicine and nursing, but also we also talked about other jobs and professions that are available in healthcare that are very important and very scarce also so so I wanted to make sure they also that we also talked about finance and healthcare and engineering and healthcare as well as medicine and nursing. You know, so, but that was a really good experience for me I enjoy doing those kinds of things so it was it was good for me. Great. Yeah, and I would just encourage you to speak with some of the other hospitals because Brattleboro for example at one point had pretty much eliminated travelers that was pre COVID, of course, so much more difficult now but I think that several hospitals are working on the grow your own which I think is terrific but it seems to me like there's potentially some lessons learned from working together there and talking about what's been successful. So I'll just put that plug out there. Thanks. Oh, that's a good suggestion. Thank you. It is it is workforce is our is very big challenge for us in Vermont right now. So, hey, can I turn a few questions here. Certainly Dr. Merman very nice to meet you. I don't think we have met electronically yet so. It's nice to meet both you Bob and Kate and thanks for coming in and thanks for entertaining my questions I appreciate your, your hard work and your, your successes and trying to close the gap here in this really challenging time and healthcare so. So that's it's it's exciting and I wish you the best of course we all want you guys to succeed so. So a few things from your presentation I just wanted to ask a couple questions on when is the impatient revenue side being below budget and if you had any insights into it, you know why that is is it volume or is it revenue per patient or are there struggles that you are having with your with there and if you could expand on that that would be really helpful. I mean I think I would have to characterize it as, you know, as volatility in demand, because it's it's it is on the demand in the emissions side. And, you know, we do a very, very hard every day to look at the patients. You know, almost all of our patients come through the emergency department elective emissions from from community providers. They happen very often so almost everyone comes to the emergency room. So our team does a does a fantastic job, working hard to look at every one of those patients and determine the most appropriate care for them. Is that something that we should keep in the community that we can take care of, or is that a patient that should be transferred to to a higher tertiary level of care. So I would say it is more of a of a volatile thing. You know, I think it is the reason I emphasized the success the FQHC is having in recruiting primary care providers, I think is very important to us because more access and more capacity in that area in our marketplace, more people hopefully will choose to stay in Springfield and receive their care. And then, you know, the the services that the hospital provides, they'll be able to receive those here. Those dollars will stay in our area and in Vermont. And, you know, if they have to be admitted, you know, they will be able to come to our inpatient unit, if if that's the right level of care. I guess the follow up to that question too is, do you think there are certain services that if you expanded slightly here or there could allow you to keep more patients there as opposed to transferring them. Well, we look at the scope of what services we can provide. And clearly the ones that I mentioned in our recruiting are ones that we believe are very important to have available in Springfield. You know, gynecology for our population here is is very important to have a second general surgeon is very important. At one time, this hospital had an intensive care unit. I don't think at this point, you know, what the numbers I've looked at doesn't look like that would be viable at this point. We have cardiology on a part time basis, but not every day. So a fantastic doctor who comes from Cheshire in King, but we don't have cardiology one side every day. So we have some things that we don't have like that. We don't have pulmonology. We don't have a medical neurologist. So there's some specialties that if we had, we would probably be able to keep a few more patients. And right now, right now we're focusing on, we're focusing on the ones that we're very confident that there's demand for. And you know, we know people, we know some of these patients are leaving the marketplace because we have access and supply problems. So, yeah, I guess one of the other questions I have kind of regarding that continuum is, is regarding transfers to tertiary care centers. You mentioned difficulties sending patients to UMass, Connecticut, New York. I know of those challenges. You know, are there, could you expand on some of those scenarios that you're, that your hospitals, I mean, I know it's not your sort of a day to day thing that you're dealing with, but it sounds like you have to get involved with them. They're reaching that level. Well, you're, well, you're right. And this, this has been something that has, I think is has changed during the two years that I've been here. You know, we were seeing less availability of tertiary beds that are traditional places where we used to refer to because they have capacity issues. And so more and more we're seeking for those patients. The closest available ICU bed for them is outside of our market. You know, it's in Albany or in Springfield, Massachusetts, or it again, I sent, we sent a patient to UMass on Monday. You know, that's not a, you know, that's not like our normal place where we would send somebody, but that was the nearest available bed that had the services that that patient needed. And so we are, and so is that, is there a change in acuity going here? We do see a lot of acute patients and we average every month about 35 to 40. ER visits a day is what we're seeing. So, you know, that peaks out somewhere, you know, the top months will be 38 or 39 patients a day, but it's seldom below 35 again. Maybe Cata knows where we are a year to date off the top of her head, but those are kind of the numbers we're seeing. But we're seeing a lot of patients that are have strokes. So we have CVAs coming in. We have patients with stammies here. We are about to embark with a telemedicine program with Dartmouth for the neurology. So we will have, you know, we have great support from Dartmouth right now, but we're about to start their teleneurology program, which will help us with the stroke population. That's great. Thank you for that. I had two questions. Do you track data relating to patients seeking care out of state? Well, that is a hard statistic to track. We have we have some numbers that we have. So we do track and analyze that with the data that we have. Not sure if that is inclusive of all patients. But we do. We do track that chair foster. And I was just curious what the dynamics are. The trend line looks like in the last quarter or last couple of quarters with regard to those dynamics. I don't have that number at my fingertips, but we can analyze that and reply to you. Yeah, that's fine. We can talk about it next time we get together. Okay. I was just curious what that looked like today versus, you know, six months ago a year ago. And I wouldn't misunderstood what the statement I just made to Dr. Merman either. We still do transfer a lot of people to Dartmouth. It's just that they don't always have capacity for it. So they're a great referral partner for us. So just to clarify that case anyone thought I'm in opposite. Right. Understood. Yeah. The other question I had was I think on slide six, you said 14 of the 31 services exceeded budget. So I take it that means financial performance and absolute dollars. Is that what you're when you say budget, you're referring to the absolute dollars you had budgeted versus achieved. Is that right? I think that those are procedural volume. So that would be like how many x-rays did we do actually do versus the budgeted number. Got it. And we are seeing a lot of those areas, particularly like in imaging, we're seeing a rebound in that volume that had been down, but we're now seeing those volumes rebound. And in terms of the 17 services that were not exceeding budget, are those relatively static or are you seeing some variation between which services are exceeding budget and which are not? I would say we're seeing some variation on those the ones we have a couple and we spoke about this at our last monthly meeting, like, for example, in nuclear medicine, we have a need to to replace the equipment in there. So we don't hardly do any nuclear medicine anymore. We need to replace that and that's on our capital budget plan. But Peter, do you have a sense for that? Let me see if I can. Some of the areas that have been down here today are our cases, our MRI procedures, respiratory procedures, physical therapy, adult day is one of them that we talked about. Our pain management cases in the OR, which is a new program for us that we started in September. So we're still starting to build that program. Our lab tests have been down. And some of those volumes are down, of course, because the inpatient census is as well. So, you know, on a per patient day basis, you know, you would have quite a bit of lab and those type of procedures. So some of those are down because the inpatient census is it's varying with that metric. Right. Okay. And that also includes the inpatient side of things too. So with the acute care unit and the Wyndham Center being down that that's part of that number as well. Makes sense. Okay. I didn't have any other questions. Anything else from the board? I'll turn it to the healthcare advocate for any questions or comments they may have. Thanks so much, Chair Foster, and thanks, Mr. Agcock and this Westcott for the presentation and the update today. I think, like other folks have said, I think there's some encouraging signs amidst the challenges. I just had one question specifically to the financial performance slides. It showed higher than budgeted expenses, actual to budgeted for bad debt. And I was wondering if you could elaborate a bit on this difference between the actual and the budgeted and what conclusion do you draw from it, if any? I think at this point in the first quarter of the year or bad debt is as highly estimated based on historical percentages. Our charity care has been down the, you know, the last year that we've had seen and talked about at the budget presentation. We are reviewing our financial assistance policy as we speak to see if we can get more people eligible for free care. So we're looking at possibly raising some of the asset tests that we have currently in to transfer more of that bad debt into the free care category. Thank you. That's encouraging to hear and happy to chat more about that. As you probably remember, that's a priority already for our office. So back to you. Thank you. We're looking at that. We're looking at that ratio. And because I would argue that a lot of our bad debt is actually charity care. We just need to think about how we're doing this. So thank you. Great. I think today, given we have three different topics, we'll do public comment at the end. We received a lot of public comment on the next topic. So I'll just wait till we have, actually, I guess I'll do it after that since the second topic that sort of seemed to have engendered a lot of public comment in the letters we received. So, Miss Westconn, Mr. Adcock, thank you very much for your time. I think we're all set with you today and thank you for coming and we appreciate it. Thank you so much. Thank you so much. Have a nice day. Thank you. And I'll turn it next to Russ McCracken and Sarah Lindberg on the UVM self-restricted funds issue. For the record, Sarah Lindberg, Director of Health Systems Finance for the Green Mountain Care Board, joined here by Russ McCracken, who's a staff attorney with us. And we are coming back to revisit for potential vote, potential modification to a fiscal year 17 enforcement action. So just to recap on the next slide, we first introduced this topic on February 22nd to talk about the update we received per request from UVM. And essentially, the staff recommendation was to consider modifying the enforcement action to make the use of the remaining funds a bit more flexible in addressing the substantial mental health need that's facing our world. And that UVM developed a proposal in consultation with our Vermont Department of Mental Health to figure out the best way to do that, which would be submitted to the Green Mountain Care Board by May 31st. We did hold a special comment period from that meeting up through yesterday, March 7th. And I just want to thank all the folks who took time to produce those comments. They were thoughtful. They were detailed. They highlight how complex this issue is and how difficult it might be to figure out the, you know, right answer quote unquote for this important issue. So just really appreciate the function of the board and being able to solicit that kind of feedback the way we do. So thanks. Thanks to those who took that time. So moving on, just wanted, I think I spoke to this last time, but just wanted to make sure it was officially noted that the Vermont Department of Mental Health is supportive of changing the restrictions so that it is not limited to inpatient capacity and, you know, further acknowledged that they thought it was helpful to be able to collaborate in this exercise. So just want to make sure that's very clear to you all as board members. And then I'll just spend a few slides going over the response that UVM gave to some of our inquiries related to these funds. So due to the pandemic, UVM's restructured some of the way it thinks about these investments. So they, you know, the pandemic made things need to be a little bit more liquid than in times before that. And so this is kind of their pandemic proofed new way to kind of think about some of these funds. But the 18 million is in their funded depreciation, which is an unrestricted investment and is included in any days cash on hand calculations done by the Green Mountain Care Board or by UVM Health Network. And their plan is to keep these funds in their short term reserve fund, which is that middle box. And it has some details about these different kind of buckets and where they put them. So this is kind of the middle path in terms of liquidity of the funds, which is helpful. Especially considering, you know, there's other kind of capital projects and improvements that many hospitals are trying to catch up on after the pandemic slowed things down. So the next slide also talks about the return that they got on these investments. So the cumulative return from April 1st of 2018 through January 3rd of 2023 was 21.1%, which was annualized to a 4.1% rate, which is the future expected annual return for that short term reserve investment pool. They noted a few inflation numbers, but just to put it on the same timeframe, the kind of general measure inflation, which is the CPIU increased by 20.1% in that same time period. And so have two countervailing forces kind of acting on those funds. And then finally, we also received a letter on Monday. I think that was Monday, March 6th, yes. And if you want to advance the slide, there it is. It really highlighted three issues. And this is also posted on our website, but it was a It indicated that the current enforcement order was a collaborative process in partnership with UVM and that the idea was, you know, overages were due to really utilization. And specifically it was Medicaid and Medicare that was driving it and that this seemed like, you know, kind of a system-wide way to invest those funds in a way that made sense. So just saying that, you know, FYI, it wasn't a punitive thing that this was kind of a collaborative approach. They also wanted to highlight the work that they've done to date, including the utility of the work to date in free reuse. A lot of the modeling that they did, they feel is absolutely reusable. And they also took a moment to shout out how helpful the breadth and depth of the stakeholder process was in the development of those plans and feel that it greatly strengthened the proposal, particularly from a clinical standpoint, which I thought is always helpful to remind ourselves of those kind of non-brick and mortar considerations. And finally, you know, they'd point out that argue that the budget order back in fiscal year 17 did not require UVM MC to track or spend any of their end returns on that approximately 21 million. So that was kind of what they covered in that letter. But I will turn it over to Russ for some more focused review of the remaining material here. Thanks, Sarah. And for the record, it's Russ McCracken, staff attorney with the board. I'm going to go through the next couple of slides for the board's review and deliberation. The first one here, which we covered last week is the FY 2017 enforcement action that we're looking at. I won't read through it again here, but if there are questions, we can come and refer back to it. We did have a public comment period open and the board received 10 public comments regarding the potential modification of the FY 2017 enforcement action. In addition, there was the letter from UVM health network that Sarah just spoke about. And as Sarah said that we really appreciate the comments. They were all so well thought out informative and very helpful. I'm going to highlight a couple of themes here in doing so. I always fail to capture all of the great points that were brought out in these public comments. So the comments are posted to the board's website. There's a link here in the presentation. They've been circulated to all the board members and can be referred to also on the website. Having said that the themes that really came out were an urgent need for additional mental health services in the state. An urgent need for additional patient capacity, including to address the challenges of having patients boarding and emergency departments. The continued disparity and reimbursements for mental health services versus other health care reimbursement, other health care services reimbursements. And other commenters highlighted the value of flexibility to provide the, sorry typo here, value of flexibility in the restrictions to provide mental health services outside of an inpatient setting to reduce hospitalizations and other interventions along those lines. The comments received five of them fairly specifically asked the board to retain the scope of the self-restricted funds to inpatient capacity. And for effectively asked the board to expand the scope of the restriction to allow mental health money to be spent for mental health services in addition to inpatient capacity. So from the staff's perspective we see kind of three basic directions the board could go in. The first option would be no change to the enforcement order. The funds remain restricted as they have since 2018 to be used to increase the mental health capacity in the state. A second path that the board could go down is that since the board had determined sufficient progress is no longer being made. The funds should be applied to reduce the commercial rate request in UVMC's FY 24 budget. This was the default position you could say in the FY 2017 enforcement action. In effect what this would look like is for the hospital's FY 24 budget the proposed commercial effective commercial rate increase would be reduced by the value of the restricted funds. And lastly which and this is the staff's recommended approach is to modify the enforcement order to prevent to permit more flexibility in the use of funds and determine expenditure plan in collaboration with Department of Mental Health. With a proposed use of funds due to be presented to the board by May 31 of this year. And so with that we have some staff some suggested motion language for the staff recommended approach. It's here on the screen. If that is helpful to any board member who might want to take might be inclined to make a motion. And I will stop there Mr. Sherrod to open up for board questions and discussion and deliberation. Great thank you both. Turn it to the board members for any comments or questions or deliberations on this topic. Any orders totally fine. So this is Robin I wonder Sarah and Russ if you could. I think he went over this last week but could you just remind us for why you think the best course of action is the flexibility. Absolutely. So this plan was all going according to what everyone expected until the pandemic hit and that substantially slowed down a lot of things. And in that same increment of time collective mental health has deteriorated even further so the need has increased as has the expense to build and so given that the need just keeps growing and that the expenses associated with the construction and the ongoing likely change to the revenue due to this being projected to be a money loss at the net level made us think that maybe we could be a little bit more flexible engage some of the experts here in the state to figure out are there like more beneficial plans for that fund and kind of look at it as systematically as possible. Thank you. I'm on Mike so I don't mind just throwing out a few thoughts for discussion and be curious to hear the other board members fuse on this in addition all of everything else you may have. But first I want to highlight this wasn't an interesting public comment period I thought we got a lot more than 10 but that's because I think they were so meaty and substantive. They were impactful because I think they are impactful on what we're deciding to do one. There was a comment about focusing more upstream on preventative mental health care rather than sick care in patient care and utilizing more of a community based integrated care approach. There is one about requiring the funds to be used specifically at CVMC for the project that was initially contemplated and requiring the inpatient psych facility. There's a really thoughtful one that grabbed me quite a bit from the Vermont emergency department directors about the importance of measure bill measuring and ensuring improvement in mental health emergency department boarding statistics and numbers. I included in that one there are some thoughts about how it's inhumane to treat patients with mental health problems by boarding them in the ED. It's bad for their care. It's extremely expensive for Vermonters and for the hospitals. And it's, I think we've come to really understand it's difficult on the physicians and for morale of the nurses and the physicians and the staff. So that comment I think was really important, at least it was to me. We've submitted one with a couple points about an RFP that was put out for inpatient psych and have only one hospital bid on it. And it was not the one in Burlington, which has a children's hospital and greater financial resources to commit to inpatient childhood psych. And then the UVM letter that Sarah had referenced, I think was important in that they pointed out. In their view, they have not been derelict and carrying out the enforcement order and this is not a punitive action. It's really just a function of there's a reality enforcement doesn't necessarily mean a pejorative here. In the UVM one. There was an email where they indicated the money wasn't the funded depreciation fund. And there's been a 21.2% cumulative return on that money. And as I think our slides here said it, it's a 20.1% CPI increase over that same time. And so to me, this is an issue that is important, which is, should this money include the interest that was returned on it. In UVM's letter, it said it pointed out that the board did not require them to track or spend any of the return. And I think my reading of it is accurate. However, it didn't allow them to invest the money and then keep the return and only spend the 18 million. I think it was silent on that. I wasn't here, but I anticipate that I expect that that was because it just wasn't anticipated that this project wouldn't come to fruition at CVMC. And notably, if there isn't interest applied to this money, the value of that 18 or $21 million is considerably less because of inflation. $18 million in fiscal year 17 is worth 20% less today. So if it remains the absolute month dollar amount, Vermonters are getting less of the money than it had been back then. Another thing that caught me as well was that in the UVM letter, it used CPI and a couple of the other generally accepted inflationary metrics. But as I understand it in the hospital budget process, we typically see medical inflation used, which is often quite a bit higher. So here it's CPI and the money is worth 20% less. But I think it would be worth less, even more less than that, greater lesser, less, even less if you use medical inflation as opposed to CPI, which I think is typically what we'd expect to see in this context. So, you know, it's a tricky issue for me on the interest because one, the order is silent because I don't think it was anticipated. Two, Vermonters are getting less money or less value for the money. Three, the money was invested and therefore the returns are because of it. And fourth, I just think that the importance of mental health options is really critical now. And so more money would be better than less. And lastly, I'd point out that UVM indicated in their letter that they're confident that they'll spend far more than the $21 million to increase inpatient and outpatient mental health treatment. So I don't really see why they wouldn't agree to including the interest if they're confident that they'll spend quite a bit more. Anyway, those were just some of the thoughts that I had. I just want to throw them out there to the other board members and to the public. Well, I'll go ahead and jump in. I appreciate you highlighting some of the details from the public comments because I think that we did receive some really, really thoughtful comments and I also appreciate that. I am supportive of the staff's recommendation to allow for more flexibility in consultation with the Department of Mental Health. I think given the issues right now around construction and the fact that the needs have intensified and grown, that there may be some outpatient or community solutions to address some of the issues which lead to the ED boarding that might be able to be implemented more quickly than a construction project, which isn't to say that if that's what people thought was necessary that I oppose that. I just think that the Department of Mental Health or the experts here allowing their input and expertise to come to bear about what the system needs is important. So I'm sort of agnostic on the interest issue, so I'm interested to hear what other people think. All right. I mean, regarding the interest issue, I think that this $21 million, I wasn't here in 2017 and have not reviewed the board meetings around this from that time, but my understanding is the intent of this money in 2017 was to be used for increasing inpatient psychiatric capacity pretty soon after that time. I think at that time it was clear that there was a lot of ED boarding, that we were under capacity. We didn't have the capacity we needed for psychiatric beds in Vermont. We still don't. In the year 2022 presentation I didn't see that Dr. Bronsted noted we are 29 to 35 beds of additional psychiatric capacity is required in Vermont. So I think in 2017 the hope was this project would happen fairly rapidly, whether I don't know if the CVMC project was on the table when this money was put into this specific restricted fund. But I think that there was maybe thoughts that there could be other rapid projects remodeling of spaces or whatnot that could have led to higher capacity. Regardless, I, you know, with regards to the interest, I think it seems reasonable to me that this $21 million from 2017 being invested at a time where we have interest that's, you know, that we have inflation that's increased at a rate, at least as the investment that was in 2017 of this month. And with that money, it seems reasonable to me that that interest should be included in the use of this money. I do also think that I was moved by a lot of the public comment and it was, it was an incredible period of time actually to read through these really thoughtful comments. You know, the idea is that we could treat patients better in the outpatient setting and increase capacity to prevent crisis situations is I think is is powerful and important and is is a is a long longer term. They're all longer term fixes to a crisis situation, I guess. Working in the emergency department. I do see patients. For lack of a better word stuck in the emergency department waiting for inpatient psychiatric capacity, you know, 24 to 48 hours is not a long time. It's often much longer and these patients sometimes are voluntarily there because they feel that they feel safer there or they had a recent or a prior psychiatric hospitalization that was really beneficial to them so they're trying to get into a psychiatric bed. They're often, we see a lot of children board for long periods of time trying to get into inpatient psychiatric beds for various reasons but often there isn't an alternative to waiting in the emergency department. Everybody tries to find alternatives but it's there's not. And sometimes patients are involuntary and. And those patients are often the hardest patients to get to an inpatient psychiatric bed but often their need is the most. And. And it's it's it's really hard as a provider. The mental health techs I think take the brunt of this. It's it's it's very stressful for them to to keep patients in emergency departments where we rarely have windows. Where patients rarely can get outside because of flight risk. It's it's really crushing to everybody involved most the patients. Most of the patients but to the others involved as well. So I would love it if this money was used previously to increase the psychiatric capacity in Vermont inpatient capacity in Vermont. And I do think we need to increase the outpatient capacity and we need it all to be we need more of it all of it and more accessible. But I also am swayed by the idea of using some some metrics to. To track how this money is being used in a reduction of I think the intent was actually at the time to reduce the board of patients. So I know that there were metrics that were presented in the UVM slides in 2022 of. Numbers of patients seeking a psychiatric bed. There's other ways we could think about this but I think it would be reasonable to. Include some sort of performance metric and the use of this money and I. I know that the department of health are the experts in this area. And we could discuss this with consultation with them but I feel strongly that that was the intent of the use of the money and I feel that is a very pressing problem. So I think I'll hold there. Thanks. Maybe I'll jump in here then. So I would support granting the enhanced flexibility provided that UVM health network works closely with the Department of Mental Health as it is laid out in this motion. Making sure that we're identifying the most impactful allocation of those dollars. To your point Dave and I think to the point of the spirit of the original enforcement action. I would like to add perhaps a sentence to the end of this suggested motion if this is a motion that others agree with. That requires the proposal to include an assessment of how the the use of funds would reduce the boarding of mental health patients and emergency departments. I think you're right and we've heard this for years that boarding is one of the biggest pain points in the system and in fact was the impetus for the original enforcement action in many ways. The idea then was that increasing inpatient capacity was supposed to reduce those ED borders. I suppose that there are other ways that that could be accomplished through, you know, thinking about downstream effects outpatient care preventative measures things like that. But I think what's really important is that we address that issue of borders head on. It's been too long. We have been, you know, trying we've been hearing about this for years and years and years in our hospital budget process. And, you know, I was very moved by the public comments submitted by Dr. Ben Smith. Who's the ED director at CVMC but written on behalf of all the ED directors across the state and he made a comment there the boarding of mental health patients and emergency departments has never been ethical or sustainable. And I think that we need to do something about that. My suggestion is to add a sentence to the end of the motion. The planned use of funds submitted by UVM health network must include an explanation and analysis of how those funds will measurably reduce the boarding of mental health patients and hospital emergency departments. And I think that would, you know, keep with the spirit of the original intent and, you know, potentially impact that care of those patients in those emergency rooms. That would be my suggestion. This, this is Tom. I'm not ready to go on a motion today because I'm pretty conflicted. I think if we, and I appreciate Dave's comments from the frontline. I want to share a quick story. I have a close friend who has a woman that works for him who has a long history of mental health difficulties. And last, last summer, fearing for her safety and the safety of people around her, she voluntarily went to an emergency room and stayed for two weeks. And is now tens of thousands of dollars in debt. She's struggling, unable to work. I thought Dr Smith's comments were spot on. Our caring for people who need inpatient care is currently inhumane. I think we need to have a reckoning as a state that our history, if we go to our own state website and read about the history of mental health care in the state. It's been unethical since the late 1800s. In 2005, the Department of Justice decertified some of our sites. What we are doing now, as Dr Smith said, is inhumane and unethical. So of course we need more funding than the 19 to 21 million. And we need more than just inpatient care. And I think that's the evidence that I could find trying to research this over the past few weeks. Best estimates that are we need about 46 beds per 100,000 people. If we had the best community mental health care available that might go as low as 36. We currently have 30. Most healthcare provider organizations consider inpatient mental health care. Not profitable. And we have seen over decades in the state that when it's considered not profitable, it does not get built. So to remove any enforcement. Where we don't require inpatient beds being built. Continues the intolerable care, in my opinion. So I think this is a call to action. Yes, the green mountain care board has the way in. Yes, the department of mental health. Did weigh in diva. AHS, the governor's office. How are we going to address this crisis where suicide is going up and up and up year over year it's never been higher. We're failing some of our most vulnerable people in our state. And we can vote to release the 20 million or the 21 or the 19 or the 18. Or we can say no, you have to use it in patient. It's not enough and the issues bigger. But because we have an opportunity to talk about it. Let's have that conversation. To summarize my fear is that if we. If we release this to be used as other see fit. Because inpatient psychiatric care is not considered profitable. It will not be made. If we release the money and all of it went immediately. To perfect effective outpatient services. We would still need more inpatient beds. We need to find a way to address that. And we need everybody. Policy makers regulators. Involved to address it. Thank you. Thank you. On the flexibility, the only thing I guess that might. I'm not sure. I'm not sure. Tom's point really hit home with me real quick. Just the fact that if it's not profitable, it won't be built. So it won't be an equal consideration potentially. Or there's a concern that it won't be an equal consideration. Which I understand. At the same time, I feel like. DMH. And mental health providers are probably in a much better position. Than I as a board member. To assess the most efficient way to do this. Right. More than just myself. I'm not sure. I'm not sure. I'm not sure. I'm not sure. Conflicted on that too. This is a tricky one. I think for sure. I don't love the history of the whole process here in some ways. It's, it's, it's a difficult one to come into. And to come up with the right solution. I didn't hear. I'm curious to hear if any, if they have thoughts. Member homes and Walsh. If you have thoughts on the interest. On the money or or not. If you don't have views on it, that's of course, totally fine. I think that the investment returns have grown, but inflation has eroded the value of those investment returns. They're countervailing. So. Also, I don't think it was, that was not what the. I think to the degree that. What we laid out in the original enforcement order. Was not. Clear on what would happen with the value of that. You know. Investment. So. I guess I would ask our legal. Team to weigh in on that a bit as well. It works in a bit in consideration. Um, The 1819, no. Isn't. I think it's important that we look at all. Tom, Tom, sorry, I'm going to interrupt. Sorry. You're muffled for some reason. I'm not sure why your mic. It's got muffled. You're clear before. And I'm just so complete. Yes, sir. Take your time. Is that better now? That's clear. Yeah. Thank you. Great. Yeah. So I think. The interest. Interest earned. I think it's worth calculating and comparing to what has happened with inflation. It, they may have canceled each other out. As Jess said, but it's important, I think, to consider it because there is such a great need. Right. It's, I just think that it's too important an issue. Um, I also don't want. Our discussion to get mired in that when, to me, this is such a big issue. It is the dominant crisis and healthcare in our system right now. So I think it's important to keep. It's affecting the patients who need care. And it's affecting. And demoralizing and contributing to the burnout of the workforce. So I think it's important to get care. Care is for these people. And so whatever we can do. I do have a follow up question, but I don't want to interrupt you, Owen. Oh, no, please go ahead. So I don't read the staff recommendation as releasing the dollars. I read the staff recommendation as. Uh, requiring UVM health network to work with DMH. To come back to a proposal, come back with a proposal by May 31st. I think it's important to get care. I think it's important to get care. I think it could be inpatient beds. It could be some other mental health. Uh, capacity increases. And I do like Jess's suggestion to tailor that more directly to the ED boarding situation because that was the problem that was presented that was initially being. That we were trying to solve. So perhaps that's me reading too much into the motion, but I just wanted to get that clarified. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. I'll add on to that, Robin. I think, you know, they're submitting a proposal that then the green mountain care board would review. So this is, you know, there's another bite at this apple to see whether the proposal makes sense. Um, In a few months, giving them some time to think about it and work with DMH to come up with the best possible plan. The one piece that I'd like to add to that is. We consider the enforcement mechanism. It's a long history in our state. And Donahue was a good example, but there was a request for proposals. We received only one. Without an enforcement mechanism. No organization has chosen to build something. That they consider. Not profitable. But I think that's a shame in healthcare, but that's what are the past several years. More than several past years have shown. Unless there's a way to compel. I worry that it won't be done. I also think this is why I like the fact that DMH is so heavily involved in this planning is because to the degree that. The sum of the reimbursements are coming out of. AHS and so how do those reimbursements meet the expenses to. Mount an inpatient system. That can be in the considerations if they're working together. Exactly. So if we. Voted on this motion approved this motion, would we then. Have another opportunity to vote on the plan. Would we have to approve the plan? Or is it just that the plan is presented to us? I will let Russ clean up in case I botched this, but my vision would be, it would be an informational filing where we would. Understand the plan use of the funds. My hunch is that it will not be limited to this 18 million. They probably will have a more comprehensive plan. So I think it's going to my again shooting from the hip. Guess it might be hard to disaggregate that specific portion of it, but I'm sure we can figure that all out as we go along. But what do you think, Russ? Thanks. I agree with you, Sarah. I had not. And I suppose it's a question for the board, but I hadn't envisioned it as a board approval of the plan. The. Thinking behind making the requirement that it be done in consultation with DMH. Was that. DMH has, I think the best. Kind of holistic statewide. View. Of. Programs and perhaps the most. Effective. Use of the funds. And so it was to get. DMH's collaboration in. In. Developing the proposal for the plan. That we had that part of the requirement. In terms of board approval, I would see it along the same lines as the existing. FY 2017 motion, which. Enforcement action, rather, which was. That. University of Health Network. University of Vermont Health Network came into the board. Provided updates. Kept the board apprised of progress. But it wasn't before the board is approving a specific. Project. Kind of within the scope. I mean, to the extent. A use of funds implicates certificate of need, then yeah, it. Could become something before the board for approval. But within the scope of this enforcement action. It was an informational submission. So in effect, that means in my right that if we approve this motion, our ability to require one particular. Approach as opposed to another would be. Gone at that point. Is that a fair understanding? It's a fair understanding. I would raise the question of whether. The board's ability to dictate one approach or another. Was there in the first place? Okay. One question on the side to get back to this, but. I want to make sure I understand on the interest. The notion that it's countervailing. Isn't it only countervailing if the interest is applied. I mean, they don't cancel each other out if one of them isn't included. Right. So. I think it's a different. I think it's the difference between whether you're trying to measure kind of the current value of the funds or if you're trying to. Spend the same amount of money in 2023 as you were in, in 18. So I think they're just different answers to similar questions. Right. I mean, the point I'm making is $18 million that was in there. 21 million, whatever it is in 2017 is worth. 20% less today buys 20% less today. And the $18 million in absolute dollars that UVM had, or the 21 is worth more than that. And in reality in the bank account today. Why don't we turn unless there's other board comment or discussion, which is perfectly fine. Wouldn't mind hearing from the public advocate. I'm sorry, the healthcare advocate and the public on this. Unless Robin, do you have something else? I'm happy to. Here from the here from the healthcare advocate. I may be interested in moving to go into executive session to get more detail about rest. What rest just said, which I think would be attorney client privileged advice. Okay, let's go to the healthcare advocate. Thanks so much, chair Foster. A lot of thoughts on this one. So I'll try to be cogent. I think this is a case where there's holding a lot of difficult truths at the same time. I do think that this. The issue of mental health in the state goes beyond the amount of money that we're talking about here. With that said, and at the risk of belaboring the point that I made last last time, I do think and I would make this argument regardless of the level of public comment that was submitted. But I do think for the sake of public accountability that this motion really does need community input. I do think there needs to be a number of community members to participate in this process. And I think the quality and quantity of. Comments that were submitted on this issue strengthens the case for that. So I do want to reiterate that point. And some of the comments that were made earlier by board members, I do think. There needs to be pretty clear follow up and metrics and guard rails for how this would be implemented. And what the consultation would look like. What the proposal would be and I do think it's important to point out that the board still has a lot of opportunity to do that. I just want to kind of put on your radar that it could be done at this stage or later on. To kind of put some of those metrics, like for example, weighing. Mental health need above profitability in an analysis and for a proposal per se. Not suggesting that specifically, but like these are things that one needs to consider putting into a motion. To have a more clear analysis and roadmap for what this consultation looks like. So I think it's a little bit vague at the moment. So just a couple of thoughts to leave with you. Eric, I know you're also on from our office. I don't know if you want to add anything to that. Sure. I'm just three quick points is. One, I would have to agree with board member Walsh that. The crisis extends that we're always going to need in patient beds that even if we focus on upstream effects. Some people will still be in crisis. And whether as representative Donnie who has talked about her experience to. And I think that's I take her lead and speaking openly about mental health issues or my experience like. No amount of upstream mediation or projects will. Eliviate the need for intensive outpatient or inpatient care in many circumstances. I think this is a very important issue and it would be something, although not specifically related to this motion that I think the board should make a commitment to actively holding hearings on and learning about this topic. I think it's. It is critical that the board focus on this to show their solidarity really with. Patients in an already highly stigmatized. Moda like a population that's already highly stigmatized. Regarding this motion I do want to point out that. There's a huge amount of wiggle room in the language in the motion of in consultation with DMH. Who knows what in consultation means. The board is not going to be able to have a second look at this if it's an informational presentation. In consultation could mean DMH is actively involved in signs off or the UVMMC only has one meeting and ignores DMH's advice. Of course I doubt UVMMC would ever do that. But I think this type of motion deserves to should be clearer about exactly what is expected of UVMMC so that the parties understand their responsibilities. I would just say as you're looking towards. You know the legal authority of the board to guarantee a specific project. One to think about whether this modification creates new opportunities to consider whether or not the board has exercised its full power in the past and what authority it actually has regarding enforcement is something that I think the board members should look at and in the past in my opinion the board has taken an exceedingly conservative stance to the detriment of Vermonters. Thank you so much. Thank you very much. Both of you I appreciate those comments. Okay at this time I'll turn it over to public comment. Please use the raise your hand function and I'll call on you in the order in which I see hands raised. Walter I saw you appear there. Okay. All right. How are you? Do you have a comment Walter? I'm not too bad. Having fun huh. Tom Walsh pretty much said what I wanted to say about this whole process and so I won't reiterate it. He's right and if you want to expand it he's even more right about the entire system. As I was listening to the Springfield debate I kept wondering what the difference was between a hospital and a manufacturing plant and as a patient I can remember feeling like I was on an industrial assembly line and I think with the mental health issue Tom is right here again. I've been working with a neighbor who has mental health issues I'm not versed in it I'm just beginning to learn this and sometimes navigating this is just absurd. Thanks to Tom and today for his comments on being on the front lines. Great. Thank you very much Walter for your comment. Any others? I'm sorry my team's just crashed I'm sorry if I missed an inquiry. No. I don't know when you crashed but nothing was directed to you. All right I see no other public comment at this time. I think in light of Tom's comment and the healthcare advocates comment I would like to actually hold off on the motion itself I thought those were some good suggestions and I personally would like a little bit more time to think about this because it is really critically important. So I hope the other board members don't have a concern with that but I would like to hold off on this just to give it a little more consideration. Sure. I'm sorry to interrupt but if I may be so bold as you do that consider those things I encourage you to think about things that we can do with the hands that dealt us in this current situation versus you know changes we want to make to our regulatory model particularly related to management so it's just helpful to me in the different hats I'm wearing to kind of think about it in those ways. Thanks. Yeah one of the things that I got stuck on was actually the healthcare advocate comment about the space and what does it mean in consultation and I just wanted to think about that a little bit more because I thought it was a good point. Okay. We will turn to Mike Barber and Lewis and Ellis on the cost share reduction draft policy. Thank you for the record. My name is Michael Barber general counsel at the board and I'm joined today by our contracted actuaries at Lewis and Ellis and we're here to talk with you about possibly adopting a policy related to rate review. Specifically it has to do with the pricing of plans offered to individuals through Vermont Health Connect and I'll try to briefly introduce the topic but then I'm going to turn things over to Lewis and Ellis who will go over the specifics. So the draft policy we are presenting for your consideration grew out of a proposal from the office of the health care advocate or HCA about a year ago they sent a letter to Kevin Mullen then share the board asking the board to pursue a policy of premium alignment for on exchange plans. They made the case that such a policy would make richer plans with lower cost sharing more affordable and they pointed to New Mexico as a state that had implemented a policy like that. Melanie will go over this in more detail but the idea behind the HCA's proposal was that the affordable care act allows premiums to vary based on differences in the plans like differences in their actuarial value but not differences in the people who are expected to enroll in the plans and some have argued that the way insurers are currently pricing their silver plans doesn't fully reflect their actuarial value and is based in part on the characteristics of the people who are expected to enroll in those plans. So after we got the letter from the HCA we met with them to talk about it. Basically we told them that there wasn't enough time to do anything for the 2023 plan year but that we would look into it for the 2024 plan year and we did. The proposal was discussed by a working group that was organized to make recommendations on the structure of the individual and small group markets. People seemed generally supportive of the idea at the time or at least not opposed to it. However in September of last year the American Academy of Actuaries took a position on the topic that changed things a bit and suggested exercising a bit of caution here. And I think Melanie will touch on it but the Academy's position was basically supportive of the status quo and it odds with kind of a premium alignment policy like the HCA had suggested. Nevertheless at the staff level we asked for help from Lewis and Ellis to draft a policy that would implement some form of premium alignment. We sent that to stakeholders for comment based on some of the comments we received we scaled the policy back a little bit and that's what we're presenting you with today is this revised policy to see kind of if it's something you're interested in pursuing. So with that I will turn it over to Jackie or Kevin. Yes hi it's going to be me today for the most part. Okay so can you all see my slide deck and when it looks like okay wonderful. Okay so hello everyone my name is Jackie Lee I am a vice president and principal at Lewis and Ellis and I've been working with the board for many years now. Thank you for that overview Mike so I'm going to kick it off with our presentation and we want to discuss kind of what's been happening then discuss the proposal and advise on the updates that we're recommending for 2024. A couple of caveats we don't have too many numbers in here but the numbers we are we have been collecting information from the carriers we try to make them as accurate as possible but I want to make sure everyone understands that as we move into 2024 we can't anticipate exactly what's going to happen with this guidance because there will be various assumptions that we did not take into account such as shifting an enrollment due to this policy so this is generally based on status quo to give an illustrative understanding to you all but not necessarily going to be what actually happens. Okay so CSRs are cost sharing reductions here's a little history. There are plans that the ACA put forth that reduced cost sharing to silver plans for individuals who had certain income levels. The lower your income the more cost sharing reduction benefits you saw and there are several there are several of these plans that kind of stare step up to what is similar to a platinum plan. These plans are still in existence. How they worked was the carrier would charge the exact same premium for these plans regardless of the benefits offered and then the shortfall between the benefits that the consumer did not have to pay due to the reductions in their plan was paid for by the federal government until 2018 at which time that burden fell to the insurers. This entered what's now known as silver loading. So what is happening here is where carriers will estimate the amount of money they thought they should be receiving and they would load it to the silver plans at least in most states which includes yours. So the on exchange silver plans have an additional load to cover these amounts. As Mike indicated the American Academy of Actuaries came out with some commentary in September. We had conversations with both carriers that are participating in the marketplace to understand how they are calculating it. So the middle section is how they are doing it and it is very similar to what the American Academy of Actuaries listed as a possible method of calculation. And that is they are trying to estimate with their experience what exactly would have been funded by the federal government and taking that and turning it into a load for premiums. The final bullet point is a little bit about what the Affordable Care Act allows for. So most people because CSR loading was not a thing when the ACA was written, most people have categorized it under a plan level adjustment to the index rate. Pardon me, this has several but not very many allowable adjustments and the most relevant one is called the actual value and cost sharing design of the plan which we will reference as part of this is the focus of the guidance that we are recommending. So there are several factors that influence. One is the distribution of similar members in each of the variant plans which is representative of their income. The more that you have that are in a 94 CSR plan means that there are more people who have platinum type benefits. So that could in some ways lead to a higher need for money because they have the highest reduction in their cost sharing. There are assumptions about induced utilization. Again, there is an HHS formula that has been utilized very heavily by the current carriers that basically says the more there is more utilization when your benefit cost sharing is reduced. And then there are plan design considerations which plans you are in and then the calculation method. We have already mentioned that the carriers calculation method and when we talk more about the proposed guidance we will talk about what another calculation method is. So just to dive into the historical CSR loads. So in 2018 there were no CSR loads. That's why they are all zero. Then in 2019 they came into effect. Blue Cross has remained relatively stable but MVP has seen a large decline in their CSR load up through plan year 2023. And to give some context on what does this mean. So this is reducing, this load is reducing silver premiums which in general sounds like a good thing except for you need to recall that the advanced premium tax credits are based on the second most silver. So if, here's an example, family silver premiums are about $28,000 a year for 2023. For every 1% load that's $280 of annual subsidies. So seeing a load go from 1.1 to 1.15 is about $1,400 per family more that they could be receiving. So this goes back to the original request of the HCA that if you're not, if you have a higher load then you will have more subsidies which could make premiums more affordable for people who qualify. Okay, so let's move to a quick discussion of what this looks like without CSR loading, what the current method is and then what our proposed guidance is. So for a typical standard silver base plan it's supposed to be an actual value of 70% meaning that the carrier pays 70% of costs while the consumer would pay 30% of the costs. Now in the current situation with CSRs the carrier is still paying the 70% but there's a load to the premiums that is needed to cover the 7% that would have been funded by the federal government and is now still kind of being funded by the federal government through the premium tax credits. And then also because we're reflecting the costs that's how much that the benefits are being reduced as quantified by the carriers today and then there's a 23% amount that goes out of pocket for the consumer. Our proposed guidance states that rather than we talked about the carrier method where they want to match roughly dollar for dollar what the federal government would have been paid but to reflect the same methodology that they're using for their current benefits for other metal tiers rather than having the special methodology where they do this double adjudication method and looks solely to the actual values of the plans as people are enrolled. This increases that load and again this is a little bit illustrative but roughly 3 percentage points to 10%. This would increase the silver costs to reflect that difference but it would also this increased costs they would want to stay revenue neutral across their entire book of business so it would result in lesser premium for other metal tiers. So that was another point that the HCA made as well. So one of the concerns about increasing costs, increasing the silver plan load is that now silver plans are more expensive. I'd like to note that there are off exchange silver plans so if you do not qualify or need premium assistance or cross-sharing reduction assistance there are reflective plans that do not carry this load so you could easily go off exchange. We grabbed this information from Diva. So it's fairly accurate but we don't have the exact amount of money for this but just to put in perspective the people who are hurt by this plan or the people who are paying full price out of their own pockets for the on exchange silver plan everybody else is benefitting in some way. There are people who should not be making this purchase but there are 3% of your population that are in fact making a decision to pay. So I think that technically should be zero because they should just be purchasing an off exchange plan for less money. So to give some perspective on the amount of people who are negatively impacted by this particular draft guidance. And that is what I have prepared today. I know it's a lot but we wanted to, you know, I know that you guys have been briefed and have been briefed as the board but I'm happy to answer any questions or turn it back to Mike to facilitate in case he wants to add anything that I missed. I don't have anything to add but I'm happy to help with questions or kind of explain more of the background here if you guys have questions. Thank you both. We can just turn to board comment or questions. This is Tom. I have a couple of questions. Thanks for the presentation. It's technical and difficult to understand, right? And there's a strange thing where premiums go up which sounds bad but cost sharing rises which is good and allows people purchasing plans to purchase a better plan. And so that's the reason that we're interested in doing this. In the September, the Academy coming out and saying that the method for doing this was not actuarially sound struck me. And so I tried to learn more about that. And I just want to make sure that I've understood it. If I could run it by you guys. I think that their method is to utilize the experience, the care experience of the people enrolled in the second lowest silver plan. That's called an experience rating as opposed to a community based rating. In the past, in Vermont we've chosen a community to use community basing because it seems more fair. Because if we use experience, we can use things like gender. And we know women particularly of childbearing years tend to be more expensive health care wise. So their premiums would go up if we only used experience. Or if we use age as an experience, then as people got older they'd have higher premiums because of that experience. Or maybe one of the most socially disturbing ones was when we used to, before the ACA, use medical history experience to make our actuarial models better. We would say, well, you've had cancer twice. Your risk of getting it again is so high we won't ensure you. And so what we're proposing to do, what the HCA is proposed to do, is that we don't use that approach. We use more of a community approach. Look at everybody that's enrolled in these plans. Now, that's less actuarially sound. Because if we put in age and gender and past medical history, we could get a better mathematical model. But as a society, we may choose a less precise model because it's more socially fair. And that's what we're trying to do here. And so I just, I wanted to talk through that out loud. It's hard doing it in public, because now you can tell me that I'm completely wrong. But I wanted to take that opportunity to try. And so if you just let me know, did I, did I. Yeah, you did a wonderful job. I have a couple of modifications. You said using the second low silver, they are using all silver members that are enrolled in CSR plans. So it is any variant. So they're using everybody, but yes, that's correct. I would also modify that it is, it is actually sound to do it the way we are proposing it. It is just not as pinpointed to the characteristics of those folks. It is still sound and a way to do it. It is, you know, to your point, we can't basically say, oh, because you are in this group, we're going to charge you more because you happen to be in this cohort of people. So it is, it's less targeted as you've noted. And your examples were very good. I will add one point that I don't think you. So the one reason I think why the Academy letter says that this proposal might be less actually really sound is the sort of subsidization issue that you're talking about right where your community rate to support people between each other. The other concern raised by the Academy letter is that under the status quo within Vermont, silver premiums are increased by a dollar amount that matches the subsidy that the feds withdrew. So I don't know the number offhand but say it was going to be $10 million. Right now the silver loads are equal to $10 million. The Academy letter voiced a concern that proposals like this or others would increase the silver loads to be equal to a dollar value that would exceed that $10 million, which again is just a made up number. I don't know what offhand. And thus that the increase to the silver premium is unsound not for discriminatory reasons or non-discriminatory reasons, but because the cause of the load is a smaller total value than the response to it, then the load itself. I just want to make clear that's, I think the key point made by the Academy letter and that is effectively just intention with the community rating type rules that the ACA has in place. So those are two competing principles at play here. Thanks. And a little to help me historically, what was the Academy's position on the removal of medical history experience? Did that decrease how actually sound models were? No. I mean, I don't know that they came out with a formal position, but there is plenty of guidance on, and what you're talking about is, you know, the development of the index rate kind of to get technical. And there was concern that you would have to guarantee issue anybody who offered coverage, but not that you couldn't rate for it. You just couldn't rate people differently based on whatever medical history they came forward with. Right. So we're digging into the weeds and I'd love to keep doing it, but we're going to lose a lot of people. My point is that actuaries talking about actuarially soundness for an insurance company, I mean, it's better for the insurance company. And so using a community approach to this would increase subsidies as you're talking about and as Mike is proposing, which is better for people. There's a little bit more risk for the insurance company. The model, the math model is a little less sound, a little less predictive, but I'm not worried about that. So thanks. Any other board questions or comment? This day, I just want to thank Kevin and Jackie for very helpful preview of this rule to help me help help walk me through this, this complexity and I also multiple other papers that Kevin sent along to me to, to read help me understand this. I don't think I would have really been able to grasp this but I think so. But so thank you. Thanks for your attention. I know this, this took our team a long time to understand. So I, it's complex and complicated. So thank you for all of your attention. I share that thanks and Mike too, because you guys sat with me a number of times and I appreciated it and to the healthcare advocate for having raised this. Seeing no other board questions or comment, I will turn to the healthcare advocate. So just a few preliminary things. One, thank you. Mr. Barber for following up on this letter and it was a, it's a during a period of a lot of flux and to keep carrying forward with this ball. We is greatly appreciated. Jackie and Kevin, I always find your memos very helpful and I feel like I'm just smart enough to know that, oh my God, I do not understand what goes behind it all. So thank you for the overview. It stresses me out that I can't reproduce any of it, but that's because I'm not trained for folks who are similarly sometimes confused by actuarial details. There are two recent articles in health affairs for front block. It's not behind a pay wall showing the different positions. So there's a article by Donna Novak at all, which lays out kind of similar to the society of actuaries position in an article by Stan Dorn at all in response. You may know Stan from his work with family USA, which he's since left. I think some of you may know Donna, but this was before my time when she was an expert witness in great review for us. So I think that's looking at those two articles gives you kind of a good sense of both sides of the argument. Obviously we support silver premium alignment. When this came out, we did not know when we sent this letter, we did not know how 2023 rates would sugar out. The impact of silver alignment would have been greater given relative cost differences. But at the same time, it's still a net benefit given the current situation to consumers in our opinion. And there's no guarantee that we won't see that pricing difference in the future. So having a difference in prices that would mean this would have a big impact. And yeah, it's unclear what's happening, at least to me in terms of pricing these days. I think, you know, if you want to see a spectrum of the details, you can look at New Mexico and then Texas and then probably PA and then Colorado. We would support New Mexico's approach of actually having setting a utilization or a load factor so that there is less opportunity for gamesmanship between carriers. But that looking at those four states, that is kind of a range of options of how this gets implemented from the state setting it to basically the Colorado approach, which is let every carrier do as it will and implement this policy, how it sees fit. We would be, we're for the New Mexico approach as we believe it would best benefit consumers, be the most transparent and minimize gamesmanship amongst the carriers. Thank you. Thank you. And I'll open it up to public comment. Okay. Hearing none. I think we are concluded on this topic. And thank you, Miss Lee and Mr. Ruggerberg for your presentations and help with us on this issue. Is there any old business to come before the board? Any new business. And I will move to adjourn. Back in. All those in favor. Hi. Hi. Hi. The motion carries and the meeting is adjourned. Have a nice afternoon.