 Okay, then it looks like we have everyone. It's 901 and I'll call to order the Green Mountain Care Board hearing of September 15th. 2023 we have 4 hospitals left and a fairly compressed time schedule. It'll be CVMC and Porter will bring back Dr. Merman and then we'll finish up. I'll turn it over to Director Lindbergh for the presentation. Okay, thank you. Are you able to see the slide and hear me? All right. Okay, great. So we won't spend much time with the setup, but you've heard it from me before. But just as a reminder, the process we're using for deliberations in fiscal year 24 is a first pass where we determine whether or not the NPR and FPP growth from fiscal year 22 actuals to fiscal year 24 budgets was below the all-payer model growth of 8.6% or less. If not, we evaluate the factors that we've discussed here and try to weigh those in determining how to establish a budget for fiscal year 24. So I will switch over to our summary for CVMC, Central Vermont Medical Center. All right. So starting at the top, we see that Central Vermont Medical Center's NPR has been adjusted or was adjusted in fiscal years 21 and 22. And there had been some rate changes in pretty much every year along the way since fiscal year 18. Their operating expense growth has generally been unadjusted on budgets. And we see that there is reliance on the commercial rate in recent years between 2 to 4% annually. And as submitted, the kind of weighted commercial approved increase would be 8.2%. We see that they have a pretty low proportion of commercial payers in their payer mix for a hospital of their size in particular. And again, we see that trend where fiscal year 2020 operating results were very challenging for most hospitals. As far as expense growth factors, the per FTE labor increase is at 4.1%, which was the eighth highest among Vermont hospitals. Utilization at 8%, which was ninth highest. Again, that's one that even though it's twice the upper end of the benchmark is not necessarily something that I would view as a bad thing. With the access issues we have, it's encouraging to see those kind of numbers that have been achievable. These are actual results and they're trying to continue those. Pharmaceutical expenses are within the benchmark at 7.6%. At fourth highest, that's probably due to the pharmaceutical mix of drugs being delivered more than anything else. And at cost inflation at five, 3.7% was fifth highest and right at the median among Vermont hospitals. As far as the year-to-date results is compared to the budget, you can see that the year-to-date is at negative 2.6% margin versus 1% margin and the operating a bit of margin at zero instead of four, which was budgeted. So those are certainly improvements from the fiscal year 22 actuals, but I'm still showing a long way to go in terms of recovery for this hospital. We see that the ratio of administrative and general salaries, which we adjusted for the University of Vermont Network Hospitals, was adjusted upward from 20.8% in the cost reports as initially reviewed to 30.9% to account for their share of the shared services in the University of Vermont Health Network. That ratio is 12th highest among Vermont hospitals and in the 96th percentile among its comparators. The CMI adjusted cost per Medicare discharge at just over $12,000 is right in the middle among Vermont hospitals and was at the 83rd percentile among the comparator group. And as far as the relative cost and pricing goes for inpatient, we see quite a low commercial cost coverage on the inpatient side. So seeing those values below 100% means that the Medicare allowable cost is not being covered by commercial payers. And we see that their standardized price for inpatient services is within the intercortile range. As far as outpatient goes, we see more substantial cost coverage north of... Dr. Lindberg, I think you frozen back. I can't hear you anymore. Is anyone else having that issue? Yes. Oh, and I am. She's in this chair posture. She's in the state office at National Life. So let me see what's happening with the internet over there. Hey, wouldn't be a last day without some technical difficulties. Just a moment while I try to... No internet, interesting. I was trying to freeze you so you could not leave us. I'm going to try a different internet source. If that helps, appreciate your patience. Locianto. I think we're good now. All right. So let me bring that back up. Sorry. The internet just stopped working. I don't know. I didn't. Sorry. This probably isn't the time or place, but I was reminded that my first day of work for the state of Vermont, there was an earthquake. So just be careful. So anyway, on the outpatient side, seeing more favorable cost coverage, but still relatively lower on the lower side towards that 25th percentile among peers and seeing that the standardized price there is within the intercortile range as well. So any questions about this summary before we move on to the PowerPoint presentation? Okay, great. Our folks seeing Central Vermont Medical Center budget request in front of their eyes. Wonderful. So we see that the approved budget in fiscal year 23 was a 12 percent growth rate in NPR, and they submitted another 15 percent growth rate for a two-year rate of growth of 21.4 percent. The change in charge over that time period was 10 percent approved in 23. Another 10 percent requested for 24 for 20 percent over the two years. But when we look at the change in commercial effective rate, the rate approved in 23 was 12.5 percent, and the request for fiscal year 24 was 10.9 percent for a two-year rate of 23.45 percent. If we were going to hold that growth to seven years, seven percent over two years, we would need to adjust NPR down by almost 11 percent, which would be done through a charge decrease of three percent and a commercial effective rate of negative 5.5 percent. If we were to constrain growth to inflation from fiscal year 23 projection to the fiscal 24 budget, you would see a 15.6 percent growth rate over the two years. So a little bit more balance across the two years in this request, but that still would involve a, you know, six percent downward adjustment to NPR. Reviewing a performance summary for Central Vermont Medical Center, expense growth was right at the median from fiscal year 22 to 24 at 8.3 percent, notably below that all-pair model growth rate of 8.6 percent. But we just discussed some of these numbers related to the proportion of administrative and general salaries to clinical salaries, which was at the 96 percentile after making the adjustment and the cost per adjusted, the CMI adjusted cost per Medicare discharge was in the 83 percentile, seeing much lower relative standard price for inpatient and right at the median for outpatient. And when we look at the longer-term change in charge over the five years at 37 percent, that's the highest amount in that time period, or I'm sorry, the lowest amount of increase in that time period. And we see that the 10-year amount is in the 23 percentile. So again, just of note that this hospital is behind its budget for fiscal year 23. So we see that that's largely being driven by less NPR and FPP than was in the budget, so that negative 2.6 percent operating margin and relatively low days cash on hand are both signs of concern from a fiscal stability standpoint. And reminding us of an analysis that was shared last week. So part of the benchmarks that were shared about how other hospitals deal with these shared services came from a company called Syntellus. And if you were going to kind of allocate Vermont's share for each of its hospitals of those shared services and compare that to the median amount of expense you would expect, the opportunity, potential opportunity for some considering some opportunities for shared, reducing those shared expenses is 14.41 million for CVMC. So the staff recommendation would be to modify the budget as follows. I would recommend adjusting the NPR and FPP growth down to 14.4 from 21.4. That's just accommodating the kind of rebasing based on the current margin to get that two-year growth more in line with where it looks like 23 is landing. And then adjust the charge down from 10 percent to 5 percent. Also, additional condition for monthly reporting submitted within three months with that improvement plan. Our rationale, again, is that operating results are about 6 percent under budget. In the case of CVMC expense growth, standardized prices are at or below the median. And, you know, we do see some of these opportunities to potentially increase efficiency across the UVM Health Network. So that'll turn it back to you, Chair Foster. Thank you. I'll open it up to my fellow board members for any questions or comments. And maybe it makes sense to just go in the same order as we did last time, which I think it was lunch, member Walsh, member Holmes, and myself. Sounds good. Thank you, Sarah, for the presentation. I am supportive of the staff recommendation. I think the downward adjustment to NPR is important, so we're not setting the hospital up for a negative margin just given where they are coming in in 23 compared to their budget. So I think that still gives plenty of room to increase access. So I'm supportive of that. And that's about all I have to say. Thanks. Thank you, Sarah, for the presentation. I'm in agreement with the decrease in NPR. I'm concerned about the 5% increase in charge. I'm not quite ready to go with that. I'm concerned about the high admin ratio and the rapidly and the high costs and rapidly rising prices. And they're part of a network that's the network's year-to-date performance has been much greater than expected. It has the ability to generate additional revenue with its CMI initiative. And there's huge potential for savings from the shared resources. Here we see no demonstrated savings from shared resources. The administrative to clinician ratio is very high here. And they're part of an interdependent network. And I think that that's an important thing to consider. These three hospitals have the ability to help each other out. They are interdependent. That's why member Merman was asked to recuse or abstain. So I could be comfortable with 3.1 for the charge increase, but I'm not comfortable with 5. So thank you again, Dr. Lindberg, for your presentation and your thoughtful analysis here. This is a hospital that struggles year after year to make a margin despite having relatively higher growth rates in their commercial rate over the past few years. So I think continuing to increase rate at more than double inflation is not likely to be the path to sustainability here. I didn't find enough information in the submission to support a commercial rate growth of 23.5 percent over two years. And I think part of that is the network's decision to submit a network narrative rather than a full narrative for each hospital. So next year, I'm hoping to see a separate narrative for each hospital. So we have really more in-depth information on what's happening at both Porter and CBMC. I will say that I support the staff recommendation for a change in charge increase of 5 percent. This exceeds CBMC's own estimate of cost inflation. It should provide a glide path for this struggling hospital. While I think the hope is that there's greater network efficiencies and admin savings are realized at the network level to earlier points there, I worry about the day's cash on hand at this particular hospital. So I am okay and comfortable with a 5 percent change in charge here. Given the tendency to overestimate NPR and underperform on the budget, I think the downward adjustment to NPR is reasonable. So I support that and I support the additional condition about adding an implementation plan to reduce costs and reduce that admin. So I support the motion as we see it. Thank you. I don't have much to add. I'll incorporate some of my comments from the medical center because I think some of those comments are relevant here. I am concerned about the need to support this hospital. I'm worried about the low day's cash on hand. And my view is there is a balance and sustainability in supporting our hospitals and affordability. And that's often a hard balance, but I do support the higher charge increase. So I support the motion and the staff recommendation at 14.4 and 5.0 so that the hospital has the resources it needs. I agree with member Holmes' comments about providing the support needed so that the hopes of some of the savings can happen. It doesn't happen overnight. So I do support the higher charge increase. I have nothing else, although I will say that I agree with member Holmes that perhaps a separate narrative submission would be beneficial so that CBNC has more opportunity to share their views. I will open it up to go to the healthcare advocate first if they have any comments. Thank you, Mr. Chair. I have very much the same comment you've heard me give all year. We stand by our written comments, which significantly includes linking growth rate to a standard like NPR. And that's our comment for CBNC and also FYI, that's our comment for the remaining three hospitals today. So if we have something additional, say I'll raise my hand. Thank you. Great. Thank you. And I'll open it up to public comment via the raise your hand function. Ms. Sarah Davies. Thank you. Good morning. I am Sarah Davies. I'm a family physician and I'm the medical director of primary care at Central Vermont Medical Center. I oversee eight practices with over 62 clinicians in the Central Vermont community and caring for about 50,000 patients within that. I am a family physician and I passionately believe that the key to excellent patient care, excellent patient outcomes and reduction of healthcare spending comes with a strong relationship with a physician or APP at the primary care level. So I did just want to highlight the very vital importance of supporting and putting an investment into those services through our healthcare system. You know, what does that mean? What do resources look like? Pardon me, resources in our primary care setting to help with this work include nurse managers, resource coordinators, dieticians, pharmacists, you know, medical systems, LNAs and nurses, and also the primary care mental health resources that Dr. Pulaski spoke about on Wednesday in her comments as well. All work we're doing in our medical home. I just wanted to give a little example about what this actually looks like on a day-to-day, how a well-resourced physician can care for a patient versus not. And so a physician, let's say about 1200 patients on her panel, a pretty average number of our patient panels, her office gets a phone call from a concerned daughter. The daughter thinks her dad's losing weight, shouldn't drive anymore, and then a neighbor recently told her that he was found wandering around and confused. So in a well-resourced office, a nurse manager was able to go do a home visit, was able to do a memory test and see that there was some moderate dementia. Also noticed there was only crackers and expired soup cans in the cupboard and then the house was in disarray and also did notice there were a few dents on the car bumper. So what did she do from there? She connected with a resource coordinator that helped to get someone to help with groceries, someone to help in the home to care for and clean, provide some activity of daily living to help them keep clean and be cared for. The nurse manager also reached out to the daughter to have some conversations about those difficult discussions about how long can this patient remain in the home, those discussions about driving, the advanced care planning discussions were started at that point by the nurse manager. The resource coordinator also connected him to a senior day program, excuse me, which provides an opportunity to do woodworking, which is something that her dad is passionate about and also arranged for transport there since they were working to have him not drive anymore due to safety. So the primary care physician at the follow up has all these things already in place and is able to have that meaningful conversation with some of that groundwork laid and really discuss then the potential causes of dementia. So doing that work that the primary care physician is trained to do as a medical professional and then also review that advanced care planning, which is so important. It is interesting that memory clinic has over a year wait. So this all falls on the primary care office. The other version of that story is that the primary care physician had a full day clinic, had over 200 patient messages in the inbox and didn't get to it until she was documenting at 9 p.m. the next night, you know, after the kids went to bed, sees it, you know, calls and has the nurse, can you follow this patient? The nurse was busy rooming patients administering the musicians, trying to, you know, waiting on hold for a prior authorization for a diabetic med that another patient vitally needed. And so at the end of the day, the office actually received a notification then that the patient was in the emergency room. He had gotten into a fender bender and hit his head and didn't remember what happened. So, you know, that's that's this happens every day. And this is the work that I think it's very important that we are supporting in our primary care world and investing in in our primary care world. So, you know, each each of us as a primary care physician or clinician goes into it with a commitment and passion to provide excellent health care and comprehensive care for the entire patient. But almost inevitably, we find ourselves in a position with the lack of resources to do this work sustainably. And that compounds the physician burnout and the challenges to patient access. So again, thank you for the opportunity to comment and highlight the importance of investing in our primary care health networks as a way of investing in the health of our community and the health of our primary care workforce. Thank you, Ms. Davies. And I'll just echo those comments and the care board's view of the importance of primary care. We've had, I think, three or four hearings now and really deep dive into what can be done to really support primary care. So I'm glad that you spoke up because I share those views and I worry quite a bit about our dwindling number and the burnout on our primary care providers. So I appreciate that. And we may be in touch. This is something that we're focusing on ongoing. So thank you. Mr. Vincent? Good morning. Just two comments to make this morning. So one is the same as the comment that I made on Wednesday related to the administrative costs compared to clinical salaries costs, just to highlight again in this presentation, the adjusted calculation that we submitted just to highlight the issue that comparison is being used in this presentation. Yet the benchmark data still is based on the data, the way that is submitted to the benchmark agency. So just as an example, we did provide a couple of examples where if you adjusted these for all of the organizations, how different the numbers look. We took a look at Southern Main Healthcare where in the benchmark data, the administrative salaries to clinical salaries is at 5.9 percent. But if you do the same normalization that we've done and provided to the Green Mountain Care Board to create a true apples to apples comparison, that number would be 34 percent. So just to give an example of our data and the calculation that we supplied is being compared to a benchmark that is being calculated in a very different way. The second point is just about administrative shared services on Wednesday. The point was made that we're at a median from a network perspective, but the focus has shifted to specific areas that have opportunities. I just want to highlight that those areas, there are reasons why we might want to make more investment in a particular shared service than another revenue cycle. For example, if there's more investment there, because we believe that there's a payoff at the end of the day, that we have a more efficient revenue cycle operation. So the fact that we're using specific areas rather than looking at shared services in totality, I just wanted to highlight that for the board as well. So thank you. Thank you. Casey Kolb-Nava. Hi, good morning. Thank you to the board for taking the time to hear my public comment. I'd like to introduce myself. I am a physician of internal medicine. I am the director of hospital medicine at Central Vermont Medical Center. And then I also chair the hospital medicine council for the UVM Health Network, which is essentially the consortium of directors at all of the sites within the network. I wanted to offer some comment to describe a little bit about the CBMC hospital-based team. Tell you some of my observations of healthcare economics from where I sit and advocate for a well-funded hospital system at CBMC as well as the broader UVM Health Network and our partner sites in Vermont. So I want to tell you that at CBMC, I'm part of what I think of as a very effective, efficient, and lean group of clinical workers. That's hospital medicine, my surgical colleagues, my nursing team, case management, and the other supporting staff that really make the world go round at the hospital. And I have to say that we really couldn't do our work without the support of our administrative team at CBMC. I've seen over this past year with transitions and vacancies in our administrative team. I hesitate to use the word chaos, but it really becomes quite an added pressure when we don't have a well-funded or well-staffed administrative team. So that's really just as important for us to be doing our work in the hospital. I will tell you that on the clinical side, we are just as committed to being budget conscious as our administrative partners. And we balance that with providing excellent quality and seeking quality improvements really constantly. I can tell you that in the past year, I've been involved in projects to decrease the length of stay of our inpatients that I think was quite successful. And that's a value that's passed on to Vermonters both financially, as well as in terms of quality of their care. I've been involved in efforts to reduce our pharmaceutical costs in the hospital, to reduce readmissions specifically in our heart failure population, and to improve patient throughput, which if you're not familiar with that term, for hospital medicine often means how quickly a patient who presents to the emergency department who requires inpatient care moves through the emergency department into the hospital and is then located in their inpatient hospital bed, and then sort of extrapolating how long they're still in the hospital. But again, and really looking forward, I see that we will continue to work on you know, not just these areas, but expanding focus to again continue to try to provide as great a value and as high of quality as we can to our patients. And I am incredibly proud to work at CBMC. I think it is an absolutely fantastic institution and we really do quite well for being a rural based community hospital. But unfortunately, CBMC is not a closed system. You know, we are subject to the pressures that are affecting healthcare systems across the country, and you know, these are national and regional pressures related to inflation. And what I see in the hospital is the increasing cost of staff of getting clinical staff into the hospital. Unfortunately, being in rural Vermont, we have a fixed pool of people we can recruit into our frontline nursing workforce in the hospital, as well as our frontline physicians. I can tell you, you know, that I have seen with my own eyes our rising dependency on traveling nursing staff. The pay for them is an absolute premium. You know, I really can't say that if I was in their shoes, I would do anything different. But you know, I've seen our own local nursing staff effectively quit CBMC to move into traveling roles, sometimes circling back to become travelers at CBMC itself. And we pay a premium for that. I can speak to my own costs when I have had in this past year to seek traveling physicians to fill gaps in our coverage. What I used to be, what I used to see in terms of a premium quoted to me would be about a 30% pay raise compared to the base that I would pay the folks working for me employed by CBMC and UVM Health Network. And now I'm seeing across the board pay rates for travelers that are 60 to 100% above what I'm paying the folks employed in my group. And that's, that is baseline. So, you know, where to go to absorb those costs to, you know, to really kind of keep the ship afloat. Unfortunately, you know, I think I will say that CBMC has done an excellent job of standing up programs to locally train, recruit and then retain clinical staff. I think that these programs are putting us in a much better position than we would have been otherwise. I'm excited to see them grow. But I think that we're still in a place where these costs of traveling staff are going to be a part of our life for at least a few more years, possibly longer. So, you know, so what am I concerned about if CBMC doesn't get the budget and rate of approvals passed that they're asking for? I think, you know, I can see in your slide that, you know, you want to see that management is, you know, that there's some reduction in management costs. Well, a lot of these things I kind of see is us looking around for coins between the couch cushions, honestly. What I really worry about is that we're not going to have the funding to continue to staff our hospital with these travelers that have really become a necessary part of our workforce to keep the ship afloat. And then what happens? Well, we have a, then every day we go into work and we have a slightly reduced nursing workforce on the inpatient side. That means that we have to push back patients that are acutely ill presenting to the emergency department. Hospital medicine is called to admit these patients. We totally agree that they need to be hospitalized. They're ill. We write admission orders for them. We want to bring them into a hospital bed to a nurse that is trained to take care of an inpatient. But we have a, you know, a slight staffing shortage. So that patient then boards in the emergency department waiting for a bed to open up at CVMC. Patients, I've seen patients boarding for 12, 18, 24 hours when we get really high census at CVMC. And this would just be compounded. Those patients individually will experience, and this is borne out in research, longer length of stays and increased rates of complications related to their hospital state just by being boarded in the emergency department for prolonged periods. Now, that's not a cost savings to me. And that certainly is not quality. And not just those individuals, but then any other patient that's presenting to the emergency department comes up against that bottleneck. We see longer wait times. We see emergency department staff that are more harried because their census is higher. And this just gets pushed, you know, further and further out. And this is not a problem that I envision being unique to CVMC. CVMC is also completely dependent on UVM Medical Center having functional throughput, meaning that their patients are getting into the hospital, getting beds, you know, akin to a low wait time. Because we oftentimes have patients that need to transfer to that tertiary center for procedures or specialists that a rural community hospital just is simply not going to be able to offer at volume. So, again, you know, even though I think that CVMC is doing a fantastic job, and we're working as hard as we can again to provide value and quality and to make improvements every day, we're simply a mercy of external forces that we have to be responsive to if we're going to continue to provide high quality care to our patients. I think I'll leave it at that. Thank you again so much for the opportunity to make the comment. Thank you very much, Dr. Kulp-Nava. Am I saying the name is Kulp-Nava? Kulp-Deva? No, you got it right. Kulp-Nava. Great. All right. Well, thank you. Dr. Ryan Clouser. Hi. Good morning, Casey. You made a lot of great points. I just wanted to say thank you for allowing me a moment to speak. My name is Ryan Clouser. I am a physician, critical care provider. I've been working in the health network since 2011 as an intensivist at the UDN Medical Center. I've worked for this health network in region, the state of Vermont and upstate New York, as the Care Coordination System Medical Officer for our health network, where I worked as a network coordinator for care for patients within our region that it require transfer among hospitals, whether it's Newport or NDRH or CBMC, trying to coordinate the best place of care for that patient closest to home. In that position, I really got a firsthand view of the thin ice our region is sitting on with regards to the ability to access care, to get care quickly, to even transport a patient from one hospital to another, because we're all working with limited resources and there are so many patients that need critical access to the life-saving therapies that our hospitals in this state and our region can provide. I've also seen firsthand that while we have multiple regional tertiary care partners that we work with, their capacity to take care of people in our region has gone away. That means it's up to us as a state and health network to provide that care, and actually back in April I moved from that position in the network care coordination system through the Chief Medical Officer at Central Vermont Med Center. And one of the reasons I did that is because I've been working with those docs and nurses and administrators for years in my prior roles and knew how special CBMC is and the role it plays in this community, just like all the community hospitals in their local areas, the role they serve their community and how important that is. We have a lot of really special talented people here, nurses, doctors, administrators, cleaners, chefs, cooks. It's a great place to be and it's very important and critical that we continue to be able to offer the services our communities need. As I mentioned, as regional capacity shrinks in our tertiary care centers, it's imperative that our community hospitals become more. We grow and offer the higher level services that our patients can't get in tertiary care beds because of our throughput issues, staffing issues, bed capacity issues, ICU capacity. We need to do everything we can to keep our patients here close to home with the right level of care so that we are not taking up tertiary care beds for people that could stay here. The problem is as we continue to run into financial challenges, our ability to grow and take care of these patients shrinks, and as we aren't able to afford the cost of staff, like Dr. Kulnava mentioned, it's going to mean we're not going to be able to staff beds and patients are going to board an ERs or they're going to wait for hours to transport either Dartmouth or UVM or even further away, which we've seen during the pandemic. So I guess in closing, I'll just say we've gotten important role to play and I understand the board's mission of trying to keep costs down. We just have to do it collaboratively because we do have an important role to play and we want to grow and change and be more for these communities and these patients that we take care of and without financial improvements, we can't do that and I think cost is going to end up going up paradoxically and I think the level of care we provide is going to suffer and the quality of care is going to suffer because we just don't have the resources to provide that much needed care. So thank you for allowing me to speak. Thank you for commenting, Dr. Klauser. I appreciate it. And Anna Noonan. Yes, thank you, Chair Foster. So first of all, I want to thank Drs. Davis, Colbenava and Klauser for adding their remarks to today's hearing process. You're hearing the voices of care providers that every day are dealing with trying to balance the care that we're providing and the service quality we're providing as well as the clinical care at the same time optimizing the value that we're trying to provide to our community. I just want to underscore how challenging these times are. This is my 42nd year in healthcare. I'm a nurse by practice and administrator for over 30 years. Extraordinarily challenging times. The pandemic is just in the rear view mirror and we're grateful that the next round of vaccines are coming out to help us deal with the respiratory season that is we're just about to enter in. I know that the chair and the Green Mountain Care Board members are aware of the devastating flooding that occurred in central Vermont in July. When those floods and the pandemics occur, CVMC and every hospital in the state responds. They respond to support our community. They meet the healthcare needs regardless of the cost. We are here to provide the care that our community needs. It is a balance every day to try to do that and meet the budget guidelines that we have. So I just want to underscore how challenging that is. I'm very grateful to the community that we're serving and the support that we get from them to our clinicians, some of which appear today before you, and the clinicians and support staff that every day are doing the best they can to serve our community here in central Vermont and our colleagues across the state. Central Vermont is a community hospital but I also want to share that we take transfers in from other community hospitals that are near us. So when they're over census, they need higher level of care. Those patients are transferred to CVMC and if in turn are also some of those patients obviously go to UVMMC as our tertiary quaternary care. Again, the first thing that's always top of mind for us is high quality care and high level of service. We also run a nursing home in our system. We do that at a significant loss. We do that because of some of the comments that you heard our provider share which is we're trying to improve the flow of patients through our system here to move them from a higher level of cost to a lower level of cost and to make our residents safe within the nursing home setting which is in turn their home. So again, we have a number of challenges. The primary challenges is workforce. We've talked about this with the board in the past. I know you know of the innovative workforce programs that we've launched here. Thank goodness we started those in 2018 and we've graduated students year after year which is not just helpful to us in meeting the care needs that our community has but it also is a game changer for them and their families. The first cohort we graduated in that program, 60% of those students, they were the first ones in their families to have any kind of post-secondary education. So it was a game changer for them and their families. That's an investment CVMC made despite the fact that we're challenged with hitting our margin year after year. It's still the right investment. Everything we do every day to take care of our community is the right thing for us to do. I just want to again say that regardless of the outcome of today's hearing, we're going to continue to provide the highest quality care we possibly can to the community we serve. We're privileged to be in the position to do that and again regardless of the decision of the Green Mountain Care Board, we're going to strive to continue to meet our mission to be central to our community and to care for our community for their lifetime. Thank you for the opportunity to speak today. Thank you very much Ms. Noonan. From board comments it sounds like there may not be consensus on the higher or lower charge. So I think we probably need a roll call vote. Mr. McCracken. I don't think the motion has been made. Right. I'm sorry. I'll make the motion. I support this. I move to approve the central Vermont Medical Center's budget as modified hereby. The 14.4% increase from fiscal year 22 actual to fiscal year 24 budgeted NPR FPP reduced from 21.4. A 5.0% charge increase from fiscal year 23 to 24 reduced from 10.0. And subject to the standard budget conditions as proved by the board. In an additional condition as CVMC shall submit to the board within three months, a plan addressing CVMC's efforts to reduce cost and control overall expense growth in connection with among other things, information technology, human resources management and revenue cycle management. Further CVMC is required to meet monthly with board staff for monitoring purposes. I'll second. Second. Fair. Additional board discussion. I have one other comment which is this condition to me is sort of more of a network wide condition. Just having it consistent makes sense to me. It's not really I think it makes more sense for it to be just for each of the hospitals since they are submitted one submission. I think it makes more sense to have have a uniform. I miss McCracken if you could take the roll call please. Thank you chair foster. I'll take the roll call in an alphabetical order. Member Holmes. Yes. Member lunch. Yes. Member walsh. No. And chair foster. Yes. The motion is approved. And thank you everyone from CVMC for commenting and for your presentation to us a couple of weeks ago or maybe almost a month ago now. We'll move on next to the Porter Medical Center presentation by Director Lindbergh. Thank you. So here we see the summary of Porter Medical Center. We see that there have not been adjustments to the net revenue patient revenue in the submissions for quite some time. All those few tweaks back in fiscal year 18. There were some adjustments to change in charge however in both fiscal years 21 and 22. And we see here the reliant if you wait the increase in charge by the commercial pair mix. That is a big jump in fiscal year 23 is approved but levels out over the two years. Seeing some operating results persisting in terms of actual to budget and declining revenue in fiscal year 21 and 22 but a significant increase in fiscal year 23 year to date. Expense factors. The compensation per FTE growth is at 1.2 percent which is fifth lowest among Vermont hospitals. Utilization is just above the benchmark at the sixth highest among Vermont hospitals. Pharmaceutical expenses within benchmark are as our cost inflation both at the fifth position in the comparison Vermont hospital group. And when we look at how their budget is performing in fiscal year 23 we see that they are above budget on operating margin operating a bit of margin and total margin. Days cash on hand are still below what is budgeted. However in testimony in the hearing we found out that that the days cash on hand at the hospital level is not maybe not as critical to the network as what that looks like at the network level. So but seeing this above 100 is encouraging probably wouldn't ideally like to see it a bit higher. And when we scroll down to the administrative cost so again we've talked about this we did adjust this but did not adjust all the hospitals with the methodology requested by the UVM Health Network. So one of those situations where it's a tough comparison but when we do apply these adjustment the admin cost ratio goes from 13.6 percent to 29.25 percent which would be the 11th highest among Vermont hospitals and that rank is wrong. I apologize that's reversed. So that would be one minus eight which I don't do math in my head apologies. And it'll be quicker to go to the budget tool it just occurred to me so that we can see what this will be corrected to right now. So that would be yeah at the right near the 75th percentile so apologies for that. And hope that was CVMC golly. Order is going to be up here so the admin to clinical ratio will be yeah probably closer to that 30th percentile so we'll get that fixed up. And then at $12,000 per for CMI adjusted our cost per Medicare discharge that's right in the middle of the pack among Vermont hospitals and 42nd percentile so within the inter-courtile range among critical access hospitals. We see here that the cost coverage is within the inter-courtile range and for both the cost per discharge it as well as the cost coverage and standardized price on the inpatient side on the outpatient side we see that they are near the 25th percentile up until fiscal year 20 where they start to get creeping towards the middle of that range and you're getting near to the 75th percentile in fiscal year 22. However despite that we see actually a decline in cost coverage over that time period so that suggests that there's probably more intensive services being provided in the outpatient setting during this time period. However the standardized price through 2020 was within the inter-courtile range so just might take some time for some of this to catch up to that RAND analysis. So I can move over to the slide deck. Oh do it this way. All right are we seeing the budget request here? Okay great so for Porter the approved increase for the fiscal year 23 MPR budget was 5.8 percent the request for 24 was an additional 8.3 for an overall growth of 28.4 percent and when we look at the commercial of a change in commercial effective rate they were granted 11.5 percent last year and requested an additional 6.9 percent this year for a two-year growth rate of 18.4. If we're going to constrain that to seven percent growth over two years the budget would have to reduce by three million dollars and involve a negative 4.5 percent change in commercial effective rate holding them to inflation is a two million dollar adjustment to MPR and would keep them at 14.6 across the two years. So the expense growth is the highest among Vermont hospitals at 17.8 percent. A lot of that has to do with utilization and the ability for the network to find capacity at Porter particularly related to orthopedics. That proportion of admin and general salaries we've talked about quite a bit but among critical access hospitals when it's only adjusted for Porter they would be at the 92nd percentile. The CMI adjusted cost per Medicare discharge is near median at 58th percentile and both standardized price for inpatient and outpatient is at or near or below median and this is a hospital that has low reliance on charge relatively speaking but for the commercial effective rate was at the 38th percentile over the past five years and eighth percentile in the past 10 years. Of note that again we are outperforming the budgeted rates here so the budget was an 8 percent margin we're at 11. My understanding is that part of that margin is helpful in supporting Helen Porter nursing home and I'm also under the impression that hopefully some of those rates have been increased and enhanced with the rebase that happened in July from our partners at Medicaid so hoping that they'll be able to find more direct mechanisms for that. As far as the opportunity for shared administrative consideration again same analysis if we compare it to that median with their share an opportunity potential of about six million dollars to get to median. So the staff recommendation would be to approve the NPR as budgeted and not adjust that at the 28.4 percent but do adjust the change in charge down from five to inflation at 3.1 percent and to the earlier points include the kind of network wide condition for additional reporting. Our rationale being that you know the operating results are pretty favorable in comparison to budget and that they are showing expense growth costs and admin to clinical salaries above the 75th percentile and seeing this opportunity to continue kind of addressing access needs across the UM health network. Hopefully that wasn't too fast. Chair Foster back to you. Well thank you for being mindful of the time. Board members any comments or questions? Being mindful of the time I will just simply say I'm supportive of the staff recommendation. I'm also supportive I'd like to make a quick comment though I'm concerned about the rapid expense growth and the admin clinical ratio at the 92nd percentile. On the admin clinical ratio and cost reports organizations complete those forms as well as audited forms any type of form that is required organizations have discretion as they follow the rules with the forms and they work to fulfill to fill out those forms to their advantage. Right what goes into a certain line how they calculate it that's thought of deeply by several people in every organization. So it doesn't make sense to apply one hospital's technique to all even unaffiliated hospitals they may disagree with that technique because it may affect them in some other way that we're not aware of. A facility may an enterprise may choose a single approach for a network or keep it individualized the mothership may look better with one technique or affiliates may look better with another but there's either a network that uses the same approach across all facilities or there are individual facilities. It's not okay to go back and forth and to try to have it both ways. The general distribution from the cost reports tends to stand because every facility is maximizing the use of the cost report for itself and with this particular network we double check the admin cost data using an additional set of data supplied by the network their centillus data and the findings of excessive admin expenses stands. So the question remains where are the savings from the shared services but something that I think we need to keep following in years to come. They've been promised since 2015-2016 and they've yet to materialize while the administrative layer and the executive salaries have continued to grow. Back to you chair Foster. Thank you member Holmes. Yeah I guess I don't have too much to add in the interest of time I'll just say that in my view Porter has benefited from high margins over the past few years and is expecting better than expected performance this year. I'm happy to hear that Helen Porter had a recent rate bump which should help that bottom line if that's accurate. Again as a critical access hospital Porter will get cost-based reimbursement from Medicare so there's less need in particular for this hospital for higher than inflation commercial rate increases given their performance and their recent margins so I support the staff recommendation here. It's not a hospital that has aspirational budgeting there are access issues in the area so I think there's room to increase utilization and meet the projected NPR but not through rate only through rate so I support the motion. I also support the motion healthcare advocate do you have anything in addition to your comment that you've made for the other network hospitals. No additional comments to chair. Thank you and I'm just all up to public comment only have to 11 today so you know I want to give adequate time to the other hospitals we have. Miss withers Natasha withers. Hi thanks so much for allowing me to do public comment today. My name is Natasha withers I'm a family physician at Porter Medical Center. I also serve as associate chief medical officer and associate vice president for population health to the UVM health network. It's been my great honor to serve in these leadership roles and it's been part of the change that way we're delivering health care at the UVM health network. After residency I had the privilege of helping build an innovative primary care model one that broke the mold on the traditional primary care experience. I learned a lot through this. After five years in New York City my family was ready to move to our forever home in Vermont. When I arrived at Porter I knew I was home. I saw the passion that people had for our community hospital the dedication they put into making a great place to work and provide care for our friends neighbors and colleagues. I saw amazingly talented people leading the way on health care delivery and I was excited to jump in and join them. When Porter joined the UVM health network our small community hospital grew to be surrounded by more amazing talented people through Vermont and Northern New York. When I saw the more colleagues were constantly striving to be better to be better for our patients our community and each other. It is through this collaboration that we have been able to begin our journey to break the mold on care delivery acknowledging that there's a better way to deliver primary health care. A model that moves away from reactionary crisis management to proactive preventative care. We do this by changing our care delivery model and building a multidisciplinary team to provide comprehensive care with wraparound support services for our patients. A team that includes care managers and laboratory pharmacists mental health professionals health educators and more. A model that acknowledges that the care is more than a transactional interaction. But rather an ongoing relationship with our patients and our families. One that is set up to be the supporter of our patients life journey. One that is well positioned to provide unique customized health care for our patients the highest of highs and the lowest of lows. We are their medical home. We have spent the last two years discussing learning asking questions challenging and innovating so that we can successfully set up a primary care system that offers our patients the right care at the right times at the right place. We are about to take the first big step in this journey. We are actively building the infrastructure and hiring the staff to make this a reality. We are expanding our care teams to improve access recruiting the very best people and working to retain their talent by creating an innovative supportive goal oriented place to work. There has never been a more critical time to support primary care in these efforts than now. This change takes a significant financial investment one that needs to be properly funded to move dreams into reality. I have listened to the discussions in the comments this week around access the importance of primary care and the need to be focused on health. I could not agree more. I wake up every morning and look forward to contributing to the change we need to make to achieve our goals. We at Porter and the UVM health network want to be that change. We want to continue to lead the way in providing high value care and primary care transformation. I ask you to join us on this journey by allowing us the funding we need to do the next right thing. Thank you very much for allowing me to comment. Thank you very much for your comment. Mr. Vincent. Just a really quick comment in the interest of time that we definitely very much look forward to working with the board on the cost comparisons. I think with what member Walsh highlights there is the way that organizations complete cost reports. There's great variability. Our point is I think there is a way to normalize that data to create a true apples to apples comparison. So we look forward to working with the board on that effort going forward. Thank you. Thank you. Any other comment? Okay. I move to approve Porter hospitals budget is modified here by the 28.4 percent increase from fiscal year 22 actual fiscal year 24 budget and PR FPP a 3.1 percent charge increase from fiscal year 23 to 24 reduced from 5.0 and subject to the standard budget conditions approved by the board and additional conditions that Porter shall submit to the board in three months a plan addressing Porter's efforts to reduce cost and control overall expense growth in connection with among other things information technology human resources management and revenue cycle management. Further Porter is required to meet monthly with board staff for monitoring purposes. I'll second. Is there any additional board discussion? I think we Mr. Kraken do we need a roll call on this one? No. Okay. All those in favor please say I got some head nods. I think we're okay. All those in favor please say aye. Aye. Aye. Okay. The vote carries unanimously for sorry negative four 40 because Merman's abstaining. Okay. We'll take a five minute break and come back with Dr. Merman. Thank you. All right. We will resume our hearing and I'll turn it back to Director Lindbergh and the team. Thank you very much. So the penultimate hospital we have to deliberate on is Copley. So as you can see there's been some adjustments to their both NPR and commercial NPR over time. Some of them pretty noticeable like the negative 17.7% in fiscal year 21. We also see that there's been adjustments to operating expenses and their change in charge. We do see that for critical access hospital relatively high commercial weight in that payer mix. So see that reflected in last year's rate which was approved at 12% charge increase. Copley was unique in that its actuals were kept relatively whole through the pandemic but fiscal year 23 is when they were hit pretty hard in terms of the recovery. The labor expense growth per FTE at 17.8% is the 13th highest among Vermont hospitals. So just a bit above the median but seems very reflecting. Mostly the provider transfers another expansion that Copley testified to in their hearing related to access. And at utilization at 2.4% is fourth highest but seeing some impressive gains there as they work to continually optimize particular their orthopedic process. This is a hospital that has some financial challenges in the current fiscal year. Their operating margin is negative 0.7 from one that was budgeted at 1.6. The budget as submitted has a 3% margin so that's a you know relatively high increase in one year for margin. But we do see the operating a bit of margin at 3%. Also below budget and total margin at negative 0.6 is below budget. That low amount of days cash on hand is something that is concerning to me as a financial regulator and seeing the age of plant where it is is you know not in line with other Vermont hospitals. So not quite as you know we've seen higher values among Vermont hospitals with the median at 16 years. For the ratio of administrative and general salaries to clinical salaries they were the lowest for Vermont according to the fiscal year 22 cost reports at 16.4%. Interesting to me that the best Vermont hospital is still the 42nd percentile among the comparators so just I think a testament to the small hospitals that we have in Vermont. Also see a relatively low average cost per Medicare discharge at 10,672 dollars. It's the fourth lowest among Vermont hospitals and it just happens to be at the same relative ranking among its peers at the 42nd percentile. As far as the standardized prices the commercial cost per discharge rather we see that coply in fiscal year 22 was above the 25th percentile so relatively low cost near to that but also quite low cost coverage for those services at 70%. And see their standardized price of 18,000 is in the middle of the mix there. On the outpatient side seeing a little bit more favorable cost coverage but also rather substantial bump from fiscal year 21 to 22. So I think some of the recent rate decisions are starting to materialize in coply's operating results but back in 2020 there were below the 25th percentile in the RAN study. So just a moment to transition back to the slide deck. Seeing the budget request before you. Okay, wonderful. So one important note about this is we did adjust some of these results so coply had initially presented a provider transfer for the additional provider they're having in their budget for fiscal year 24 that was unanticipated given the way that the provider transfer is designed to work. I actually see that more akin to what Southwestern was explaining in terms of improving access and given that they are low cost efficient high quality provider for those services. I think it's a warranted increase in NPR but I think it should be reflected in the increase and not kind of taken away through a provider transfer lens. I think the other two services for the provider transfer makes sense but it was just the orthopedic provider that I think should be accounted for in the budget increase. So when you do that the increase from fiscal year 22 to 24 as submitted is 20 million which is a 21.3 percent increase. The 12 percent charge approved last year and coupled with the 15 percent requested this year would be a 27 percent growth rate. If we're going to try to constrain that seven percent over the two years it would be a negative five percent charge increase this year and if we were to constrain the growth from fiscal year 23 projected to the 24 budget it would be 15.1 percent over the two years. So again after we make that adjustment for the non-provider transfer the expense growth goes up to 12.1 percent which is the 69th percentile among Vermont hospitals. However again the lowest rate of admin and general salaries clinical salaries in Vermont in the 42nd percentile among its peers same comparative place for cost per Medicare discharge and those inpatient and outpatient prices quite low and again that stops at 2020 so some of that catch up is probably going to start coming through in future years. They have had the highest kind of rate increases in the past five years to that point and in the past 10 years it's been the eighth percentile among Vermont hospitals. We do have some concerns about that margin being under budget that's driven primarily by the higher than budgeted salary benefit and contractual expenses so part of that is the price of expansion and increasing access so just an important point as we think about some of these budgets and why they grow it's not always for one reason so the upshot is that we would approve staff would recommend approving that NPR and FPP growth as budgeted after adjusting for the provider transfer at 21.3 percent but adjust the change in charge from 15 percent down to eight the rationale being the historical low reliance on rate increases balance with the relatively larger increases in recent years their ad or below median admin to clinical ratio and costs and standardized price and this also you know helps bring them in line with peers over the two-year period that these budgets are designed to review so with that I'll turn it to you chair foster. Thank you I'll start with Dr. Merman. Do you have any comments or questions? Thanks Sarah. Thanks Owen. I think Copley's a hospital that I think is a little bit challenging to evaluate for a couple of reasons one is their their commercial prices have been so low for so long at least it appears that way through the ran pricing and going back to the five years prior to that with pretty low rate increases and so I think even with the ran pricing the ran price from 2020 if we look at the the increases since then they're still fairly low but they're also really efficient and so they've I think they've been able to to be a very efficient operating hospital with high quality in the context of these low prices so some of my thoughts on this are that other than low prices so I'm just reading through my notes here they also have very low they have low outpatient prices and low inpatient prices and I think those prices have taken a while to come back and I don't think the rate increases that they've had over the recent years get them back to their peers they also have the low administrative clinical salaries they have a low one of the lower adjusted CMI just a cost per discharge that said you know Copley's utilization seems to be trending up they're adding multiple providers I think their utilization will help them increase their revenue this year so I don't think that all their revenue gap needs to be made up for in in rate and that their increased utilization I think is maybe it may be about what they're expecting so I think that looking at them in the context of one and two-year inflation is a little challenging given their low prices over time so I'm comfortable going over the one and two-year medical inflation and going with the staff recommendation of eight percent I don't I don't think that the request of 15 percent is quite supported in the submission and from the other benchmarks that we're reviewing so I'm comfortable with this staff recommendation number lunch I really don't have anything to add so I'll just note that I'm also supportive of the staff recommendation number Walsh I can be comfortable with this I did note in the presentation from Copley they justified they're somewhat aggressive raising of prices due to come in trying to come in line with local peers but it reminded me though that there's great value and being a high reliability organization that can safely deliver outstanding outcomes and high quality at low prices and a race to match local prices is not sustainable for Vermonters as a whole so I hope that I hope that they can continue to focus on being a high quality safe great outcome low price organization number home yep I can support the staff recommendation here this has been a high performing low cost low price hospital I do think that given the relatively high charge increases over the past few years that they may no longer be at the bottom of the pack I think the ran data will be updated soon and we may see an increase in the percentile rank of Copley on standardized price but they have a low price low cost hospital as a critical access hospital they are going to get cost based reimbursement from Medicare so I didn't see in the submission a justification for a 27 percent increase in charge over two years but I can support the staff's recommendation here days cash on hand are low compared to the median in Vermont there are significant capital improvements needed and so this higher than inflationary rate should support some of that necessary investment so I support this proposal motion I have a high degree of confidence in Copley I think they are a high performer can I view the rate increase as an investment in that performance and I do want to give additional resources to places that can perform high and Copley has and so I support this large increase I'll note I think the date this is the largest rate increase that's been approved by the board and from my notes it looks like it will be the the ones we've done so far I think it'll be the second highest overall rate increase over two years I think Rutland was higher and they were the ones that came in under the budgetary guidance so the non-budgetary guidance hospitals I think this is the single highest one year increase so far the board is granted and the second highest in two years and I think that is reflective of what we've seen in the historical performance so I also support it as an investment in a hospital that's doing quite well for its community and I hope it continues so I will open it up to the healthcare advocate if they have anything I don't see their hand raised Mr. Fisher no further comment Mr. Sherry thank you thank you and I'll open to public comment and I see Mr. Wooden's hand is raised he is the CEO Joseph Wooden please go ahead can you hear me yes sir great just a couple comments I really appreciate all the work that you guys do and have been doing for many years this is probably one of the more gamey years for discussions about working at hospitals and rates and I know you guys are trying to objectively stay strong and I appreciate that and I think you're doing a very good job we don't give you enough accolades or maybe we're not sincere but I really do appreciate that this is tough stuff and we're all trying to figure it out we're all Vermonters we're trying to get to data that helps us so I don't have any written remarks of course but just a couple things I want to say we do provide excellent care at a very low cost and I can appreciate the comments and accolades but our prices it's funny these words you know our our cost our prices what we charge they have been so low for so many years and I've been a CEO in Vermont since 99 so I have data going back almost 25 years but we're never really catching up so when we get 8% and other people get 4% but their number is so high 4% of $200 charge versus 8% for our $40 charge it doesn't work I can't seem to make it work I have been here four years next month and I'm really trying to figure out what is the issue that makes a specialty for the most part center of excellence orthopedics hospital and we appreciate those labels and accolades that you guys give us and people do come to us and we have amazingly good care and we get staff who really sincerely give up themselves with great empathy and kindness as well as clinicians who just do an amazing job and our surgeons are just fantastic but I can't seem to make it work I don't know how to make it work and I'm really trying to be thoughtful having worked in four hospitals in Vermont so much so that I'm going to actually do something that is I'm going to ask you if you can treat us like the UVM network and meet with us monthly and try to help me figure this out because I don't know the answer we were managing expenses we're trying to ask people to cross train we're doing everything possible but when our rates continue to be so low when you say in essence like well you'll make it up on volume I'm losing money every time I do this if I if this year I'm going to have a negative operating margin next year I'm going to have a budgeted negative operating margin that'll be nine years in a row of negative operating margin except one year when I've had relief from the feds because of COVID but if I didn't have that I would have had a negative 1.2% operating margin nine years of a negative operating margin doesn't work volume when I do more volume I'm still losing money and so you know maybe there are folks out there that thinks we should join the UVM network or close close the doors you know go into bankruptcy much like Springfield I don't think those are a good idea for the state of Vermont I think the prices of all our services will go up but I'm really just emotionally employing that I need some help I'm not angry but I'd love some help I'd love Green Mountain Care Board or consultants that you might use help me understand what we're doing because the the data that I've shown that I showed in the presentation I mean some of the highest hospitals in terms of their charges are like 900% higher some are 700% you you saw the charge data that I showed but you're you're I'm sort of saying if you could just give me average I'm not even looking for you know compensation or you know past sins that haven't been made up for 20 plus years even if you just gave me average what the Vermont hospitals have for charges that that constitutes about a 40 to 50% increase in all of my rates just want you to sort of think about that and I know Sarah has our data given our day you can look at us I mean I feel like we're just in a unique situation where I can never catch up and then when you say well that's a good rate increase that should help you it kind of does and it doesn't because everybody else has gone up and I'm still sort of managing way behind so I apologize for being emotional and explaining my plea I do want to get some help and I would love you guys to maybe dive into what we're doing here because we do provide excellent care we have a waiting list on so many services which is great people people from far and wide come to us and our staff are extraordinary and it's my job to make sure that we're giving them a fighting chance to continue with the culture and a delivery model so I appreciate all that you do I I don't look at five or 10 years the past five years yeah we've got the you know your data is interesting my background is you know data analysis like you wouldn't believe so yeah if you look at the past five years you say well you've got the highest increase in the past five years it still it does nothing does nothing if you look at the past 10 years 15 20 years we are so pathetically low in our increases so you know it's a systemic issue it's sort of generational and I'm doing the best I can and I love this place and I think we provide good care but I'm going to have to maybe ask for some help and help us figure this out because because this reduction is a $6.5 million swing in the operating margin so I'm budgeting a negative $2.8 million loss and if we come up with a negative $2.8 million loss as the goal hope that you meet that and don't lose more I just think we're sending wrong message to sort of the wrong player but I'm not telling you I have an answer I have a lot of ideas though and I don't have a lot of people that appreciate them and that's fine I don't mind being alone a couple of ideas which I think would be helpful for you folks is that I have heard repeatedly discrepancies in data how data is reported how it's used how it's calculated I've brought this up before I think the state ought to go over a single auditor I think you ought to mandate that we have a single audit firm a national firm so that when we look at everything from free care or how you're calculating compensation maybe benefits defined retirement plans whatever you're looking at every so many times during this hearing you guys have come across people saying well it's a little different we do it this way we don't do that we you know we ask our auditors to do studies for us they're great we use a national firm I think if you're going to do this process of overlooking this expensive resource in these budgets you really got to make sure that the data you're looking at is not discussed in a way that always gets discounted or should be adjusted so that's just one suggestion my second one would be streamline the payer systems with regards to Medicaid and commercial which we have control over so that we are more like Medicare so that could really start to look at efficiencies so that there's a lot of things we could do some people might not like these ideas that's fine but I want you guys to do a better job and have beta better data too I mean we're all in this together it's not like I'm angry with you guys you guys have a really difficult job very difficult job and I think you're doing a good job at it so I'm just petitioning if I can get some help over this next year that would be great but thanks for listening thank you thank you thank you Mr. Wooden and here's comment about asking for a monthly meeting really struck me and is part of why I made a comment about how we had a lot of confidence in the leadership because of the collaborative approach you've taken so I appreciate that comment it's sort of a unique thinking in perspective because I think other times people don't feel that way we are here to help and make every hospital sound as we can so thank you for recognizing that and recognizing that we're trying to support hospitals as much as we can while balancing all the other considerations we have so thank you for the collaborative approach with us I really appreciate it and for your suggestions we will talk here at the board and make sure that any resources we have whether it's our talented team or our contractors are here to do anything they can to help solve some of these problems any other public comments I will move to approve Copley hospital's budget as modified hereby with a 21.3 percent increase from fiscal year 22 actual to fiscal year 24 budgeted NPR FPP an eight percent charge increase from fiscal year 23 to 24 reduced from 15 and subject to the standard budget conditions as approved by the board second any additional board discussion all those in favor please say aye hi hi hi hi motion carries unanimously I think the final hospital we have is northeastern that's right so as you can see northeastern Vermont part of me regional hospital has had some minor adjustments in fiscal years 18 to 20 and hasn't had their budget adjusted since fiscal year 21 they also had a relatively high request in charge increase for fiscal year 23 to 24 which does have a higher weight in on the commercial rate payers in these past couple years and then highlighting here that they're working hard about on their cost per FTE some significant efforts to kind of move efforts that were designed to enhance payment related to covid to bring them in-house and make them more sustainable on a go forward basis so seeing their downward adjustment is the lowest among Vermont hospitals the utilization is a bit above benchmark and their cost inflation is the lowest reported among Vermont hospitals their year-to-date performance is above the budget they had only budgeted a 0.2 margin last year and they're at 1.1 with a total margin at 3 over the 0.4 budgeted but again seeing some concerning days cash on hand at this facility as far as the admin administrator in general clinic ratio of administrative and general salaries to clinical salaries at 21 they were the fourth highest among Vermont hospitals with a 46 percentile among their comparators and their average cost per Medicare discharge after adjusting for CMI was at 13,224 dollars right in the middle of the pack among Vermont hospitals and at the 71st percentile among their comparators when we look at their commercial cost per discharge they are near the 25th percentile and had quite a stretch there of relatively low commercial cost coverage that's just above or at cost now in fiscal year 22 and we do see their standardized price at the 75th percentile as of 2020 on the outpatient side seeing a little bit of a jump in fiscal year 22 or I'm sorry fiscal year 21 which had carried forward to 22 but still despite that still at 200 percent of the commercial cost coverage so that's above the 75th percentile so an indicator of relatively high commercial price and see the standardized price at outpatient also right at that 75th percentile so moving back to our other material so here we see that the requested NPR last year went up or approved NPR went up by 4.2 percent seeing a more substantial growth requested for fiscal year 24 at 11.4 percent for 16.3 percent over the two years that's on the kind of mid to lower side of the request over the two years but we do see us a relatively higher reliance on the change in charge to get there with the 15 percent increase for fiscal year 24 that puts them at 25.8 percent over the two years if we were going to hold that to the 7 percent that's a pretty substantial reduction that 16 percent of their NPR and a negative 3.8 percent rate increase this or chart change in charge increase and just holding them to 3.1 percent over fiscal year 23 projected would be a 10 cut to NPR for 13.9 percent over the two years their expense growth at 14.6 is at the 85th percentile among Vermont hospitals as we discussed their near median for the admin to general salaries and near the 75th percentile on both the costs and standardized prices on the on the inpatient outpatient settings their five-year reliance on charge is at the 38th percentile at just under 24 percent in the longer term 10 year rate at median at 46.5 percent so they are outperforming their budget primarily driven by higher than budgeted NPR and FPP but at 1 percent not a not a ton of wiggle room in that margin ideally would like to see that near you know 3 percent for a non-profit hospital this is probably the hardest recommendation that we've grappled with the staff so what were we landed in consultation individually with board members is adjusting the NPR growth from 16.3 to 9 percent with a commiserate adjustment their operating expenses and adjusting that charge from 15 percent to 8 percent is interested in the additional quit condition about monthly reporting to submit three months the improvement plan addressing areas of particular concern the rationale here is trying to you know try to develop some equitable way to look at the charge growth across all our hospitals acknowledgement of those costs and standardized prices being toward the upper end of the the range and the relatively high expense growth I will note that this is a hospital that's trying to partner and work with peers and you know kind of reform in a in a difficult way and I just this is a hard recommendation that's a substantial change to their budget so just we'll turn it back to you with that note okay thank you we can go in the same order for board comment or questions starting with Dr. Merman thanks I agree I think this is one of the hardest budgets to to review and to understand how to to work with IVH I think it's a critically important hospital that provides health care services to one of the most rural and underserved regions in Vermont there's really few other health care options in this region along with north country they together provide health care services for arguably one of the most economic disadvantages in the state with transportation difficulties and really complex social needs in their community I know that in VRH has really done exceptionally well working with community partners through blueprint programs now for a decade the challenge I think with in VRH is that they do have these very high standard prices and have had just below uh you know average cumulative rate increases over the last five years so it it puts sort of a complex lens on this large ask that said they have had lower rate increases than many other hospitals and I I saw that they're lower than Rutland this is prior to this year Rutland, CVMC, Brattaburro, EVMMC, Copley, North Country and Porter so they're they're kind of in the middle for the five years coming into today or this year I'm very concerned about the relatively low days cash in hand it appears they have a reasonably solid margin so far this year I guess I I would like to hear other board members thoughts on this a percent charge before committing to a position on it number one my apologies I have some dog chaos happening so uh if you hear dogs in the background I'm sorry um I agree with member Merman this is a very tough budget um I do appreciate all the St. Johns Berries and MBRH's commitment to their community partners we've seen as as member Merman mentioned very strong partnership there um but I am concerned about the high commercial price given the socioeconomic demographics in the region and um how tough that must be on the community so um you know I won't say this isn't it hasn't been an easy choice but I do I will support the staff recommendation um similar to my colleagues this is a difficult decision I think member Lunge spoke to the charge increase and the socioeconomic status of the region wages across Vermont have gone up about eight percent across the state if you look it up but that's probably not the case in St. J and so um in future years trying to get some more um neighborhood level data on things like wage increases could be helpful um the continued rapid growth in costs and prices um is becoming more unaffordable for Vermonters and the inability to pay for health care makes for an unsustainable future for organizations that deliver care so I'm very concerned about the eight percent um having said that um I think Sarah's and her team's analysis here um I know that she's struggled they've struggled with this type of situation and I can approve this motion as suggested so so thanks uh to the team again for the analysis I agree with my colleagues points already this is a tough one um and I think it's a significant adjustment to one of the critical hospitals in our state but relative to the peers it's a high cost high priced hospital already and I think it's very difficult to find compelling evidence to support a 26% increase in charge over two years particularly as others have mentioned given the socioeconomic demographics of of that region of the state um but similar to Copley I worry about the relatively low days cash on hand um so I think an eight percent change in charge is is warranted um I you know I think this hospital needs to get on a on a more sustainable path that does not rely so much on high commercial rate increases um they are getting you know uh cost-based reimbursement from Medicare so that's important to remember so I think the improvement plan might help and I think working with this hospital and thinking through some of the shared service opportunities that they are working with with other hospitals in the state um and I think you know it'll be fruitful for this hospital to think about you know a zero budgeting approach for next year to really see if there's any other opportunities for cost savings and I look forward to being able to work with this hospital over the next you know several months to try and figure out how we can get on a more sustainable path I think acts 167 work may also be helpful in this regard so in some I I support this recommendation and this motion thank you I also the same thing everyone said this was the hospital gave me the greatest struggle in what with the right approach was I really went back and forth many times and struggled with what would be best and ultimately I did conclude that a large rate increase is needed and we need to support St. John's Berry and the hospital so it is a large increase and we I think it's needed I think it's needed for sustainability and I support the 8 percent increase um I don't have anything else I'll open it up to public comment I'm sorry I should healthcare advocate I'll go to the healthcare advocate first I'll just say no no further comment and I also want to just at least take a second to say thank you to everyone involved in this year's process thank you Mr. Fisher Mr. Tester thank you so first off I just want to acknowledge I I know that you're on the last fumes here and you're wrapping up this entire process and I appreciate everybody's time the staff of the Green Mountain Care Board has been really great to work with over the last several months as we've worked through this process and we appreciate everything they've done you know again it's this is challenging and and in the budget we submitted represented represents are what we believe we need to best support this community's needs as some of you have noted you know the northeast kingdom this is this is the oldest region of the state has a high some of the highest poverty rates in the entire region I get the cost side but at the same time you know we've worked really hard over the last decade to meet those community's needs working on social drivers for health not just taking care of people when they show up in our emergency department in our clinics or need our hospital services the budget we submitted really represents our best effort to make meaningful investments into some of those efforts and projects that you already discussed it's it's really exploring the partnerships that we feel are necessary to best meet our region's needs but it also represents the investments we're making and our staff and attempting to grow the workforce so that we're not relying so heavily on travelers I am concerned that this budget language if you adopt it as presented it will impact our ability to move forward we can't do it without days cash on hand and we can't do it without margin and and and I I do believe that this proposal will put us at risk that said I understand that you have a difficult task ahead of you so we'll we'll work together to figure it out thank you mr tester and I I appreciate you discussing the investments in the social drivers of health and the partnerships those are something that are important that we did know in your submission thanks for highlighting those because they are somewhat unique and important um and the other public comment right I'll read the motion and I I will move to mutton to approve northeastern Vermont regional hospitals budget as modified here by with a nine percent increase from fiscal year 22 to 24 budgeted mpr fpp reduced from 16.3 and a commensurate reduction operating expenses from the submitted budget an eight percent charge increase from 23 to 24 reduced from 15 and subject to the standard budget conditions as approved by the board and an additional condition that nvrh shall submit to the board within three months a plan addressing nvrh's efforts to reduce costs and control overall expense growth further nvrh is required to meet monthly with board staff for modeling purposes a second mr mccrappin would you take a roll call on this please hmm yeah chair foster i'm gonna call the roll in alphabetical order um member holmes yes member lunge yes member merman yes member walsh yes and chair foster yes um the motion carries unanimously and um there will be an eight percent charge increase for nvrh and nine percent increase in nvr and fpp um we had one last agenda item uh which is a review of the standard conditions and i'll turn to mr mccrappin for that um thank you chair foster so um we're wrapping this up with a fraction in the standard conditions that we had been presenting as um we had discussed before there have been some rewriting here and in the revisions um some provision of it was omitted so i'm going to add that back in here we look at condition b the approvals here are to the hospital's overall change in charge and commercial rate increases um that obviously has been a part of the board's motion language as you've gone through and approved the hospitals uh so we're correcting that in this clause b by adding that back in um i will just take a minute to to um remind everyone how we changed the way that these particular conditions were frayed were were written up um they now say at the hospitals they are a cap on the hospitals change in charge and commercial rate increases um we've made that explicit that it's a cap uh we've also clarified that no commercial rate increase for any payer can be above that cap and we've also made explicit uh as has been the board's intention in past years that commercial rate increases with respect to any payer may be less than that cap as that's negotiated between the hospital and the payer um also flag the condition that we've added this year that the commercial rate increase in that cap is a maximum and it's subject to negotiation between the hospital and commercial insurers the hospital shall not represent the maximum commercial rate increase approved by the board uh or the expected commercial npr based on that rate increase as amount set or guaranteed by the green mountain care board in the hospital's negotiation with insurers um and then we've also included here that the hospital is expected commercial npr based on its budget either as approved or as adjusted in the order um is an amount that if approved as submitted was included with the hospital's budget and if modified is something that we can back into holding together holding constant the other assumptions in the budget we're asking the hospitals to report their actual expected commercial npr if it's different than that um not later than march 15th or if there are particular hospital situations that require a later date that could be approved by the chair um there are reasons that that expected commercial npr would change um related to kind of the payer mix or other factors but that would be for the hospital to explain if there was some variation uh so with that I would like the board to um if it's acceptable approve the correction that we've noted in the prior slide I'm happy to take any questions or comments as well I have no comment or questions um on this if any other board members do please go ahead then I will move to approve the correction to the standard budget conditions as presented to the board second second all those in favor please say aye hi hi hi hi member lund for you and I as well I was all right the motion carries unanimously um there's one short additional agenda item that was not on the calendar which is a big thank you to uh sara linberg we will miss you sara uh there's really unique in that she has respect uh everywhere uh the board staff at the board level across the health care advocate and all the regulated entities um member lunge has worked with uh director linberg for a long time so I'll turn to her for some comments first of all sara my apologies because you're gonna be embarrassed so just say that up front I know you well uh sara and I have worked together for at least a decade I think a few years longer than that and so I just wanted to say thank you sara you've been an incredible asset to the state of vermont and the green mountain care board um in my former role working for governor shumlin as the director of health care for the state of vermont I had three data people that in the state the entire state that I would call upon and sara was always my first call as you might imagine in that role we had some very heavy lifting to do in terms of reports and analysis and planning for health system change and I could not have done that without sara she has taught me a lot about data about statistics about vermont specific data sources which ones are better than others um and I know I'm not alone in that um she has also behind the scenes tire tirelessly work to ensure that data sources have been improved um under her stewardship at vcures has become much more stable and reliable as a data source um that is really important and really not sexy work um and she recognized the importance of it and highlighted it when others I think um did not do so and then just lastly um in her current role she really has transformed this process into being much more data driven as she has said many times we still have work to do but we wouldn't be where we are today without her and she's done all of this all of this tirelessly I can't say how many times I've woken up to see emails at two third from her at two thirty in the morning um I'm not waking up just to be clear I'm not waking up then but that's when she sends them her humor makes her a joy to work with and I just can't say enough how sad I am to see you go sara but your new employer has no idea what an asset they have although they will soon learn and um appreciate you as much as we do so thank you the state of Vermont has really benefited from your service thank you very much member lunge uh well said I know we all feel those share those feelings so thank you thank you sara we will have a little kickoff party for you tonight or goodbye party and thanks for everything you did in this possible budget process yeah and with that is there I'm sorry go ahead there do you want to say yeah I just um yeah it's been an honor to serve and I just um yeah and I wish I could have got some more done but I'm gonna I'm gonna keep working got a great deal done so thank you all right uh is there a motion to adjourn so moved if I don't second does that mean sara can't leave I was wondering if you could play that out I'll second um before before you vote I will also thank the health care advocates for their amazing diligence in this process and also each of the 14 hospitals and their executive leadership these are really immensely difficult decisions and the data and information the conversation is critical to doing so I hope and appreciate everyone recognizing how hard these calls are and we recognize that they're not one size fits all and there's a lot of judgment and discretion and expertise that goes into it including sara's um quite heavily so thank you for all the entities that put in so much work to making this as positive processes could be and with that I'll call for the vote all those in favor please say aye aye hi all right hi we are adjourned