 So, good morning, everyone. Welcome to the Green Mountain Care Board. My name is Kevin Mullen, chair of the board. And we are proceeding with hospital budgets. And we went through several yesterday and we are going to proceed where we left off. So at this point, I'm going to turn it over to Patrick and his team to lead the discussion. Patrick. Good morning. Good morning, board members and members of the public. Lori is going to get the slide deck up and we will begin with Springfield Hospital. All right, Springfield Hospital, their fiscal year 21 NPR FPP request is 5.4% over their FY 20 budget and request, which exceeds the 3.5% growth ceiling. The requested change in charge is at 4%. They do see this as a recovery budget as this is a hospital that is looking to navigate its way out of chapter 11 bankruptcy in the coming months. And the anticipated restructuring will begin in the fall of 2021 and carry them into the new calendar year. Their utilization as they noted assumes 100% as of October 1st pre COVID levels, plus a 0.5% increase in the justification continues with surgical cases affected by a new full time surgeon. And they've made a $9 million expense reduction from 2018 actuals to the 2021 budget as they begin to restructure the organization. So as you can tell at the top here on slide 60, this organization going into and coming out of bankruptcy is a different organization from when they went in. They were forced to reorganize some of their service lines, which obviously will impact services that support or are connected to some of those services as well. And they no longer carry the service with the birthing center, which would obviously in some way affect free and postnatal care at that hospital and in that region with those patients now being distributed to other area hospitals in the valley. And as we all know, their financial struggles have compounded over several years. However, this year, they have reduced their operating loss. Some of that has been due to federal funding. Some of it has been due to state support. But in the coming 2021 budget, they are looking to make a small margin of 0.3%. So our request here at 5.4% staff believe we should reduce this to the 3.5% gross ceiling as they exit restructure and exit bankruptcy. Like we said, this is an organization that has changed quite a bit since it went into bankruptcy. And we think the 5.4% may be a little aspirational for this hospital as they come out of bankruptcy and into kind of a new role as a hospital. However, we would approve their 4% change in charge so that they could produce the very slim margin that they've budgeted for at this time. And the additional recommendations where we do need to have them improve the timely and accuracy of their submissions, that is going to be more important than ever in the coming year. With all of the unknowns out there, and we do really need every hospital to submit that information to us either by the deadline that we have on a monthly basis or within a couple days of that. We can't really wait too much longer than that as we move into facility or 21 included in that MPR reduction would be a commensurate reduction in the expenses. And should they fulfill their goal of exiting bankruptcy, any budget revisions that would be paused by some of the conditions of that bankruptcy, we would suggest be represented to the board at the appropriate time. So with that, we would turn it over to the board for discussion and dialogue on Springfield hospital. Okay, board members. Yeah, I support what the staff has presented. I mean, this is also a hospital that did not ask for a commercial rate increase last year, so they had zero commercial rate increase. I do believe even the three and a half percent is is high, because they were tracking down 3% through February pre COVID. So to be up that much, I think is high relative to what we've seen for other hospitals. But based on our discussions yesterday, you know, going, you know, taking below three and a half since that's in compliance. I can stick with the three and a half I would just caution for the hospital to really be watching where their revenue is coming in because their expenses are tagged to even at three and a half what could be too high of a top line. And therefore, too high expenses and they continue to lose money, but I support their recommendation. Other board members. I would just echo what Maureen said. This is a hospital that's missed in 1617 18 and 19 their top line and I, you know, given where they were in February, I'm concerned. So I would be comfortable with the three and a half and with reduction in expenses commensurate with that. You know, concerns about their negative margins. So hoping this is really a turnaround, but I'm comfortable with the staff's recommendation. Thank you. Other board members. I agree with Jess and Maureen. A little bit. It's a little bit like throwing darts at this time, get that they are in bankruptcy. Yeah, we, we found out yesterday that there was some state assistance that was kind of set aside hasn't been appropriated yet. So there's so many moving parts here that are kind of outside our purview that the staff recommendation seems to be, you know, a basic recommendation to until we know more about the outcome from the bankruptcy. Robin. I'm comfortable as well. As well too. I think that I have very big concerns about after they emerge from bankruptcy. I think they should be very appreciative of the efforts made by the state to get them the dollars the dollars aren't there yet, but it's in the budget as it proceeds. And this is one that Mike Halstead and his team stepped into a mess to try to clean this up. And my fears are when he leaves if the hospital can continue on the path of correction, but there's nothing in here that is outside of our guidance and Maureen hit it accurately. I think we'd probably be happy if they even had a half a percent increase in their NPR because it means that they're not continuing to fall. So with that is our board member that would like to make a motion. I can move that we approve Springfield hospitals budget with an NPR FPP increase of 3.5% from fiscal year 20 to 21 budget with commensurate reductions to expenses, a 4% increase to overall charges as submitted subject to the standard budget conditions as outlined on slide 27 and improved timeliness and accuracy of data submission. And although it is part of the standard conditions that it's up to the board chair, this is one Patrick and team that we will definitely continue monthly monitoring on. Is there a second to the motion. Second. Okay, is there further board discussion before I open it up to the public hearing none. The motion is to approve Springfield hospital budget with an NPR FPP increase of 3.5% from FY 20 to 21 with commensurate reductions and expenses and a 4% overall increase in charges. All those in favor of the motion signify by saying aye. Aye. Any opposed saying nay. Let the record indicate that this was a unanimous vote. Patrick, before you go on to the next one, I just want to say a few words because we did receive a letter this morning. And I just wanted to have the board focus on what was actually in our guidance for this year. It's our guidance said that factors considered during review the board may also consider the following factors when reviewing NPR FPP and changing charge requests. The first being the financial solvency of the hospitals, including days cash on hand and other routinely collected metrics. Second, the hospital's expense reduction plans, the hospital's long term strategic financial plans for sustainability data and information provided by insurers and third party administrators regarding actual and projected utilization and price changes. And the next one gets to the point. There was an assertion that late in the game, the Green Mountain Care Board brought in consideration of government relief dollars. And it's very clearly in the guidance that says the amount to which the hospital was compensated through COVID related stimulus grants. So impacts on Vermonters and employers in the commercial market, including self funded employers and other relevant factors proposed during the budget review process. So that's just an answer to the letter that will end up in as a public comment to us that alleged that this was a last minute consideration and I just want to. It was always a consideration. So with that Patrick back to you. Thank you, Mr. Chair. Next up is Copley Hospital. Their FY 21 requests represent the 6.1% and VR FPP increase over fiscal year 20 budget. This is this request. The 3.5% growth rate ceilings set forth by the board and the guidance their change in charge as submitted is 8%. The hospital has undergone some new leadership at CEO and CFO, most notably, and there are some changes being made at hospital to make process improvements, find deficiencies and savings, etc. And make use of the resources they hand to control costs. This is a hospital that has had some negative operating margins the last couple of years and is looking to rebound and rebuild to make necessary capital improvements. As you can see here on slide 66, the negative margins have have grown from 16 and 17 into 2018 and 2019. This year they are projecting a operating gain at the hospital and their budget offers up a 0.6% operating margin. Copley has done a lot to note some of the improvements they're doing and we'd like to see leadership take advantage of that. Laurie, if you could navigate to the final thank you. We would like to see leadership efforts come to fruition and find cost savings on their income statements and throughout the organization as a whole. So this is a hospital that is in February was operating 3% over budget, which was encouraging at the time prior to COVID. However, we think the 6.1% increase is a bit high. And the history has not proven out that that's attainable yet and they do have new leadership. So it's still kind of unknown. We hope that that's something they can achieve and rebounding some of their growth. But however, time will tell for that. So we would reduce the change in charge and thereby reduce the submitted MPR. Again, the change in charge we feel should be reduced to 6.5%. They received the 9.8% last year. However, with the onset of COVID, it was not fully realized on their financial statements. So we think that with the 9.8% and a slightly reduced charge of 6.5%, they should have the opportunity to make good on some of those cost savings initiatives and produce an operating margin for the hospital. So again, this is another one where we'd like to see more timely and improved accuracy for submission of financial data and commensurate reductions in expenses to go with the reduced MPR FPP. And with that, we turn it back over to the board for discussion and dialogue on Copley Hospital. Thank you, Patrick. Board members, Copley. So this is Robin. So because the 9.8%, you mentioned, Patrick, that the 9.8% last year was not fully realized due to the drop in volumes to COVID, because of that, one of the ideas I wanted to throw out for discussion is whether to shift some of the change in chart into the COVID related temporary increase, because it seems to me like once volumes come back, which presumably they would, if they were COVID related, we don't know when, of course, which is why we have the COVID provisions in part. So that, because that's built into the base, it would become realized at some point. But in the meantime, I'd be open to a higher change in charge, but bifurcating it between the standard and the COVID. So recognizing that Copley has had some financial challenges and has had a fairly low rate increases prior to last year, those are also factors for me. Other board members. Last year, I'll add a few things. One, I do think their, I actually think their top line requests for NPR was not unreasonable, because they were trending ahead through February, I believe about 6% prior to COVID. And if we look at what their, their budget was 72.7 million for 20, and they're projecting to come in about 67.6. So yeah, that chart or the other chart that showed. So they're missing their projection by 5 million this year, although they had been tracking ahead by 6%. And now they're making up, if you will, the 5 million from 20 to 21. So even though, so, so those two years, you know, even though the overall increase shows a higher request over the two years average, you know, they would still be in compliance for what we had talked about for enforcement and things like that. So I think, you know, their request on the top line was not unreasonable. I do think when talking about their commercial rate ask, I also agree with Robin that one of the, maybe not principles, but one of the things going through is maybe there's a commercial ask that we look at as being, you know, acceptable, whether that's 4%, or a number that we say is, is, you know, what we've done for the other budgets. And then a piece, if we go above that would be COVID related. And if we do that for some of these requests, that gives us the opportunity to be looking as either midyear or through the whole year next year. And maybe it will show that that rate needs to continue and that we can't adjust for it. Or maybe it will show that that there's some flexibility because, you know, one of the things that we are also looking at here is, you know, commercial rate impact on consumers. And that's, you know, one of the things when Kevin was just going through, I think it gets overlooked sometimes that we all are also needing to factor in, you know, as part of this process, what the commercial impact is, you know, on consumers. This is also a hospital that put in their numbers for, they didn't ask for additional funding, because they were able to benefit from many of the federal programs, including the PPP program, the Payroll Protection Program. And for now, they are very conservatively assuming that they'll have to pay all of that back, which I know that they know we haven't gone through the process to assess, but I would have to imagine that they qualify to some degree for many of their expenses that they have captured in that PPP. So that will really strengthen their balance sheet, which is another one of the things when we look at liquidity that is a factor in here. So when people have talked about what they get in 20, shouldn't necessarily impact 21, if the financials we're looking at don't include the benefits of what they receive, that will dramatically impact their financial statements, particularly their balance sheet and cash flow, days cash on hand, which are all positive things. So I do appreciate that they've suffered at a loss for quite some time, but it looks like if that $5 million just drops to the bottom line, they will end up being over $6 million and quite strong this year on their income statement, as well as their balance sheet. So the 8% still is a high request. I would definitely want to bifurcate it to a COVID piece. I believe this hospital also seemed to potentially put a higher number in for their provider tax of about $400,000, which would be equal to 1% on the calculation because their provider tax numbers are higher for 21 than 20. So that may also be a factor to consider. So I'll stop there and see what everyone else comments on. Thanks. Other board members. Yeah, I'm happy to jump in. I really like the idea of bifurcating in particular for some of these hospitals that are asking for higher rate increases than we typically allow it allows us some flexibility going forward. And again, as we've been hearing, these are recovery budgets. So how do we think about that? So one of the things I do want to point out a couple of things actually. The, you know, slide seven, Patrick, if you can go to slide seven early at the beginning and it's the average overall change in charge. One of the things I want to ask that I, you know, was sort of thinking about this chart this morning. And one of the things I want to ask the hospital budget team to do is actually redo this. Taking into account what the changes they made yesterday. To UVM Porter and CVMC. Their, their overall change in charge, for example, Porter is listed at 3.3 on this chart, but the revised chart yesterday now shows them at point 86. And UVM on this chart is at 2.9 the revised chart has them now at 1.1. And CVMC at 2.6, they're actually at 2.27. So the reason I bring that up is that I think it would be helpful as we're thinking about these changes in charge, but also to put into context, Copley at point 6%, which looks like an outlier. Now when we update this chart with the revised information from those other three hospitals, they're still low and they're still the lowest, but for example, Porter's at point 86. So it's interesting to compare Porter over the last five years and Copley over the last five years. And what's happened to both of those hospitals where Porter, you know, this is almost a tale of two hospitals. One hospital is seeing positive margins. The other hospital is seeing negative margins, even though the rate change in charge has is roughly the same. Whether that's the benefits of consolidation or expense management, I'm not sure we could dig into that at some point, but I just want to the outlier of Copley here is important, but it's not as stark as it will be. It was once we change this chart. But the other piece that I would just want to say is looking at the commercial to Medicare ratio, which I keep looking at, I think maybe the only one, but I think it's interesting to me. The Copley commercial to Medicare ratio is actually higher than Springfield's and VRH of Scott needs Northwestern and Porter, and it's about the same as CVMC and VMH. So I just want to also put that into context that actually makes more sense. Now that we're seeing the revised. Once that change in chart is revised it actually that, you know, the fact that Copley is actually higher than most of those hospitals now makes sense to me, but I just want to kind of lay that out there. I think it's important that said, you know, I do think that they have had these negative operating margins over the past four years their days cash on hand is low. You know, their fiscal year 2021 they're only projecting 66 days cash on hand. That's, you know, quite low and I'd like to see that higher. So we do need to consider their financial position. So I like the idea of bifurcating. I would just say that their npr of 6.1% hold on a second Jess we have somebody that in the background has not muted. If people who are not speaking could mute themselves so that we can hear the calls and speaking. Okay. Okay, I just want to say, you know, the, the 6.1% npr is all price driven. So if you go to the chart there. Patrick where it's the percentage of Yeah, the change in charge is a percent of npr FPP increase. Basically, the entire, you know, amount of npr they're expecting decreased volumes, but they're making up for it in a in a larger commercial charge. And so what troubles me a little bit is the expenses are increasing at 7%. So expenses increasing at 77%. If that was tracking a volume increase that would make sense to me. But this isn't a volume driven increase in npr. This is a price driven increase in npr. So expenses shouldn't be exceeding in my mind that npr. So, you know, I'm comfortable with some sort of bifurcation here. I'm comfortable with with a rate increase that's perhaps even exceeds medical inflation because of their financial situation. I would like to ask coply to reevaluate their expenses and really better, you know, have an expense reduction, because I do think that this seems high, much, you know, the average expense growth is higher here than most other hospitals. And their npr increase seems to be price driven, not volume driven. So that's those are some of my thoughts at this moment. Other board members. So let me add that I, you know, I think that we've had a change in leadership at the hospital. And they haven't been there that long. And I think from our meetings and from the material that they sent in, they are trying to put themselves on a more stable foundation. I will note that the recommendation of the staff in terms of reducing the charge at one and a half point reduction, that's a total of a million dollars in terms of revenue that they've got to account for and their projected operating margin, given their request was only four hundred and thirty eight thousand. So kind of from the math of it we're we're pushing them into into a position of having to find in their budget savings of over a million dollars in order to just get back to that operating margin, which was only six tenths of one percent. So they're operating on very, you know, on a very thin margin as it is. They do have this PVP this five million dollars, which I think they're going to find out in October and November, you know, how much of that they can keep. And I do agree that the provider tax is a little rich, but both of those are like one time on events that that that helped them a little bit. But the ongoing issue in terms of the expense cut is a little different matter. And I would note that that's expense cut to in order to get back to an operating margin of four hundred thirty eight thousand dollars. So the expense cut of a million dollars is equal to one point three percent of their operating expense. And I just I that doesn't sound like a huge number, but it's probably bigger to a smaller hospital like Copley than it is to a larger hospital that probably has more options to reduce their expenditures. One other comment I want to put on to is, you know, last year this hospital did also get a nine point eight percent commercial rate increase, you know, to help correct for the issues. And I also agree with where what Jess was saying about their expense increases relative to their their top line increases are high. And the other one of the other factors we're always looking at is cost efficiency and savings and making sure that those are optimized. And I think, you know, I think we should put some pressure there, particularly on this hospital to achieve that. Other board discussion. Well, like Maureen, I to support a bifurcated rate on this hospital. I think that it would be unfair to assume that any portion of the five million is going to be forgiven, but it's also likely to assume that all of it will be forgiven. And the uncertainty is the troubling part here. So placing a COVID related piece of this change in charge, I think, is appropriate. I'll defer to others what they think the appropriate amount of the COVID related piece might be, whether it's one and a half to or whatever. But I do support reducing the the request from the eight to the six point five overall. So other board members. Yeah, I would throw out reducing it to six and having 4% as a base rate and 2% is COVID to start a discussion and see where people net with that. Is that a motion Maureen? And part of the rationale for that is, you know, 1% looks to be in provider tax and then an additional 1% in cost savings relative to the increases that they're projecting. Jess is exactly right. The five million increase from their budget last year is all price. So going from the 67 to 72, yet their expenses are going from 72 to 77. So, you know, up the entire $5 million. So to to 1% rate, I think was what 400,000 or so. You know, to put that amount as a cost savings, you have 383,000 was 1% on the commercial side, I guess 673 in total because of what they're saying for Medicare which we wouldn't be reducing what they would get for Medicare. So I think we're looking really at the commercial ratepiece is 483,000 per 1%. Is that a motion Maureen? Yes. And are you likewise reducing the NPR FPP by the equivalent of the half a percent that you reduce the change in charge? The change in charge reduction was was 2%. Oh, sorry. In total, yes. Yes. Yes. Yes. Yes. Yes, yes. Yes from the from what the staff had said it would be an additional 3%. And yes, reducing the NPR for that as well. So Patrick, maybe you could go to the slide with the suggested motion language and Maureen could fill in the numbers and we'll go from there. if you do want to restate it with the suggested motion language? Yeah. Move to approve Copley's budget with an NPR increase of, I'd have to calculate what an additional half a percent would do. It's probably about 4.3 or something. I think they would need to tell us what that calculation is. Patrick, can you give us that calculation? Because one and a half percent was 1.4. So it's probably about a 4. The other way to do it, sorry. No, I couldn't hear you. We're not really prepared to do calculations on the fly. Maybe we could take a brief recess to make sure we get that number right. The other way to frame the motion would be to frame it around the change in charge with a commensurate decrease in the staff recommendation and then not use the number. And then the staff can come back with the calculation. Yeah, I agree with that too. So move to approve Copley's budget with commensurate reduction from fiscal 20 to fiscal year 21 budget. I'm going to go back to the NPR in a second with commensurate reductions to expense. A 6% increase to overall charges, 4% representing a traditional commercial increase and 2% the COVID increase, and reducing the requested 6.1% NPR by the impact of the adjusted change in charge from 8% to 6%. Subject to the standard budget conditions without binding on slide 27 and approved timeliness and accuracy of data submissions to the board. I'll second. Board discussion. Hearing no further board discussion, I'm going to open it up to public comment on the motion for Copley Hospital to reduce the overall increase in change of charge to 6% with a 4% regular component and a 2% COVID component and a commensurate reduction in the NPR FPP. In my mind, I think that's literally one third of what the change was between the request and the staff proposal, but we'll leave that open for the staff to confirm that. And it'll be subject to the standard budget conditions as outlined on slide 27 and improve timeliness and accuracy of data submissions to the board. So with that members of the public. Yeah, Kevin, this is Mike Del Treco. I'm sorry, I couldn't raise my hand. That's okay, Mike. Could you, I'm trying to capture that motion. I understand sort of what you've outlined, but did somebody document that so it could be read back potentially? So it will be part of the transcript, but again, the motion is to reduce the requested Copley Hospital request for a change in charge from 8% to 6% with 4% of that being for a standard commercial increase with the other 2% being for a COVID related increase, resulting in a 6% total change in charge. And there'll be a commensurate reduction in the NPR, FPP increase to reflect that reduction. And it's subject to the standard budget conditions as outlined on slide 27 and improve timeliness and accuracy of data submissions to the board. And Kevin, one other thing and also reduced expenses commensurate to the reduction in top line. Thank you, Maureen. Does that answer your question, Mike? Yes, it does. Thank you. Thank you. Other public comment? Other public comment? Is there further board discussion? If not the motion before the board is to reduce Copley Hospital's request for a change in charge from 8% to 6% made up of two components, a 4% commercial regular change in charge with an additional 2% bifurcated COVID change in charge resulting in a total of a 6% change in charge with a commensurate reduction in the NPR, FPP along with a decrease in expenses to reflect that decrease. And subject to the standard budget conditions as outlined on slide 27 and improve timeliness and accuracy of data submissions to the board. All those in favor of the motion signify by saying aye. Aye. Any opposed? Let the record show that the motion carried unanimously. Patrick. Thank you, Mr. Chair. Next hospital up is Rutland Regional. Excuse me. Their FY 21 request represents a 7.6% reduction in NPR FPP from their FY 20 budget. This is well below the 3.5% row ceiling set forth by the board. And Rutland is also submitting a 6% change in charge. In their presentation and their justifications were a $12.7 million reduction in costs. They've negotiated with their nurses union to postpone salary increases in the coming year and have opted to not contribute $2 million to the pension which is currently appropriately funded. They are working off an average daily census budget of about 82. They're currently at 77. There did seem to be some hesitation of attaining that 82 in the coming year. And their utilization assumptions for impatient volume were between 88, 90% and outpatient of 100% of 2020 budget for 95% utilization average. This is a hospital who has had historically low history of change in charges. Lori, if you can navigate to the change in charge page, please. So that has been, overall, the average has been approved at about 1.8%. Lori, if you could navigate up please. Right, thank you. This is a hospital who has a history of strong budget management. In the last several years, they have produced relatively stable operating margins, including their projected FY 20. And in fiscal year 21, they are budgeting for an operating margin in line with the past several years. They have been able to operate with lower than average changes in charges while at the same time continuing to produce a positive operating margin, even though it may not be the operating margin that they would aspire to. It is of note that their NPR for 2021 is more aligned with 2016. And as you can see here on slide 72 and 16, they produced almost an $11 million operating margin. And five years later with costs having grown over several years, that margin is being budgeted quite a bit lower at 1.7 million. This hospital also came in with requests for reductions in change in charges to lower that margin back in 2016. Our staff do feel that it is time for a change in charge increase to keep them on track and earning positive margins. So with that, Laura, if you can navigate to the motion slide, thank you. We would approve the NPR fee as submitted and we would also approve the 6% change in charge as submitted. And with that, we turn it over to the board for discussion and dialogue on Rutland Regional Medical Center. Thank you, Patrick. Board members. Sure, I'll start on this one. They, Rutland certainly has put forward the most conservative of all the hospitals in what they're projecting for NPR in 2021. As you stated, it's equal to about 2016. It's below, it's the only hospital that's requesting numbers below 2019. And they were trending slightly, they were trending about 4% below their budget through February and the commercial ass that they're asking for is $8 million. So I'm hoping that their top line numbers may actually be conservative. Every hospital has taken a different approach to what they believe their utilization will return to and this one seemed to take the most conservative approach and they've cut expenses accordingly. So what I would propose on this one is also bifurcating the change in charge to 4% and 2% as we just did on the prior hospital and really looking at the potential that they may come in stronger for their NPR coming forward into 21 if they have more recovery, we won't know and that's why I would put some of this change in charge in a COVID related piece. But other than that, it would keep everything the same except separating that 6% to 4 to 2 would be what I would suggest. And I can either make that motion or we could have further discussion with everybody else first comment however you want to handle it. Well, a board member can make a motion at any time and if you would like to hear from the other board members, that's fine too. Would another board member like to jump into the conversation? I would just say that I thought Rutledge presentation was one of the best and that's in my view been a pattern over the few years that I've been here. They have well considered the risks that aren't accommodated in this budget of COVID reemerging or paramount shifts or ACO risks now that they have a more wholehearted embracement of the ACO tension payment deferral for a year, some liquidation of investments. So they've done what they have to do to put themselves in a position going forward. And I don't mind splitting the charge 6% and 2%. I do note that yesterday Mike Smith said that Rutlin was in line for a $13.1 million healthcare stabilization grant. But in this situation, I could also stay with the change in charge at 6% as it is just in terms of rewarding a hospital that I think has done the right thing. Other board members? I'll jump in since nobody else is. This one like Southwestern Vermont, I'm actually worried about some of the numbers in that when you look at whether it's 0.6 or 0.7% operating margin with increased risk in healthcare reform, those are things that concern me. I also worry about if workforce issues continue to persist, how all the reductions across their staff are gonna play out as far as being able to retain their best employees. And after the whole fiasco that we witnessed at Blue Cross, even though I think that they can justify it based on the valuations in their pension fund, I do worry about anybody making decisions to not to fund the pension. So those are my concerns and like Tom, I could approve it with or without a COVID charge and I'll leave it to board members to find where their comfort levels are. So this is Robin, I'm a little uncomfortable with the 6% change in charge, but I think I can get there given the low margin. I agree with Maureen that the 7.6% reduction in NPR seems quite a bit low considering what we're hearing in terms of volumes in other hospitals, but balancing that out with the fact that they were down 4% in February. So I think I can get myself comfortable with bifurcating the change in charge to 4% and 2%. And part of that, quite frankly, is because they have been very strong in their budget management and when they've been running hot, as was mentioned, they came in and asked for an adjustment. So I trust them to manage to it. And if things are going differently then they expected that they would, you know, let us know given their history. So I think I'm, I'm, I'm there. Jess? So I am, I'm comfortable with the four and the two. I could also probably get to the six if needed. I think that, you know, they're, if we look at where their rate increases have been over time, they've been low. And even if we gave them the full six, their five year average would still be below the median. I say that though, we're also saying that they are the third highest commercial to Medicare ratio. So, you know, their base was higher, but their growth rate has been slower. So I, I'm comfortable with that. I think they submitted this budget prior to the decision to join the, the ACO in Medicare that takes additional risk and also additional investment in primary prevention. So given the huge cost savings initiatives that this hospital has undertaken much more so than any other hospital, I'm comfortable that they are managing their budget well and, you know, could, I would say that I could be convinced of the six. I'm comfortable with the four point four and the two. Would anybody wish to make a motion? Sure, I'll make a motion. Move to approve Rutland Regional Medical Center's budget as submitted with a 7.6 decrease from fiscal year 2020 to fiscal year 21 budgeted NPR FPP. Six percent increase to overall charges separated as 4% standard commercial rate increase and a 2% COVID rate increase and subject to the standard budget conditions as outlined on slide 27. Is there a second? Second. Further discussion from the board? Hearing none, we'll open it up to public comment. Does any member of the public wish to comment on the proposed motion to approve Rutland Regional Medical Center's budget as submitted but slightly amended with a 7.6% decrease from FY 20 to FY 21 budgeted NPR FPP. A 4% standard commercial increase, 2% COVID related increase for a total increase in changes in charges of 6% and subject to the standard budget conditions as outlined on slide 27. Is there any public comment? If not, all those in favor of the motion signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Let the record show that the motion carried unanimously. Patrick. Thank you, Mr. Chair. Okay, moving into our next hospital is Brattleboro Memorial. And yesterday you approved provider transfer and any accounting adjustments that were submitted along with this budget. So that has been squared away. Brattleboro's request is 5.3%. FY 21 budget over FY 20 budget. This does exceed the 3.5% gross ceiling. That's at 4th in guidance. Their change in charge is 4.9% total. That's 2.9% standard and 2% COVID. Their revenue, they stated was 95% of their FY 20 budget was the new normal gross revenue. That is sorry, FY 21 budget, they assume they will maintain 95% of old information is the new normal. I'm not sure what that means. I apologize. 2% is driven by COVID portion of the rate to cover increased COVID expenses, including 15 FTE screeners to cover the hospital entrances. And they noted that they are the 4th busiest hospital in terms of emergency department, treating mental health and psychiatric patients. And they do this in collaboration with Dartmouth and Cheshire hospitals. As of February, 2020, Brattleboro was operating about 0.5% over budget. We noted that they are projecting a 2.6% margin. Thank you for this year. So their budget in 21 would bring them back down to a 0.5% margin, which is slightly under their actual 2019. This is the hospital too that has been showing signs of recovery from the 2016 to 2018 period. And moving to the motion language slide please, Lori. Thank you. We would reduce the NPR growth to 4.3 with the accounting adjustments and provider transfers. It would be 4.8. In the change in charge, we would reduce to 2.9%, which represents the standard rate. And we are doing that based on the provider tax. So Lori, if you could scroll down to slide one, I think it's 135 to kind of show some of the trend analysis we did. And I believe it was board member Pelham who asked them about their provider tax. Thank you, Lori, at their hearing. And it was stated in the transcript that they made a mistake and calculated off FY21. And when the question was posed again, they noted that they had received guidance from Diva. So we contacted Diva and Diva had noted to us that no guidance had been handed out to their knowledge. So we think there's probably room here to reduce the COVID portion of the rate and therefore allow the overage on the provider tax to fall to the bottom line. And they would be able to cover COVID costs using a portion of that as well. So our rate reflects a reduction to 2.9 standard with monies being found as part of that miscalculation, leaving that expense structure in place there, but bringing it down slightly in coordination with the NPR FPP. And additional recommendations as you've already acknowledged the provider transfer and accounting adjustment. But again, another hospital where we need more timely and accurate submission of financial data so that we can better track each individual hospital moving into a year of uncertainty. So with that to recap, 4.3% NPR FPP growth, 4.8% with the acknowledgement of the provider transfer and accounting adjustments yesterday and a 2.9% change in charge for Bradivor Memorial Hospital. We'll turn that over to the board for discussion. The board members. Sure, I'll go ahead. Actually, on this one, I would throw out to keep their 4.9% change in charge with the COVID piece of 2%. I do appreciate and like the look at the provider tax and that that's gonna bring them favorability. And I do think that's important and will be a factor as we look at many of the hospitals, their operating margin requests for next year was 0.5%. And their total margin was 1.2. And looking at this trend, they're a hospital that lost money in 17, 18, marginally made some money in 19, 20. They were able to benefit from the COVID programs and are gonna end up, it looks like with some a stronger, much stronger cash position. But their request to be at 0.5 is very low relative to many of the other hospitals. And I think the fact that if we kept the 2.9% as a straight commercial standard and continued with the other 2% as COVID, we'll have time to assess that. And what we've said with the COVID is we can look at it at six months and we can look at it as a year. And if we see that they are turning around more and then we could adjust that. So that's where what I would put forward on this one. Other board members. I'm just looking at some of my notes here in the past and I have a note that they received more COVID money, about 1.8 million the necessary to cover costs. And their response was in June, July and August revenues were a bit weak against. And so I think this was one of the hospitals that kind of moved some of their COVID money into their balance sheet. And it's having it sit there until they know what an audit might reveal about whether or not it was eligible. But there does seem to be some kind of a COVID cushion in their balance sheet. I'd have to go back and look at it in detail but that's what my notes say. Other board members. I'm comfortable with Maureen's suggestion. I do think that given the low operating margin that they asked for and the financial issues the last few years that it makes sense to ensure they're in good financial health. And like to the extent that Tom's point to the extent that the money balance sheet looks good because of the COVID money, if it wasn't used then it'll have to be paid back which is probably why it's not reflected the 21 margin would be my guess. But so I'm comfortable with Maureen's recommendation. I'd also just add to the point that Brattleboro was not on Mike Smith's list yesterday. There is a second round but and I understand that we shouldn't be looking at Mike Smith's money as operating money. It is to fill a gap due to the pandemic but Brattleboro was not on that list yesterday. And that's consistent with what we heard from Steve Gordon at the hearing that they didn't feel they would be in a position to qualify for the state relief dollars based on the dollars that they had already received in federal relief. So that didn't surprise me but you're accurate Tom. I can support Maureen's recommendation. Again, this is a hospital with very low margins. They're trying to do the right thing by their staff. They're increasing their staff wages, trying to impose a $15 minimum wage. They are all in in the all payer model trying to make investments in primary prevention. So I think this is a hospital that needs a stronger margin and I'm comfortable with keeping it as is. Well, it's not really keeping it as is. It's breaking that into two components is what I heard Maureen say but I haven't heard anybody make a motion. So perhaps somebody would like to make a motion. I can do it if you want Maureen or unless you want to. Oh, you can do this. Okay. I moved to approve Brattle Memorial Hospital's budget with an NPR FPP increase of 5.3% from 20 to 21 with an effective NPR FPP increase to be calculated by the staff reflecting the adjustments previously voted on with commit a 2.9% increase in standard overall charges and a 2% increase in COVID charges for a total of 4.9% increase to charge subject to standard budget conditions and improved timeliness and accuracy of data submission. So that should reflect the budget as proposed by Brattleboro. Is there a second to the motion? Second. Is there further board discussion? Hearing none, we'll open it up to a public comment on the Brattleboro Memorial Hospital budget. The proposed motion. Is there any public comment? Hearing none. Is there any further board discussion? Hearing none. The board will attempt to rephrase the motion and Robin correct me where I go astray. It actually might be easier if Lori moves back to the previous slide because it's basically the budget as submitted by the hospital. Well, yes, but so as I understand the motion it's to approve the 2.9% standard component of change in charge along with a 2% COVID related change of charge for a total of 4.9% as requested in their budget submission. And after reflecting for the accounting changes I am still not positive of what the exact NPR FPP is. Patrick, do you have that or should we just say commensurate with the change in charge? Yeah, I would say commensurate to be calculated by the staff. Thank you. With the additions of improved timely and accurate submission of financial data and recognizing the standard budget conditions as outlined on slide 27. Did I accurately get that Robin? Yes. Thank you. Any further board discussion? If not all those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show that the motion carried unanimously. Patrick. Thank you, Mr. Chair. Next on the docket is Mount of Scutney. Thank you, Lori. So Mount of Scutney's FY21 request for NPR FPP represents 4.6% growth over their FY20 budget. This is in excess of the 3.5% growth ceiling set forth in the 21 guidance with a submitted 4.6% total change in charge. This is another hospital that had requested a bifurcated rate and of that 4.6%, 2.4% is a standard rate and 2.2% is a COVID related rate. Their justifications were 94 to 95% of their normal volume for their FY21 budget from 2020. Cost savings, limited retirement and termination of the pension authorization that will be the remainder of which will be transferred to insurance company and they're keeping their benefits flat year to year. Also they were, now this may not be fully accurate anymore now that they have intended to continue with all ACO programs, they're not booking $1.5 million in reserves at the time of the original budget and the 2.2% COVID rate is related to ongoing expenses for supplies, staffing equipment, replenishment of cash, urgent and deferred capital investments and the hiring of seven to 10 new FTEs for COVID safety. And again, this is another hospital who has made an effort to add capacity for mental health treatment at their facility. Moving on to the NPR and operating margin slide please, Corey. I think there's a delay with Patrick getting them. Yeah, they're in, we switched both last week. Okay, so this is a hospital who has had kind of an up and down operating margin over the last few years, dipping to a loss in 2019 and projecting an increase gain of this year of almost $900,000 and budgeting next year very slim margin at 0.03% which is below some of the numbers that we've seen in the past on average. And so their margins have been pretty slim as of late and in February they were operating at 7.4% below budget. Their 4.3% change in charge is consistent with their five-year average. That 4.3% is now 4.6% with their resubmitted budget and increased by 0.3%. In the last couple of years, their change in charge averaged a little over 3% in the last three years it averaged about 3.67%. So this is a little higher than what they've requested the last few years. Again, as with several hospitals, fiscal year 16 seem to either have a large submitted and approved rate or a very low submitted and approved rate. So tying that back to our conversations yesterday when that drops off, it will have an impact on the five-year average and all depending on what occurs this year. So to recap, because this was a resubmitted budget that didn't have a whole lot of movement in it, the overall change in charge is now 4.6% and as opposed to what they put in prior to that. Lori, if you could move on to the motion language, please. Thank you. We would approve the request as submitted for NPR. We would also approve the change in charge at 4.6 as well with the 2.2% COVID rate with an additional recommendation around that the enhanced services that we ran through yesterday do not qualify under the guidelines provided transfers, but our next a part of the explanation for the increased NPR FPP, which accounts for 1.8% of that increase. And with that, we will turn it over to the board for discussion on Mount of Scutney. Thank you, Patrick, board members. I'm comfortable approving as submitted. They had separated the change in charge for the COVID piece. They've now added some more ACO participation. Their top line may still be high. They were tracking down 7.4% through February and I know they're getting 1.8% is relative to the transfers and they also have the change in charge that's gonna contribute year over year, but I would just caution that they may have some top line issues. The other thing that's a little bit unique for me when I look at this hospital is they are affiliated with Dartmouth-Hitchcock and in prior years Dartmouth-Hitchcock has put some funding in and then when they do well, they don't put that funding in so it's hard to look consistently across their performance bottom line. They did talk about borders that they have but in the past they've received patients from Dartmouth that maybe they were losing money on and so that was kind of part of that. So I'm not alarmed by their low operating margin that they're projecting for 21. It needs a little more to look at the backdrop of what's behind that, but I am supportive of the recommendation as stated. Yeah, I can support it as well. I will note that they're well aware of some risks that they have in their operating statement. I think their provider tax is in there at 4% so I think there's a little bit of upside risk there that could be looking at their 2020 projected could be almost a million dollars of risk. They have the risk of, I don't think they budgeted for the reserve for one care and they have the borders risk where they need to find more permanent homes for some of these folks. So there's a lot of risk in the budget and to quote Maureen, I love Maureen's ending quote at the end of their discussion with Mara Scottney where Maureen concluded by saying time will tell, right? And so there's a time will tell element here and but I think that the staff recommendation strikes a happy medium. And just to jump in, you talked about not booking for risk but the reality is that they did amend their budget after they changed their participation and there is three tenths of a percent increase factored into here for that. So just wanna clarify the record that it did increase what they originally submitted from the 4.3 to the 4.6 that you see in front of you today. Other board members? I'm comfortable with the request for all the reasons that other folks have spoken to. I mean, I guess I was comfortable with the original budget request and was thinking that the 0.3, we typically don't allow for and historically we've not said that the increased risk associated with the ACO can be allocated in the change in charge. So I'm intrigued by it. Everybody else seems to be very comfortable with this including the 0.3 adjustment for now the ACO participation. So I just wanted to throw that out there as a conversation point. Yeah, I could go with the 4.3 as well. The 0.3, I agree with the 4.6 but I also agree that we don't wanna look at putting the risk into the commercial rate and so I could go with the 4.3 and go back to their original request. And that's really where I was headed when I was pointing out to Tom that it was factored in because I think that in my mind, the 4.3 is more appropriate approval but I'll leave it to the rest of the board. This is Robin, I don't disagree with that either. I think the reason why I was comfortable with the 4.6 is because when you take out the COVID request is actually a pretty low standard that's maybe even a tad under medical inflation. So that's why that point for you didn't bother me so much even though they articulated it as ACO, the underlying standard change in charge in my mind was still pretty low overall. But I'm comfortable either way. Would somebody like to make a motion? Shall I do it? I'll go ahead and do it. I would move to approve Mount of Skutney Hospital Health Center's budget as submitted with a 4.6% increase from 2020 to 2021 budgeted MPR FPP a 2.1% standard increase to overall charges and a 2.2 COVID-19 related increase to overall charges subject to the standard budget conditions as outlined on slide 27. So my motion went with the overall 4.3% change in charge but kept the MPR the same. Is there a second to the motion? I'll second. We got two seconds. So the motion before us is to approve Mount of Skutney Hospital and Health Center's budget as originally submitted with a 4.6% increase from FY20 to fiscal year 21 budgeted MPR FPP with a 2.1% standard commercial increase to overall charges and a 2.2 COVID-19 related increase to overall charges subject to the standard budget conditions as outlined on slide 27. Is there further board discussion? I would just like to say that, you know, I understand the discussion about the one care reserve. That makes sense to me and I agree that we should not be paying for that through higher commercial charges but I will also note that in this situation which is not the general case that their provider tax, they budgeted at 4% and that's almost a million dollars that if you calculated at the 6% rate that's almost a million dollar increase. So I could live with the 4.6%. Independent of the reserve issue but just because they have so underfunded their provider tax. But given that there was the motion in two seconds, you know, I'm counting heads here and thinking maybe an amended approach wouldn't work. That's not necessarily true. The whole point when you second is to then have a discussion you could still say no to it after. I do think you bring up a valid point about their their tax and maybe Patrick and Lori can weigh in on that. You know, I know they had done some looking at some of the what people had put in and, you know, we're certainly looking at it from the other side. If people have overfunded it, I think that's a good point. If people have put in and, you know, we're certainly looking at it from the other side. If people have overfunded it, if they've underfunded it, you know, that that should be a consideration as well. And then if we if we did keep the request as they had requested it, it would not be because of the ACL. It would be because of the provider tax piece. Patrick. Lori. We will have to look into that. Is this one that we should set aside till after lunch, Patrick? If you're going to hang it on the provider tax, then yes, we will need time. Ford, is it okay to set this one aside till after lunch? Absolutely. With me. Sure. Yep. Fine by me. Objection will pass over Mount of Scotland for now and move on to the next hospital, Patrick. Thank you, Mr. Chair. The next hospital up is Northwestern Medical Center. Their FY 21 MPR FTP request represents a 0.2% reduction from their FY 20, but the new request is within the 3.5% gross ceiling set forth in guidance. Their change in charge total change in charge 21.1% consisting of a 19.9% standard request with 1.8% of COVID-19 requests. Their justification was seeking parity on change in charge with their peers in order to remain financially stable. They have had service area growth and volume continuing to improve in their service area in Northwestern Vermont. They are continuing to evaluate and repriorities capital spending and $21 million, $7 million approved for a emergency department renovation that will be paid through cash reserves and not in the increase in rates. They are making ongoing investments in primary care, pediatrics, OVGYN, and strengthening their intensive care and sleep services. Those were a couple of the items that we went yesterday. And every lifestyle and medicine into primary care. Rise BT has been resized for sustainability and alignment with the ACO, and they've transitioned away from their hope and recovery and outpatient neurology to other community partners. And that's another component that was discussed and acknowledged by the board yesterday. They have noted that they're not in compliance with their death-service coverage ratio covenant on their bond. And historically they made their case as a low-cost hospital in the state of Vermont. With that, as of February, they were operating about 7.3% below budget. This is a hospital whose financial difficulties in recent years have been well known. And also they came to the board back in April for a rate increase and were denied the state to feel glory. You can navigate to the motion language. We felt they made a compelling argument for being a low-cost hospital. We felt they made a compelling argument that they took what the board said back in April. Seriously, we as staff were encouraged by the fact that they are taking efforts to mitigate the cost that they have been incurred by the hospital by the electronic medical record rollout. And that was not something that was apparent to us back in April, but it sounds like they have a roadmap to reduce those annual cost burdens that have been brought about by that EMR and turned that around in a way that doesn't impact the rate payer. That said, they do. We feel they do need a higher than normal request going into the next year. So the change in charge, we would fall in line with Board Member Holmes' previous comments on Matt Scottney. We could not justify the 7.25% change in charge attributed to the ACO dues, risk and reserve funding to be placed on commercial rate payers. However, we would accept the 12.67% standard rate left after that reduction of 7.25%, which would be historically the highest rate approved by the board. And we would also approve their COVID rate component as well for a combined rate of 13.85% for the coming year. That would, of course, reduce NPR growth rate to negative 3.8%. With the Accounting Justice and Provider transfers, it would be negative 3.5%. We'd like to see the continued work on their behalf to reduce expenses accordingly. And also improve timeliness of submissions and financial data. And we recognized yesterday at the enhanced services around the ICU, et cetera, do not qualify under the guidelines for provider transfers, but are an explanation of the increased NPR total in 1.5%. So with that, we would turn it over to the board for discussion and dialogue on Northwestern Medical Center's FY21 budget requests. Thank you, Patrick. Board members. This is a hard one for me anyway. Yes, it is. So one of my concerns that I would love to hear other people's thoughts on is, Lori, if you could go back to the margin slide. It seems to me somewhat realistic to think they're going to go from negative 8% margin in 19 to 2.3 in 2021. And that what they're trying to do is basically recoup that through the change in charge. So I'm a little bit like as opposed to trying to make progress over a couple of years to recover. So I am comfortable with doing a change in charge that's higher than what I would consider sort of typical for what we're doing this year so far or typical in a normal year. But I'm still concerned that it's that it's just not that it's just too much to try and push on to rate payers in one year and that maybe over a couple years it would make more sense. But I don't know. Those are just my initial thoughts and I'm definitely open to being convinced by other folks. Thank you, Rob, and other board members. So I'll jump in. One of the things I'll say is I think that the expense reduction efforts by Northwestern are laudable and I know that they worked very, very hard to reduce their expenses and increase their sustainability. Their commercial rate is low and has been low. Their five year growth rate, you know, it was 0.7% according to this change in charge chart that we have over the five years. And so their growth rate was low. But also if you look at their commercial to Medicare ratio, it's also quite low relative to other hospitals. So their base is low and their growth rate has been low. So, you know, I do want to echo the sentiment that we said earlier at the hearing. I mean, largely that's driven in part by that minus 8% in fiscal year 16 that they submitted themselves. So in part we approve what they submitted. But I will say it certainly is low and over over the five years. So if we take 17, 18, 19 and 20, you know, the approved percentage change in charge is, you know, 2.8 or so percent. So if we take off 16 for a second, we look at the last four years. So if we were to approve a 13.85, their five year average would be only whatever about 5%. So they would certainly be in line then on a five year average with their peers. And if we approved a 10, it would be a little bit lower to be at four and change. So the way I look at it is I think an adjustment between 10 and the 13.5 is where I sit in terms of what I'm comfortable with. I do think there has to be some adjustment for prior low growth rates. And in fact, their base was low. They are a low cost hospital. So I'm also, so I'm comfortable in that range. And I do, I am worried about their bottom line. I am worried about their delivery of services that are needed in their community. I want to see them continue investments in primary prevention and chronic disease management. I am concerned about the tele, you know, ICU making sense given their low census there. And I'm concerned that is the sleep center really addressing a pressing community need? Are there other needs in that community that are more pressing that those investment dollars might have a bigger impact on? So those are concerns that I have with this hospital. But I do have to acknowledge that their change in charge rate has been low and their base is low. So I'm comfortable in the 10 to 13.85 range that, you know, where the staff ended up at 13.5. And I'd even be comfortable going starting at 10 somewhere in there. Sure. I'll add some context too. I think, you know, one thing just going to comment on the growth rate overall for, you know, all these hospitals and using that as a metric, one of the concerns there is that, you know, I think, and Jess has alluded to many times is, you know, where people are starting from, right? And this is a low cost hospital. And then I do look at where the rate increases are. But the reason I say that about the rate increases and looking at these numbers where we have to be careful is many times the reason the rate has been lowered, like their minus 8% and 16 was because of their huge overages in the prior year. And so that then actually does, of course, factor into their five-year average. But I look at that, you know, as certainly a factor, and we're going to see that in other hospitals that we look at after this one as well, that it's impacted by some of the overperformance they've had in the prior years. But they also have shown and we've seen on reports that they are a lower cost provider. And that has created some issues in managing their expenses when their reimbursement tends to be a little bit lower than some of the other hospitals. So I would look at, I'm also comfortable within the range Jess talked about, you know, what I was thinking is, you know, we also do, of course, have the flexibility of using the COVID piece. I would be comfortable with probably a 10% standard rate and a 4% COVID. I just rounded up a little to give them, you know, to the 14%. You know, we did give Copley 9.8% last year. I think, you know, they have been impacted clearly by other things as well. Their medical record system that they put in created some issues and they did show that they've tried to resolve that. And, you know, I think the numbers they put in for the ACO, you know, that shouldn't be supported by a commercial rate. You know, I don't know if they can work with the ACO to try to work with them on. They've backed some of the hospitals in case things go south, but I don't think that should be at the commercial rate payers. So I'm comfortable within that between 10% to 14% range. I'm looking to split some of it maybe a little more into the COVID piece than what was presented here by the staff. Other thoughts? Well, for me, this has been a bit of a buggy ride because we go back last April and, you know, the issue was the travelers and the EMR system that they were implementing added up to a $9 million problem. And that was a real problem. When we came to this budget process, I couldn't find any evidence of that problem being referenced until we got to the slide presentation. But in the narrative, it was all other stuff. I also kind of look at the change in charge being worth $11.5 million, but their NPR, but in terms of, but their NPR is only up 5.6 million and is actually down by $233,000, you know, at the bottom line of all NPR. I'm not comfortable with that relationship. But go back and yes, Northwest has had one of the lowest charge growth rates over the past five years. If you take where they were in 2015 and both play that simply up by 3.5%, you come to $112 million, which doesn't include any of the accounting changes or provider additions. So, you know, I'm, you know, they need help. I mean, there's obviously a big problem there and they need help. And I also notice that their provider tax looks like it might be a million dollars short. So, you know, I don't know where I land on this. I certainly, you know, think that, you know, I trust the judgment of Marine and Jess in terms of kind of looking at this probably more closely than I do because I can't resolve the fact that the change in charge is up $11.5 million, but their NPR, you know, overall is down by 233,000. So, there's something in that their deductions from revenue are up 24%. And maybe we had a long discussion with Northwestern about the fact that they are kind of feeling bad about this requested increase in terms of co-pacing deductibles, you know, of their customers. And so, there was a big increase in bad debt and free care. And so, I wish I could be more clear than that, but I'm certainly at the low end of Marines range and I would go higher than that. So, thank you, Tom. And my thoughts on this hospital is that it is a hospital that is in trouble, that is slowly digging its way out, that has made some very strong strategic decisions to move forward to balance itself. And at the end of the day, I like Robin have concerns that trying to write the ship in a short period of time may be a little bit too much to do all at once. And where I came in, and I think we're all probably similar features, but where I came in on this one was 10.5 standard and a 2% COVID for a total of 12.5. But I'm certainly, you know, listening very carefully to what my other board members are saying, because this one was probably the hardest hospital this year, realizing the condition that the hospital is in, and realizing that you can't ignore that they need a path forward, but also realizing that such a tremendously large increase on commercial rate payers is very difficult to justify, even given the historical record of their changes in charge. So that's where I felt, I don't know, is anybody at a point that they desire to make a motion? Kevin, I'll just add a couple things to, I mean, the other thing we didn't bring up about this hospital is their days cash on hand is high. So they at least do have a strong days cash on hand where, you know, that has been well over 200 days cash on hand, even with what they've been through. And part of that was because of their over-performances that they had back in like 15 in some of the prior years. So I do think that is a consideration when looking forward to what we do, because, you know, that's not a driving force here where they only have 60 or 70 days cash on hand. They're also, I believe they had 5.2 million on the list yesterday from Mike Smith, which will help to improve that and it's possible that since there's a second bite at the apple there that they may get more. So at least that part is good. But I do keep going back to, you know, they are the lower cost provider and, you know, this is the catch 22 we've been in. We tend to focus a lot on the rate increase itself and look at whether a 3% or 4% or whatever rate increase. But, you know, some of the hospitals have pointed out in the past, it really is where they start from. So if they're starting from a lower base and they get a whatever increase 4% increase, you know, they're never going to catch up to those hospitals that started a higher base and get a 4% increase every year. And so, you know, that's what was really swaying me to try to help, you know, correct some of that, you know, in a whether it's a 10% and a 4% or, you know, a 10% and a 3% or of course we could shift more into a lower base rate if we wanted to. I think that's an option, you know, that maybe we want to talk about to some of the concerns that Kevin and Robin have brought up, you know, maybe it's an 8% standard rate and a 5% COVID rate with, again, the COVID rate can become a permanent rate adjustment. And we'll have more time to see what actually happens this year with the rest of any COVID funding that comes in and that what happens next year. So I would just throw out, you know, trying to discuss where do people want to go with that and the flexibility in putting something more in a COVID rate. I would add a couple more things. Number one is that they are on the list for the health care stabilization fund for $5.22 million, which should help their bottom line. And in terms of splitting the rate, I know that they are in a technical default of their bond covenant and that during the testimony, they were clear that they're living month to month with their underwriters in terms and looking at this process to decide what to do about it. So it's, you know, maybe we do have another year, you know, and can spread this over the recovery over a couple of years, but I do worry that they are currently in technical default and that their testimony was that they have to report in every 30 days now. They're on a short leash. Yeah, and, you know, they did get some themselves and some issues with the replacement, the EMR replacement and, you know, they weren't able to clearly articulate in all cases what happened and it did change. You know, first it was some reimbursement by government payers that was an issue and then there were some issues with losing volume at the practices that they had that was going to stay lost and if that was the case, we said you need to, you know, then you need to reduce your expenses. So, you know, they're getting that together, but, you know, that is going to influence then your bond requirements and things like that, but they are getting more money in maybe than what had been projected when they looked at some of those things from the, you know, extra from the five million they're getting now from the state and some other things, so hopefully that will alleviate some of those concerns. So, in hearing the discussion, I think for me, I am comfortable with a 10 or 10 and a half percent standard based on what I feel convinced that, especially given, you know, like what we did with Copley and some other things like that, that that makes sense. And with the COVID amount, I think I would be comfortable with two to three percent. And that's in part influenced by the 5.2 and the fact that they do have strong days cash on hand, so that gives them time to recover. Does anyone feel comfortable making a motion? I do, but can we go to the other language? I like the other language. Let's see, I said, can we go to the other page, the one that has, the one that usually has your motion language on it? Wasn't it, didn't you usually put it on the, nope, okay. Because of the provider transfers and the accounting adjustment, it's the third paragraph. Okay, so move to approve Northwestern's medical center, including acknowledged provider transfers and accounting with an NPR 50 decrease to be calculated based on the adjustments that we make to the commercial. So you're going to have to come back with that. To a, with a 10 percent increase to standard commercial rate and a 3 percent COVID increase related to the overall charges and subject to standard budget conditions as outlined on slide 27 and improved timeliness of data submission. So I think we're going to have to come back and get the NPR based on the reduction that we did on the commercial rate. I'll second it. Excuse me, was that you, Robin? Jessica. Oh, Jessica. So let the record show that the motion was made by Maureen and seconded by Jessica. Is there board discussion? Hearing none, I'm going to open it up for public comment. And as the chair understands the motion, the motion is to approve a 13 percent overall increase in charges with a 10 percent standard component and a 3 percent COVID component staff to calculate the commensurate NPR FPP decrease and subject to the standard budget conditions as outlined on slide 27 and improved timeliness of data submissions. Maureen, did I get that correct? Yes. Thank you. Public comment. Hearing none, all those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show that the motion passed unanimously.