 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullen, Chair of the Board. And the first item on the agenda for this afternoon will be the Executive Director's Report, Susan Barrett. Thank you, Mr. Chair. I have a couple of announcements and just some scheduling reminders. First, I wanted to remind the board and to announce to the public that per 18 section 93.74, the board has submitted our billback report to the legislature. This report will be posted on our website under legislative reports, billback. And if you have any questions or need any more information, please reach out to me and I can share that with you. In terms of our schedule, I just wanted to remind the board and the public about our schedule this week. We're obviously here today to hear from Secretary Smith and others from H.S. And then after this presentation, we'll take some time for deliberations and potential votes. Then on tomorrow, we're scheduled to come back again together at 8.30 a.m. And really scheduled for the entire day for deliberation and potential hospital budget votes. And then tomorrow evening, Wednesday, we have our primary care advisory group meeting which takes place from five to seven. And then on Thursday, we also have scheduled starting at 8.30 deliberations and potential votes on hospital budget starting again, as I said, at 8.30. And then just a reminder that next Monday, 9.21, we are holding our Green Mountain Care Board general advisory group and that takes place from two to four. All of the information on how to access these calls is on our website. And again, if you have any questions, please reach out. That is all I have for today. I'll turn it back to you, Chair Mullen. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, September 9th. Is there a motion? So moved. So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, September 9th. Without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor signify by saying aye. Aye. Aye. Any opposed? Thank you. Then we'll move right on into the business of this afternoon. And first, we're going to hear from Secretary Smith and Secretary Smith is going to update us on the state coronavirus relief funding. And Mike, will Ina be speaking as well or just you? We can't hear you, Mike. If I can unmute myself, Ina and Alicia Cooper will be speaking as well. And Alicia is on the line here. Great. So whenever you're ready, go ahead. So thank you. I was trying to convince Dr. Fauci if he would give this presentation today, but that didn't pan out. He did a wonderful job at the press conference, but he said he had something at the White House at two o'clock. So let me just go over what I want to present today and most particular, really zero in, I think, on what you're most interested in. And that's the health care provider stabilization grant program and an update on hospital awards that will be forthcoming. The program review that will, I'll just go over the overview. We'll do a program review. Then we'll have a program update and the hospital applicants and the awards that we will be sending out and some considerations that I want to talk about. I want to give a program description because this is only sort of the first round of a two-round process here. So there may be other rounds that there is another round planned of this program, but I wanted to give you an update of where we're coming from. As you know, there was the Legislature passed the healthcare provider stabilization grant program. They appropriated $275 million. It does have some requirements to it. It must be administered to the federal requirements under the CARES Act that allows for permissible use. It also has to be needs-based in the application process, and we'll talk about that in a minute. And one of the things that was interesting that the Legislature did, and we promoted, actually, was that it should be a broad array of healthcare and human services providers who are eligible for the program, spanning self-employed practitioners to peer services providers to hospitals. We're going to be focusing on hospitals in this presentation, but there are some, you know, if I look across the spectrum, there were a lot of applicants in different sort of healthcare environments, I think is the word I want to use. Like I had mentioned in the beginning, we were going to see how this went in the first round, and if we had money, we were going to have a second round. We're going to have money. We're going to have a second round. The Cycle 1 application deadline was August 15th, and for the time period for revenue loss and expenses for the time period, March 1st, 2020 to June 15th of 2020. Then Cycle 2 will be planned for October, and it's for the time period March 1st of 2020 to September 15th. That shouldn't... I'll... You know, is that time period right? That time period is not right, is it? For time period March 1st, 2020? That's time period... That is the correct time period because, well, it is a second cycle and if the applicant comes into the process new and hasn't applied for funds yet, their need can be met starting March 1. Okay, I stand corrected then. Conditions for the grant, the grant must be expended before December 30th. As you know, that's the requirement of the CARES Act as of this date. I don't know if Congress is going to extend it or not. They have not been too inclined to do anything lately. So we're going with that. Everything has to be expended by December 30th. Grant funds will be used to cover costs and loss revenues associated with the coronavirus with COVID-19 disaster. Grants are subject to requirements of a single audit and where applicable provider organizations will continue current participation and value-based payment initiatives through 2021 if you accept this grant award. One of the application inputs, I'm going to turn to Alisha to sort of explain the application inputs in terms of what we are looking for as we put these applications together and Alisha, I'm going to turn to you later on and talk about the application review status as well, but can you just go through the application inputs? Certainly. So as Secretary Smith noted earlier, we were looking at this as a needs-based application process and in order to evaluate needs for the different types of provider organizations that we're going to be seeking grant funding, we needed to evaluate a number of different areas. Some of these areas related to revenue changes, we were looking at 2019 as a base year and then the application period of March 1st through June 15th, 2020 as our comparison period for this application cycle. And so the application collected information from providers about their build and paid amount in 2019 and their build amounts for the corresponding period in 2020. We also collected some information about non-claims-based revenue and I think this is mostly relevant for ACO payments that were being delivered directly from OneCare Vermont to ACO participating providers for which payers would not necessarily have been issuing fee-for-service payments. We also captured information about gross staff wages and any relevant changes that providers experienced in those wages from 2019 to the grant period of March 1st through June 15th and information about organizational operating costs. We also collected detail about COVID-19 related expenses in a number of different categories, which we can talk about more in detail later. And then the last category of information that represented an important input was any financial assistance that providers have received to date. This may have included information about federal relief that has already been issued and information about grants that providers may have received previously through the Agency of Human Services through some of our earlier provider stabilization efforts. And in some instances, providers had other grant sources that they included in this area as well. So that's sort of the methodology that we use to go through the grants application. And one of the things I just want to highlight, this is and was and is a fairly intensive, labor-intensive process. We didn't realize, well, we realized that we were going to have to reconcile, but there was a lot of reconciliation that had to happen in this process about what was submitted and then questions that came up after the submission in terms of getting the documentation that we would need to verify the various aspects of the application. And just to give you a program update of where we are and how we did things, we had an application portal that was developed by Salesforce and it aligned with... We wanted to make sure that the platform that we were using was communicating with other platforms throughout state government that were having similar sort of grant programs. So we aligned Salesforce with the other CRF grant programs across the agencies. If you can go to the next slide, Ina. Whoops. Anyway, we also received... There we go, but just right there. We also received just to give you an idea of how many applications we received. We received 351 applications from eligible providers. We also... 78% of those applications were new to AHF relief and 22% have received prior approval. And now the applications we receive are a broad array of provider types. The largest group, not dollar amount, but just in terms of numbers, were dentists at 27.7%. If you can go on to the application review status and Alicia, I'm gonna ask you to sort of let the board know where we are on things. Certainly. So one of the things that we have been doing is tracking our status and applications have gone through a review process with the agency of human services team. This figure here represents a snapshot of the close of business yesterday. And I'll sort of orient you to the different steps that we have that applications could be in. And you'll see that we don't have applications in all of those statuses at this point in time. But we were tracking applications as they were in a pending review status, which meant that none of our reviewers had had the opportunity to look into the application in detail. We also had a first review complete and ready for second review status. As you can see, all of our applications have been through that first round of review. The next status, which is this gray color, is applications that have gone through two rounds of review by two different reviewers and have been flagged as requiring additional follow-up with the provider that submitted the application. And as the secretary mentioned, because of all of the information that we were collecting from providers, we had inputs in the application itself. And we also had supporting documentation that was supplied to substantiate those inputs. In some instances, we weren't able to reconcile differences between those inputs and the supporting documentation. And so those are primarily those instances where we will need to do some additional follow-up with providers to make sure that we are understanding the application information correctly and making funding determinations using the appropriate information. The next status is applications where we're waiting for that provider input. And so we'll give providers a fixed amount of time to provide that input. Once that provider input is received or for any applications that don't require provider follow-up, we have a status that indicates that they're ready for either a third review of that newly submitted information or a final quality control check. You can see that we have approximately 13% of our applications in that status at this point in time. And then the final application status is all reviews complete. And you can see that currently 42% of our applications are in that status. That does include the hospitals that we'll be speaking about shortly, as well as a number of other applications for which documentation and application inputs were matching. And we were able to process those as part of this first wave of funding. In the first wave of funding, we're getting out about 4.4 million in what I would call to smaller entities, those that were pretty easy to review and substantiate their what I call low-risk entities. And that money is going out the door real shortly. The next group... Mr. Secretary, what did you say the dollar amount of that was? 4.4 million. 4.4, thank you. Yeah, but it is a bunch of small organizations. So it is... The dollar amount may... When we go to the next slide in a minute, the dollar amount is small compared to the next dollar amount you're going to see. But to those people, it means a lot. And so we wanted to make sure we could get those out as quickly as possible as we move forward. We know the next slide you're going to be very interested in. So we are moving to the next slide, which is the hospital applicants and awards. We had eight applicants. Maybe... I just want to make sure because there is somebody that we have to talk about, Porter Medical. Alicia, is this eight or nine with Porter? It's nine with Porter. Nine with Porter. We had nine applicants in total. Not every hospital applied for funding. I want to talk about Porter. Just there seemed to be some miscommunication with Porter, and we are giving them some time to submit some additional information that is due Thursday. We will turn it around and have a number for you. If there is, in fact, an award, we will have a number to you on Friday. That award, if there is an award, the information we're seeking, we've gone back and forth with them. We just need more information to complete that application. But as you can see through our application process, the amounts of money that the various applicants will be getting based upon the formula that Alicia had talked about. A lot of hospitals got a lot of money through the federal government. As you know, the formula took that into consideration. UBM Medical didn't get as much in various federal cycles as other hospitals did in proportion or per capita basis. I guess it would be the word. You can see based upon the formula, the driven formula, what the various entities will be getting in awards. Those awards will be going out. I think I signed off on them this afternoon at some point. But those award notifications will be going out very, very shortly. Mr. Secretary? On the two that are zero, those are two that applied, but at the end it just didn't meet the qualifications. That's true. That is absolutely true. And is there any way at all that we could get a range on the possibilities for Porter? I'm unsure of the possibilities right now, but as soon as I know, I will let you know. Okay. I would appreciate that very much. Thank you. The two that you mentioned, Copley and Springfield, obviously Springfield is in bankruptcy. We do have money in, you may or may not know, we do have money in the big bill in the legislature for some money for Springfield Hospital coming out of us. I don't see that, but you know, that's all general fun. And we were just hoping you could find some creative solution for the taxpayers of Vermont to funnel it in a different way. But I'm sure you did everything you could. I tried every which way, but it didn't meet the criteria, especially when they're in their reorganization. It just didn't meet the criteria. So total cycle one hospital awards is $5 million, $65.6 million. And again, Porter is still pending. And we'll get a number to you in the next few days on Porter. Very appreciated. Thank you. Is there anything else, Alicia or Ena, I missed or should be saying? I'll move along to the considerations slide and we can look there if you'd like. Move to that next slide, Ena, on this particular slide, like University of Vermont Medical Center, UVM has different entities like the medical practice is separated out. Did they apply and were they successful or are they lumped into this one here or is this just hospital? I believe that this is just the hospital. Mr. Chair, I think this is just the hospital. Okay. Thank you. There are some considerations that you should be aware of as we move forward and some considerations where more money could be going out the door to hospitals. There's another round. So that is something. This was a funding formula and it's needed base. And if you remember, the federal government has provided considerable direct financial relief to healthcare providers, reducing overall need. A lot of these, what we were trying to do is maximize the federal dollars. So FEMA is anticipated to cover 75% of new costs expenses due to COVID-19. Therefore, the hospital award amounts include coverage for only 25%. I just want to caution the board that those FEMA applications have not been approved yet. So if they're rejected, we would probably come back under this stabilization program in the second round. The funding formula uses a ratio of bill-to-paid claims in 2019 compared to 2020. We recognize that calendar year 2019 base period may favor providers differently, but we really needed just to apply a consistent base over the time period. And this financial relief is one time. Retrospective to the eligible periods and covers only documented losses and expenses due to COVID-19 in 2020. We didn't look at anything else other than sort of zeroed in on the COVID losses and the COVID revenue losses and expenses in 2020. And we use 2019 as the comparison year. Now, I'll just like clarifying question, Mr. Secretary, on the FEMA funds, you said that they're not guaranteed, but it sounded like if they did not receive it from the federal government, they would still be eligible from the state. And so in my mind, it seems like we ought to be able to count those dollars as we're calculating the financial position of the hospitals. Is that correct? I would say in many of the cases, that would be the case. I'm just not sure whether the FEMA eligibility transfers directly, but I would say that in most cases, that would be correct. Thank you. And I don't have people in the room that can kick me in the shins when I'm wrong anymore. So I will ask Alicia and Ina to speak up if there's something I'm saying that's wrong. Hearing none. It was a 50-50 proposition and I must have guessed. So, Mr. Chair, we will get the Porter number to you as quick as possible. We, I think both Porter and us were surprised on that and we're scrambling to make sure that you get the numbers quick as possible. We appreciate that very much. And let me just say that it's very exciting for Vermont to have had Dr. Anthony Fauci participate in your earlier press conference. And it speaks volumes for the work that you, Commissioner Levine, the governor and everybody on Team Vermont is doing. And, you know, just keep up the good work and keep us safe. I'd like some sleep one of these days. Do you, how do you want to handle this? I'd like to open it up for questions from the board first and then public comment if that's okay with you. Fine with me. Okay. I'll go in alphabetical order starting with Jessica Holmes. Jess. Hello, Secretary Smith. How are you? I am fine. Thank you. You look well for somebody who hasn't slept in six months. I will say that. I do have a couple of quick questions of the 275 million. How much has been allocated already? And we have 65 million for hospitals. I'm wondering for the other providers. I think that was on one of the slides. Maybe I can go back. Is that right? Money out the door. Money out the door. Shortly will be this amount. Plus the 4.4. And I would say we're over a hundred million dollars and probably roughly, don't quote me to that, but we're roughly over a hundred million dollars for the first phase. Okay. That's great. And then I'm just, I am curious a little bit about the second cycle and whether the the rules will change. I know some of them are federally mandated, but I'm wondering whether or not you're expecting a different allocation mechanism internally within the state and or different set of applicants, repeat applicants and just sort of wondering how you're thinking about the second cycle. How would be different? I don't think there's going to be a lot of difference. And Alicia and Nina, please, you've been in the trenches on this, but I don't think there's going to be a lot of difference. There may be some tweaking along the way. But I don't, I don't, I don't foresee a lot of difference. The second thing is I think we're going to have some repeat applicants. I think we're going to probably have some hospitals that didn't apply in the first round come through. I mean, you got to think about this. The hospitals were a lot was thrown at them all at once, you know, the stabilization, the budgets, you know, the federal things that were happening as well. So we have heard that at least one hospital is going to apply in the second, in the second round. Whether they do or not, that's, that is up to them. I also think that, you know, there are some hospitals here where they're still bleeding some expenses, although our system is still up and running, they are still bleeding some expenses. And I expect maybe they come back in and take advantage of some losses that in that next time period that they have that extended time period. Did I miss anything, Ina or Alicia? I think that's, I think that's right. I think you captured also what is a very small pattern that we saw with our first round of stabilization back in the spring and that we saw some return applicants, but also quite a lot of new applicants in this next, in this current cycle that we're administering. Is there any concern that if the second round is in October, but it has to be expended by the end of December, that that time period is so short? Is there any concern about that short window to expend whatever stabilization funds are allocated in the second cycle? Not with this program in particular, because it's retrospective. We're reimbursing them for expenses and revenue loss in the rear view mirror. We have to verify all this, so that's what we're doing. So I think generally, I don't think that's a concern. Okay, great. And then the FEMA awards, do we know when they're going to be announced? I don't know. I'm just thinking the window is closing, right? And if those FEMA awards aren't announced and there's an opportunity for hospitals or others to apply for this program before having heard whether they have FEMA, just worried about the window. Yeah, I will say this. We are internally talking about how much we reserve for FEMA, if there are. And we're breaking it down into probably, we're working with DPS, or we will be working with DPS to break it down and what probability we funded, what is medium risk and what is high risk? And we'll figure out a pot of money from there. Great. And my last question, just I don't want to waste too much time, but the stipulation that there was current participation in value-based programs or payment, is that maintaining the current level of participation or any participation? So if a hospital, for example, was in three programs but dropped down to say one, are they still eligible for this funding? How does that work? In my mind, it works that you stay with the current participation that you have. Okay. Great. And that will be true in the second cycle? It will be. Okay. Thank you. Very helpful. Okay, we'll move to Robin. Robin, Robin lunch. Thank you, Kevin. Just asked all of my questions. So I'm good. Thank you. Wow. You two are mentioned. We often have a Vulcan mind meld going on. So there you go. So next we're going to move to member Pelham. Tom. Just beat me to the mall as well, except for one. I'm just wondering how independent providers fared in this process. So given that a lot of them don't have backup of a large institution and staff to kind of prepare, which what I sense would be a complex application, what's your sense of how, of their participation rate? Yeah, I'm going to turn to either Ina or Alicia on that. I think they fared well. But I mean, we still have money going out the door, but I'll turn to either Alicia, Ina, on answering that question. We have 351 total applications for this program. And I think that smaller independent providers of a variety of types are fairly well represented in that total number of applications. And I think you will see that a lot of them will be funded. Am I right? You're asking me? No, I'm asking Ina. Yeah, it's a lot of them will be funded. You saw where we were with our review process. And I think it's, I think we would want to complete the process of all of the layers of review before opining on the, on the final funding. Okay. That's all I had, Kevin. Thank you, Tom. And next we'll go to Maureen, use for Maureen. Thanks. I have a couple of questions. One of the things the hospital said when we talked to them is they really didn't know how much they were applying for. They were kind of putting in all their, their variables and they really weren't sure what was going to net out of that. And I think you guys have had a discussion with the hospitals. Once you came up with their amounts, I mean, what they're expecting more or less. Did you get any feedback on that? You know, you've spoken with the hospitals. I think that in general, the, the feedback that we received was indicated that the applicants understood the formula and how the inputs were used and that the award amounts made sense based on the information they submitted. Okay. In general. Okay. And then just going back to the, the, the piece that FEMA was going to cover, are you guys covering 25% of that in this? Cause I know, you know, there was two components, right? One was lost relative. And then the other piece was the, you know, new expenses. I don't know who's talking. Can I ask whoever's not muted to please? That's always objecting to my question. No, somebody's, somebody isn't muted and we're hearing their background. Sorry about that, Maureen. So the question is, does this include the 25% component? And if so, can you tell us by hospital, how much is that piece of it? That way we'll know, you know, what was lost revenue piece versus what's the 25% piece of the new expenses. Because we had heard from some of the hospitals, they had asked for that. And so I think UVM had said like they had asked for, they thought 12 million. So I think nine was going to come from FEMA, maybe three came from this. And I just want to be able to understand what that piece is. I think we can get that information for you. Okay. Great. And then, you know, as, you know, we've only used, I guess about, you think about a hundred million of the dollars. If it doesn't all get spent, does that go back into then, you know, what could be used for other COVID expenses as well? Obviously I hope it gets, you know, expense here. I'm not, but if at the end of the day, only 175 million gets used, does that go back into kind of the state fund? I think there will be discussions about what to do with the other remaining monies. If there are remaining monies here. I think that's a legislative and administrative sort of process that we're going to have to go through of what we do with the remaining money in, we're going to know fairly in short order after October where we are. So we're going to have to, it's going to be a negotiation process probably with the legislature and the administration. And I want to, you know, we're not counting sort of the chickens before they hatch yet until we see the second round. Okay. Yeah. No, because obviously we hope this as a state, we can use all of the money somewhere. And if we can't use it in this area, in other areas. And then can you tell us who the hospital is that may apply in the second round that didn't apply in this round? Do you know who that is? I don't know how they, how the conversation was. Was it sort of an off, off the record conversation or was it, I didn't have it precisely. You probably had the conversation or somebody else had the conversation. Yeah. It was somewhat off the record conversation. I think we could confirm with that hospital and get back to you. Okay. Yeah. Cause I would assume that most of the hospitals that did apply may certainly apply for the second round, right? For the, the kind of between the June 15th through the September 15th, but then if there's also another hospital that's potentially in the mix, you know, it would be good to at least know who it is. And I think this is, you know, this program is great. I'm glad there's money being funded for it. You know, I just would like to understand, you know, for round two, there might be somebody else that comes in. And that's all I have. Thank you. Thank you, Marine. A couple of follow up questions. Just to comment, you know, one of the questions is whether the hospitals got more or less than what they asked for. And if I, if my memory is correct, there's a few that it looks like they got less than what they had hoped for. But then you look at, say, for example, UVM, what they had testified in their hearing was they hoped to get a little over nine million in FEMA, about a three million plus match for that remaining 25% from the state, and then another nine million. So that would have only been a little over 12 million. And here they're getting close to 32 million. So I think we have to go back and look at the transcripts for the different hospital hearings. But that's one that really jumped out at me as a significant $20 million difference from what they told us at hearing still today. On the, and I will say I heard from a number of hospitals that said they wished to apply in the second round if they figured out a clear path to do so. So I imagine it's going to be more than one that hasn't applied so far. And I would hope that everyone that hasn't applied looks to try to figure out a path if they qualify to at least put the application in. And following up on that, I am, it's hard to take off your old hats, Mr. Secretary. And I'm just curious since I hope the legislature is not going to be around at the end of October, if there's language put in that the emergency committee or JFC could agree with the administration on future things so that we don't let the clock run out. Is that the plan? I think the legislature and the administration through the secretary of administration is working on a plan right now to how we would use unallocated money. I will say that's on the forefront of the administration's mind to make sure that we don't leave any money on the table. And it's certainly going to be, I think, it's of mutual interest both by the legislature and this administration not to leave any money on the table. Perfect. So were you surprised at the low numbers that are in front of you today compared to that $275 million pot that you had or were you pleased with what you saw or what was your reaction? I'll be honest, I expected more to be honest with you. But then you start to look at these considerations that we went over. You got FEMA money that's being injected. You've got the HHS money that's being injected that, you know, we looked at, you know, if a hospital's 19 year wasn't, was better than, you know, another year from another hospital, you know, there's a lot of factors that you look in on this so I can understand what happened. But I was, I frankly thought all 14 would apply. That's what I had hoped for, but not what we saw. But you mentioned 19, we had a few hospitals. It was more than one. That ran into some unforeseen, probably should have been foreseen, but scenarios where their revenues declined in 19 because of changes we can pick like Northwestern, for example, they implemented a new health record that cut their productivity immensely. We saw problems at another hospital, pretty clear at 2VM when I say what I'm about to say that had to shut down its surgical operations at a site. And those are the type of things. I'm just wondering if there's a way to do some creative accounting to account for the fact that they're being put against numbers that would have been much higher if it hadn't been for those situations that occurred in 19. Yeah, I mean there's always an argument for that. And there's always an argument in every year for that, depending on the institution. We wanted to be as consistent as possible in this allocation. And so we were consistent in terms of making sure everything was apples to apples and oranges to oranges on this sort of process. But you're absolutely right. If you had a bad revenue year in 18, you are under this formula, you're not going to unfair as well as if somebody had a, excuse me, 19, if somebody had a good revenue year in 19. Okay, I think that is probably it for my questions. No, actually there's one more. So a number of hospitals have made the argument to the board that these dollars are fixing shortfalls in 20 and should not be calculated into any decisions on their budgets for 21. What are your thoughts on that, Mr. Secretary? Oh, man. My thought is, I don't know what my thought is, so I'm going to make it up as I sit here. I mean, these are fiscal year 20 expenses. They were mostly in this round, they were mostly before the end of their fiscal year. I don't remember what hospitals fiscal year is. I think UVM is September 30th or the end of September. I don't remember if the rest of them are on a federal sort of fiscal year, as I would say, or a June 30th fiscal year. But if it's on a June 30th fiscal year, I mean, these are expenses that happened in that fiscal year. That's why you guys... It's an October 1st fiscal year for all of them right now. What's that? I'm sorry. It's an October 1 to September 30 fiscal year for all of them right now. Yeah. I would say the bulk of these expenses happened in a 2020 year. The bulk of loss revenue and expenses happened in 2020 year. I would defer to the good judgment of the board how that would play out in terms of your deliberations. Let me try to ask it in a different way. Was one of the goals of the State of Vermont to try to keep down the impact felt by Vermonters in rising rates? I'll tell you what... I don't know if I'm going to answer your question precisely, but I'll tell you what the thinking is behind this. And it's always been the thinking. I was really worried during the height of the pandemic that our healthcare system was collapsing. And I was trying everything that I possibly could do to make sure that it didn't collapse at the time when we needed the healthcare system up and running. And not only needed it up and running for that period of time, but needed it up and running after that period of time because we're going to open it back up again. So everything that I drove, all my thought process, including the stabilization fund, which basically came out of this office, was under the mindset of stabilizing the healthcare system. That was the main motivation for all what I was doing during the time. Great. And a lot of people don't know that just how important government was in the early stages of this pandemic to make sure that institutions weren't talking about the possibility of having to close doors. And I know that at least one institution you put money out to. And I will say this. I usually criticized the federal government quite a bit. I was just amazed at how quickly they got money out the door. And without that, our healthcare system would have been a complete mess. And of course, whenever you have to hurry to do something, you don't make it perfect. But I'll tell you what, if the measurement is that nobody had fears about the healthcare system collapsing in Vermont, it was achieved because of swift action from government and for no other reason. So I know that you played an integral role in that. And thank you very much for that. With that, I'll open it up. Sorry, can I ask you a question? Sure. Just on your inputs for comparison, did you factor in if a hospital had asked for, you know, a rate increase, which most of them did for 2020? So example being, right, if in 2019 during this time period, they did 100 million and they had a 10% rate increase. Of course, we didn't get that. But so in the same period, they would have been 110, right? And now they're coming in at 90. Did you only give them 10 or did you give them 20 for the fact that, because I think that is a mess. So I just want to understand your formula. Yeah. I don't think we calculated that in, but Ina helped me out or Alicia helped me out on it. I don't believe the formula is that I don't believe the formula does include and acknowledge that. Yeah. Because if we're, you know, trying to look at what really was missed, that would have been missed. So if you're looking to spend some more of the money and the hospitals can, they'll say, is this more marine saying this? No. But if you're looking to spend some more of the money, I mean, I think that's a potential way to look at that. Because anything, whether it was Medicaid, Medicare or commercial, if there were rate increases that were embedded into their forecast, that was assumed they would receive that and their expenses are aligned up with that. So if we're looking at that miss, I think that is something that should be factored in. Let us look at it. I mean, there's a second round. But let us look at that. Okay. Okay. Because that, you know, because certainly it was in their budgets and, you know, they're that that would be part of it. So I think it would be a good thing to look at. Thanks. Thanks. Other follow up questions from the board, Robin. Yes, thank you. My follow up question was from your and Mike's interchange. And what I was noticing is that so in our guidance, we did allow hospitals to ask for a one year commercial charge request related to 2020 expenses. And there are two hospitals who did that, who did not apply for AHS relief funds. Brattle borough and Mt. Scutney. So I'm curious. So my reaction to that is that I would want to encourage them perhaps strongly to apply in the second round. So I just wanted to get your reaction to my reaction to see if you thought that was an appropriate request of them. I would encourage you to apply in the second round. Thank you. I think there might have been a third one as well, Robin. Okay. I'm I. For some reason I'm taking Northeast fits in that same. Yeah. No, I think you're right. Yeah. I think you're right. Okay. Other follow up from the board. If not, we'll open it up to public comment. So I have a hand raised from Jeff team and Jeff. Jeff, are you there? Star six Jeff. Just kidding. I do see your hand raised Jeff. Hopefully, yeah. It looks like he's on mute though. From the participants list. He's muted. How do. Star six. Is that true? Is it star six? I think it is for this too. Abigail, anything you can do. Unfortunately, no, he's participating through the computer. So you have to unmute yourself. So Jeff, did you try clicking on the mic? So, so this is Mike Del Treco. I'm texting Jeff to let him know he's on mute as well. I don't know if he's on mute or something along those lines, but I'm happy to. I think where we work so closely together, I'm happy to sort of fill in on the public comment. And really probably what I am thinking he might be saying is, or would want to say is that these COVID funds, we should really look at those as the current year. And not, not 2021. 2021 is an independent year. The losses occurred in 20 retrospective, not prospective. And I think it would be in, you know, great jeopardy to start reducing hospital budgets based on these dollars. Because they're really designed to cover COVID-19 losses. Impacts to expenses. And there's certainly several conditions that were in play. The FEMA piece participating in the value based programs. So, you know, really retrospective, not prospective. And so that would, that's the, the comment that I would make at this point in time. Can people hear me now by chance? We can. Okay. Thank you. I apologize for that. I was literally madly pressing both my camera and my microphone. And they were not responding as I asked. So now the camera is not working. So can't show myself, but I'll just underline Mike's comment. Cause I think he, he captured what I was going to say. And I, you know, cause I wanted to emphasize, I think secretary Smith's point on the cares act money being retrospective, not prospective. And then the only other point I would add to Mike Del Treco's comments is that even at the federal level with the cares act dollars, there was not an intention, at least not any kind of stated intention to mitigate future rate increases or, or otherwise address sort of consumer coverage or cost issues from a system standpoint. So wanted to get that point on the record as well. Thank you. Thank you, Jeff. I see Susan Erin off stand up. Yes. Hi. Thank you, Mr. Chair. So this is either a question for the board or for the secretary, but I am curious about the hospitals that did not apply. Because of the requirement to maintain their existing ACO footprint, their one care participation. I know that Mount escutney was one of those hospitals. I'm wondering which other hospitals didn't apply for that reason. And what you would say to the people who depend on those hospitals for services about that need to be to maintain their ACO footprint if that doesn't seem to be in the hospital's best financial interest. And yet they risk losing out on this money. Thank you. Before I turn it over to the secretary, I do want to point out that Mount escutney did file an amendment to their budget and they are participating fully in the all pair model. So they would, if that's a reason why they chose not to apply, they certainly could do that in the second round. Mr. Secretary. Yeah, I didn't hear of any hospitals that were talking about the reason they weren't applying was because of the requirement of participating in sort of the all pair model. I did, I do anticipate that what was happening was there was a lot of federal money coming in from different places and how it would stack up with the formula. Once all that federal money came in, probably was not going to show that they were going to be successful in getting a grand award with the federal money that was coming in through the door. I think when you see the second round and they can look over a broader period of expenses, they can start to see some of the hospitals that didn't apply apply. Well, with respect to Mount escutney, I appreciate Mr. Chair that Mount escutney might have amended their budget, but what they had filed and what the narrative said, the slides that were presented to the board was that in response to the question from the healthcare advocate, they specifically stated that at that point in time, the reason they weren't seeking the funds was the requirement to maintain the ACL system. I think they're feeling that was just too risky a decision to make at that time. So it just seemed like competing requirements, you know, you want to help the hospitals, but then you have them hamstrung into this risk arrangement. It's a coalition of the willing, Susan. Or the chorus. Yeah. Other public comment? Any other public comment? If not, again, I want to thank you, and I know that you guys have been putting in a lot of long hours trying to get this figured out. And we're glad to hear that it's not just the larger players that are being able to receive some help. We certainly have heard from a lot of independent practices, the hardships that they endured. So I'm very pleased to see that it's a broad brush approach to trying to help the entire healthcare system. And thank you again for all your efforts. Thank you. And thank you for the time. We'll see you later. And hopefully you'll have another celebrity to foist on us in the near future. I think we're out of celebrities. See you later. Okay, with that, I'm going to turn it over to Patrick and his team. And one of the things that I thought might make sense to do first, and I did ask Patrick to work on this, is to try to go through the different provider practice changes transfers and also accounting changes and try to, you know, start to vote on some of those things that are in my mind some low-hanging fruit. Is there any objection from any other board members? Okay, hearing none, Patrick, it's all yours. Thank you, Mr. Chair. Can you hear me? We can. Excellent. My computer has decided it doesn't recognize speakers anymore, so I have to call in today. And Lori is going to drive the PowerPoint. One second, please. Before we get into the accounting adjustments and the provider transfers, we're just going to give the public a brief update on some of the changes we've made since the last presentation, and we provided that to you all yesterday afternoon with the updated slide deck. So in full transparency, we'll run through that really quick, and then I'll turn it over to Lori for provider transfers and accounting adjustments. One second, please. Your's may not be the only computer that's acting up today, Patrick. There you go. Great. There we are, Lori. Okay, so as Chair Mullen described earlier, Mount of Scotty has submitted an updated budget. We have taken care to update the appropriate slides with all of that information. I won't run through all of those because their update does tweak all of the system slides as well slightly. There isn't much of a movement of the needle there, but they have submitted an update to their budget with the intent to participate in the one care programs in the coming year. Lori, if you could move to slide 20, please. We have updated this slide as well to indicate Mount of Scotty's participation. And then Lori, if you could navigate to slides 114, or maybe it's 115, I'm sorry. Yep. Up one. No, I guess it's down to 116. I'm looking for the change in charge slide that we updated for Porter. If I had my slides off, it's 113. So per the board's request, we broke out the overall and commercial effective rates for Porter Medical Center and Central Vermont. We did notice while doing this that there's been an error in fiscal year 17 that dates back several years where we had it listed that they were approved for a 5.3% increase, but they only asked for a 3.7% increase and that does not make any sense. So we're going to own that mistake and we have corrected that. We've also in breaking this out, we recognize while we were doing so that we've been intermingling the two when looking at the approved and submitted overall and commercial effective rate increases. You can see there are several years there in 17 and 18 and in 20 where Porter did not ask for an overall increase in change in charges, but they did ask for a commercial effective rate and were approved for a commercial effective rate. And we've been intermingling the two when looking at the approved and submitted 5 year average. So those figures on the right for both Porter and Central Vermont are going to be different than in the last presentation. And that is why we've been using two different numbers to talk about approved versus submitted. And now we're going to break that out. And as these network hospitals are the only hospitals that applies to, there won't be any correct aid to the remainder of the hospitals. Moving on, Lori, to slide 128, please. I hope I have my number right. Second guessing myself now. All right. It is correct. We have added in some columns that show the impact of the staff recommendation on system-wide NPR, the fourth column to the right, versus the column directly to the left of that as submitted by the hospitals. And on the far right, that would include the adjustments should the board recognize those. And that's what Lori is going to talk about in a couple of minutes. And finally, Lori, if you could navigate to slide 132 through 135. Thank you, Lori. And we were asked by the board, the last go-around, as we made some recommendations regarding hospital provider taxes to post some information within this slide deck. So we've included it in the appendix. And that includes a reasonability assessment that we did on the provider tax, applying 6% tax to the FY 2020 projected NPR as submitted by the hospitals in their budget. And I think that's a good point. And to support the argument we were making last time, we pulled an extract from one of the hospitals submission that talks about how the tax is calculated on the prior year net patient revenue. And because there's going to be a reduction in that revenue in fiscal year 20, the results will be a lower tax in 2021. And our argument has been that there are a couple of hospitals where the discrepancies seem to be not falling in line with that methodology. So on the next slide, we've done a brief analysis of the year-to-year growth in the tax for those three hospitals that we were discussing in our recommendations last time in UVM, central Vermont, and Bratiborah. And you can see here that the year-over-year growth takes a significant spike moving into the fiscal year 2021 budget for the medical center. On slide 134, you'll see a similar trend with central Vermont. And on slide 135, we'll also see it for Bratiborah as well, showing that they are budgeting a half a million dollar increase in their provider tax year-to-year. So those were requested by the board to show support for the recommendation in the discussion last time. So we've taken measures to include that in the presentation updates for the discussions moving forward. So with those updates, I will turn it over to Lori to begin to discuss the hospitals who have either noted some of the provider transfers or accounting adjustments in their budgets. And Lori, when you're ready, take it away. I'm ready. We should be on slide 76. Everybody, I'm sorry. We should be on slide 76. Everybody, I hopefully can see that. We're going to be talking about Bratiborah Memorial Hospital, Montes-Gutney, and Northwestern. But mainly it will be Bratiborah Memorial and Northwestern because Montes-Gutney's adjustments were enhanced services in there. We're just explaining their changes or the growth in their NPR. So we showed you these slides here. We're asking the board to acknowledge slide 78, where Bratiborah Memorial is having just so pediatrics coming out of their hospital and going to their independent primary care instead of staying in the hospital. We're also going to be having the board acknowledge their accounting adjustment for ACO fees, which we ask them to stop netting it against NPR to record it in their operating expenses. So we've asked all the hospitals to do that. And so Bratiborah and Northwestern are showing those accounting adjustments. This year, the other ones had corrected that type of information in previous years. So this is a slide showing the NPR, the expenses, and the profit and loss that is supposed to be affected for July 31st for this just so pediatrics. It's a 1% effect to the NPR. And this was their justification for making this change. As it says on this slide, the Bratiborah primary care consolidated due to the insufficient inadequate just so pediatrics office space and because of COVID. And so they also had clinicians retire and also they had an inability to practice on site due to COVID. So this practice had three quarters of a provider FTE and eight non-provider FTEs. And like I mentioned, their 1% impact on NPR. This chart shows their gross revenue, net patient revenue, expenses, and they're not operating income or loss. And we are asking the board to acknowledge this provider transfer. And it was affected July 31st. Just a quick question for our legal counsel. Is it more appropriate to separate out motions for the same hospital? In this particular case, there's a provider transfer issue and there's an accounting issue. Should they be combined into one motion or separate? In case there's disagreement amongst the board members, I think it's best to separate them. Okay. We put in suggested motion language if you want. This is on slide 86. So just on the practices first, does a board member wish to make a motion? I can go ahead and move. That the board acknowledges Brattleboro Memorial Hospitals request to adjust its 2021 budget to reflect consolidation of just so pediatrics clinic into Brattleboro primary care on July 31st, 2020. And I guess with an impact on their NPR 1% and condition on required notice to patients first in attack 143. So it's been moved and seconded. General counsel, do we have to open it up for public comment on each motion? I think that would be the best practice. Okay. Or have staff go through each of these open it up for public comment on everything and then do the motions and votes after that either way. But yeah, I think there should be public comment on these. Okay. I'm going to stick to one issue at a time. So we're just do the provider transfer and any board comment. Is there any public comment on the motion? Is there any further board discussion? Hearing none. All those in favor of the motion signify by saying aye. Aye. Any opposed? Let the record show that that was unanimous. Lori, if you could move on to the next. Well, Do you want to handle the accounting adjustment first Kevin or? Yeah, I'm not sure that she walked us through that yet though, Robin. Basically, there wasn't that much. All I was talking about was why we asked them to do the accounting adjustment. It was the ACO dues that were included in their net patient revenue as an offset. And now we're asking them to record it in their operating expenses. And it's an effect of a 0.5% to their NPR. Sorry. I didn't say that previously. Okay. So if you could move to that motion, is there a board member that wishes to make a motion? I will move that the board acknowledged. Good. Is there a moved motion? No. Thank you. grandfather Memorial hospitals requested accounting adjustment reclassifying their dues. To one care Vermont. From an offset to NPR to operating expenses with an impact to NPR of negative 0.5%. Is there a second second. Thank you. Just. happened with some other hospitals? And I'm just wondering, are all the hospitals now in the same bucket in terms of how they handle their dues as an expense versus an offset against revenue? As far as we know, we can ask them that question again probably next month in the year to date September report for fiscal year 20th. We want more clarification. Yeah, just trying to make sure it's apples to apples as much as possible. Oh yeah. Very helpful. Okay, other board questions or comments? Is there any public comment? Is there any further board discussion? Hearing none, all those in favor of the motion signify by saying aye. Aye. Any opposed signify by saying nay. Let the record show that it was unanimous vote. And I think we'll hold off on anything other than those type of decisions for a hospital at this point. So if we could move to the next one. Scottney is not necessarily asking you to approve these because this is slide 88 where we're just explaining expansion of services. And so they had a urology and a neurologist. And in total, they have an impact of 1.8% to the NPR. So we are not giving any motion language on these particular, but it was just an explanation for some of their growth. Well, my mind, if we could stick on Mount of Scottney for a minute. I actually think it's helpful if the board does acknowledge it because what we're talking about here with the urologist isn't new dollars to the system. It's dollars moving from a different area. So I think it's important that we do acknowledge that there are new dollars that are added to Mount of Scottney, but there was a decrease in dollars from a nearby hospital. That's correct. So would someone like to make an motion to acknowledge? I can, Kevin, but I would actually like to take a quick look at Act 143 because I think that I'm not sure that this actually falls under Act 143. So I think we could just acknowledge it in our underlying budget discussion. But maybe Mike already looked at that. I did. I'm familiar with it. Yeah, I think we all came to the conclusion that this was not a provider transfer that was covered by that act and by our policy, but was more of a justification for an NPR increase. And so it was not something you really needed to vote on and could kind of absorb into your discussion and deliberation on the on the budget. But OK, I'm comfortable with not taking an action if everybody else is. I just thought it would be better to acknowledge the fact that their NPR shouldn't be a little bit higher due to this expansion. But well, maybe, Kevin, what idea would be to include that as in the order as that as a consideration that went in there or a very good suggestion? Robin, thank you. So, Mike, if you could make sure that it gets into the written order. Yep, I'm making a mental note. Thank you. Go ahead, Laurie. So then the other enhanced service was the neurologist. And that was at the Veterans Hospital. So they're sharing that provider. Yeah, I think we're good with the amount of Scottney now. All right. So Northwestern. They had provider transfers, service enhancements and accounting adjustments. Provider transfers were the Colt Hollow Family Practice and Northwestern Partners in Hope. I'll go to those first. They Colt Hollow Family Practice was in their fiscal year 20 budget, and they found that they did not acquire this practice. So they want to take into consideration that information when they're doing the 21 budget. So these are all negative dollars against their 20 budget. And it was one provider and eight non-providers and it's equal to point 65 percent impact to the NPR. This is the Colt Hollow Family Practice. And this was effective this last January. The other one is the Northwestern Partners in Hope and Recovery. We heard about this one this summer that they invested of this particular practice. And now it's in the community and is equal to one provider, but 11 non-provider FTEs. And it's an impact of point 25 percent to the NPR. And it was effective July 31st, 2020. I don't know if you wanted to vote on those first. And then I'll show you the enhancement. That would be good if you could get to the language on that vote. Sure. The first the top part. So does the board member wish to make a motion? I'll make a motion that the board acknowledge Northwestern Medical Center's request to adjust its fiscal year 21 budget to reflect transfers of Colt Hollow Family Practice in Northwestern Partners in Hope with an impact to their NPR of point 9 percent and conditioned on required notice to patients for certain to act 143. Is there a second? Second. Thank you. Is there board discussion? I do have a question. Go ahead. It's Laurie I did I meant to go back and check on this. So I but I forgot. So my apologies to ask you out of the blue. But the Colt Hollow Family Practice was the practice that we had approved last year. Right. That's correct. OK. And is my motion actually right that we're adjusting the 21 budget even though both of these transfers happened in 20? It's basically how we're doing these type of adjustments. We're kind of adjusting the 20 budget to reflect it'll be less when you compare it to the 21 budget. So actually it's going to show that 21 is more in NPR because of these two practices. Got it. Thank you for that explanation. I'm good. OK. Anyone else from the board if not I'll open it up for public comment on the motion hearing none. Is there any further discussion by the board hearing none. All those in favor of the motion signify by saying aye aye aye aye those opposed signify by saying nay motion carries unanimously. Laurie go to just to give you some idea on the enhancement expansion excuse me is they talked about the ICU Nutella ICU with Dartmouth and they talked about this also this last spring in their request for an amended budget. This is they wanted to offer this to retain the lower QD ICU patients and allow them to receive service locally. It is effective April 1st 2020 and they have zero provider FTEs but five non provider FTEs. This is an impact of 1.3 percent to the NPR. And like we mentioned this is just a justification for any growth in their NPRs. The next one is pulmonology and this is a routine expansion at Northwestern. This is zero FTEs to end non provider FTEs and a negative 0.2 percent impact on NPR. We are not asking for any motion language on that those. So I'll go back to the accounting adjustment and that again is with the ACO and that was 931,000 and that was originally in there and offset against their NPR and now it's going into operating expenses and it's a negative 0.8 percent. For NPR impact. So the motion language is the second paragraph. Is there a board member who wishes to make a motion. I will move that the board acknowledged Northwestern medical centers requested accounting adjustment reclassifying their one care Vermont dues from an offset to NPR to operating expenses with an impact to NPR of negative 0.8 percent. Is there a second. Second. Is there board discussion. Hearing none I'll open it up for public comment. Is there any public comment on this motion. Hearing none any further board discussion. Hearing none all those in favor of the motion signify by saying aye. Aye. Aye. Aye. Those opposed signify by saying nay. Let the record show that the motion carried unanimously. Lori. So with those approved and when you go to make your vote this will be reflected in the last column of this particular graft. So right now at staff recommendations system wide is 2.93 percent growth in NPR. And that concludes our discussion on transfers and accounting adjustments. Thank you very much Lori. If there is no objection I next would like to proceed to what the health system finance team believes might be the low hanging fruit just to see if we might be able to knock off a couple more today. Okay. Certainly. And just to be aware do we have an hour left Kevin. I will leave it to your discretion if you wish to keep going or if you need more time at any point we will delay proceeding till tomorrow Patrick. But as far as my understanding is I think everybody has till 4.30 blocked off. But again we don't we're not going to make decisions if you're not ready to have that discussion. Certainly. Okay Lori if you could proceed to the first slide on Gifford Medical Center please. All right thank you. So to begin the discussion on this year 2021 budget that NPR approval and change in charge here we are again at Gifford nothing on this slide has changed since last week their request is a negative 0.6 percent from prior budget with a change in charge of 4 percent and the staff would approve this as submitted. The change in charge is lower than their historical five-year average and this hospital has budgeted conservatively going into the next year and they have made a solid effort with cost reduction plans in the past couple of years to turn the hospital around financially. And of course there's also the hospital justification here that includes that improvement plan and cost savings programs. This is a hospital to that also has an aging physical plant that is going to have to be updated in the near future and they will require an appropriate level of funding to do so. So with that we would Lori if you could move to the motion language page. First off do we want to show this. Yeah this is more excuse me. That's it. So with that we would turn it to the board to open it up for discussion. Board members Gifford Medical Center. Anybody wish to kick it off. Yeah I'll just you get it started by just saying that they're in compliance with our guidelines. I think we've all followed them over the past few years as they've dug themselves out of a very difficult situation and you know have righted the ship of state at Gifford they seem to have handled the COVID situation very well and with outreach programs like the veggie van go and I you know I can support the motion as presented. Did you wish to make that motion. If nobody else has any comments I'll try to read the motion as well as Robin reads them. I don't know if you can do that. I don't think I can. I'm sure you can. I'm sure you can. But I have a question that is a little bit more of a global question which is I was curious how people are thinking about the CRF money that we just talked about because Gifford is one of the hospitals that did receive CFR money from AHS. So I didn't know if we wanted to talk about that on kind of a higher level in terms of how we're thinking about it. Yeah I think that that's a good point and I just was pulling out their projection and you know they they received about nine hundred thousand dollars in the CRF money there. They were projecting three point six million dollar well they were projecting a one point three million in net operating income compared to their budget of one point five and three point six and total operating income compared to two point four. Not sure how they handled the nine hundred thousand. I'm thinking it's not in there. So it's it's probably just going to strengthen their cash position for this hospital. I am OK with their this request including the change in charge and their NPR request including knowing the fact as well that they did get nine hundred thousand. I think it just helped strengthen their balance sheet and they struggled a lot in the past several years. But but I do think it's important as you brought up Robin to to bring up what people got because it does change their cash flows going into the future years as far as what the amount of cash they'll have and days cash on hand. You know we've heard some public comments about it's 2020 which it is 2020 that this is occurring in but those hospitals that receive money is certainly strengthens their balance sheet if it more if it wasn't reflected in their original submissions. I would just add to that that I think Gifford has the worst age of plant as a problem. They're at a twenty one point three years versus a system wide average of fourteen point seven. So if they can strengthen their bottom line they certainly have a call on on some money going forward in terms of their investments in in in plan. Thanks Southwest. They do have to with the age of plant. They seem to be the two oldest. I can support the budget as submitted for the reasons outlined. I think this has been a turnaround hospital. I think they do need us to support their bottom line. I do think their age of plant is high. They'll need the capital to make those kinds of expenditures. I just want to note my hope is that next year the requested change in charge is on the lower end. They have been there at the top. Their five year change in charge average has been four point five percent. So my hope just going into next year is that there is a way that they can not be at the top and work towards reducing the change in charge. But I do support this budget for this year. And I would echo that same comment in that not only their five year average but their total cost of care for that service area is high. But Giffords if Patrick am I correct a one point eight percent operating margin proposed under their budget. Yeah. So you know that's another reason why I would support this budget is they're not asking to for what I would call the moon. They're asking for reasonable numbers here even though the change in charge does trouble me as it has troubled others. But I do think that this is a reasonable request. I do again think that thank you to government for what they were able to do because not only was government able to help the hospital side of this equation but we heard in the hearings where the FQHC is sitting on some substantial dollars there as well. And again this is one of the three FQHC owned hospitals in the country. And you know they've come a long way from a couple years ago. And so again even though that change of charge troubles me to some extent I'm very supportive and look forward to supporting this budget request. So Kevin if I can chime in real quick Laurie can you scroll down a slide to the change in charge breakout. Yeah so with this approval that FY 16 significant change in charge at 5.8 is going to drop off. So once you average in that 4 percent for this year that 4.5 should be coming down pretty quickly. And just to add again though that the total cost of care in that service area is high compared to others. So you know sometimes I worry about these heavy reliance on change in charge is because what could be 5 percent change in charge for a hospital could still result and then them having lower cost for specific procedures than another hospital that only got a 1 percent change in charge. So that's one of the things that has always troubled me as a member of this board. Other comments from board members. Let me just make sure I know that Tom you were ready to make the motion. So I move to approve Gifford Medical Center's budget as submitted with a six tenth of one percent decrease from fiscal year 2020 to fiscal year 2021 budgeted NPR FPP at 4 percent increase for overall charges and subject to the standard budget conditions as outlined on slide 27. I will second. Okay. Thank you. Is there further board discussion. If not I'll open it up to public comment on the motion. Hearing none. Is there any further board discussion on the motion. Hearing none. All those in favor of the motion signify by saying aye. Aye. Any opposed signify by saying nay. Let the record show that the motion carried unanimously. Lawyer Patrick. Thank you Mr. Chair. Next up we are moving to Southwestern Vermont Medical Center. As you can see their FY 21 request is 3 percent below the NPR FPP request approved budget for fiscal year 20 with a change in charge of 3.5 percent. They did note that they are budgeting down in a few areas where they have not historically hit numbers in recent years but also due to some of the considerations around safety protocols, etc., that COVID will bring about as part of their business, a part of their business moving forward. Again this is a hospital with an average age of plant that is rising. Capital improvements are in the near future. They do have improvements that are really close at hand to becoming to coming to fruition so they will be outlaying some capital to make those improvements. This is a hospital that continues to make significant use of telehealth and will continue to do so so they are kind of on the cutting edge of that and part of that is their association with Dartmouth-Hitchcock and they were operating below budget about 5 percent going into February or pre-COVID. They do continue to plan participation with the ACO and there's no service line adjustments coming for this hospital and they also have a, Laurie, if you could navigate to the next slide, yes, they have a strong history of budget management and even though this is a year of uncertainty, historically their work has proven out very close to what they've come to the board for. As you can see also their operating margin here compared to historical figures is minute at a 0.1 percent operating margin budgeted for fiscal year 2021. So, Laurie, if you could navigate to the final slide, the motion language. This is a budget that falls within our guidelines, the NPR 3 percent below. Budget to budget, a change in charge of 3.5 percent. Staff have recommended that both of these be approved as submitted and we would turn it over to the board for discussion. So I'll start the discussion just by saying that this is a hospital that again has a very old age of plant that I actually hope that this is the year that their actual numbers come in different than their budget even though this is one that has managed to their budget so well. I would like to hope that their revenues exceed the expectations of this budget. And the reason for that is that bare operating margin that is about as close to zero as you can get and I just worry that this is an institution that needs to have a better operating margin than just above zero. But I think the credit goes to them because they recognize the uncertain times that we're in today. And I have to say that I was very impressed with at the hearing by what Steve Majetic and Tom Dee had to say. And so I'll kick it off by saying that I would support the staff recommendation. Others on the board? Yeah I also support the recommendation and just going back to the chart that you had on before with their margins they are all sauce black and they have I think they were getting 6.5 million in the proposal that we just saw from Mike Smith so that should bring them back for their 20-year end projection closer to their budget had been 6 million and they're coming in at 1.5 and I'm assuming that 6 million is going to come in there. So they'll be back on budget. But yes in 21 they did not ask for much at all in their operating margin. So I do support their increase. You know one thing we should note is when we looked at Gifford with their 4% increase they had 4% across the board including professional. This is 5% for hospital inpatient and 5% for outpatient just 0% for professional which is what we see that a lot of the hospitals where they don't change the professional based on the rate sheets they have. But it will be a 5% change for inpatient and outpatient even though the overall change in charge is 3.5. But I'm still supportive of it. I just want to make sure we're acknowledging that as well. Thank you Maury and other members of the board. I would just like to add that Southwestern I think has the highest or second highest participation with in fixed prospective payments. And I think they've been pretty high for a number of years. So that's something to applaud I think. Would a board member like to make a motion or further comments? Go ahead. This is Robin. I was going to say that I agree with what you and Maureen have said. So I'm there as well and I'm happy to make the motion. Okay then I move to approve Southwestern Vermont Medical Center budget as submitted with a 3% decrease in their fiscal year 20 to fiscal year 21 budgeted NPR-SPP a 3.5% increased overall charges and subject to the standard budget conditions as outlined on slide 27. Is there a second to the motion? Second. It's been moved and seconded. Is there a further board discussion? Any comments? If not I'll. I'll speak to my comment actually Kevin. Which is just a simple one. I support this budget as well for all the reasons outlined. But I do want to just point out that my hope again is that the change in charge next year is not in the 5% range simply because their commercial to Medicare ratio is actually the highest of all the hospitals already. So I just want to kind of throw that out there that as we're looking at you know changes in charge next year that I'm hoping that this is a year where they can you know fully recover and find other mechanisms to make their bottom line rather than change in commercial rates. Thank you Jess. Is there anyone else from the board who wishes to offer any comment? If not I'll open it up to the public for discussion. Is there any public comment on the current motion before the board to approve Southwestern Vermont Medical Center's budget? Hearing none I'll throw it back to the board if there's any further discussion. 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 carried unanimously. Laurie and Patrick. Thank you Mr. Chair. Moving on next is North Country Hospital. Their FY21 MPRFPV request is being reduced 1.1% from their fiscal year 20 budget with a request of a 3.6% change in charge. The hospital was operating about 2.7% below budget as of February. Again the pre-COVID months of fiscal year 2020. They are projected to end 2020 and having recovered all of the operational losses from 2017 and 2018 and again this is a hospital that was under financial duress but in the last couple of years has made a rebound in that arena. They did outline some service line changes on all the slide is updated Laurie if you could over here. Divested Derby Green Nursing Home the Neurology Cardiology of Ophthalmology. They are partnering with other area hospitals to meet the needs of their rural community and this is something that has been encouraged by this board as well and the work that they are doing with Dartmouth and NBRH hoping to do with NBRH would kind of meet those aims of the Green Mountain Care Board. So we feel that they are actively exploring alternatives to providing some care and thinking outside the box and that growing collaboration is important to meet the challenges in a rural state like Vermont to provide necessary health care. Laurie if you could navigate down to the budget and margin slide please. So the budgeting margin of 1.7 percent this is in line with what they are projecting for this year and what they received in 2019 and with that it would approve as submitted both the budget and the change in charge for North Country Hospital. Who would like to start off for the board? Yeah I'll just start off I mean I'm supportive of the budget as provided they were one hospital that did appear to get quite a bit of support from all the funding sources and you know do bring them back whole or even more than whole I think we're looking at whether they were going to have to pay back some of the money that they received but I think both their margins this year and next year are well this year could be hot depending on what they get but you know are where they should be so I'm supportive of this this especially with where they can looking at their history of 17 and 18 they're you know back on the right track so. Other members of the board? I don't know much to add I think this is a reasonable request and backed by the evidence and the submissions and I support it and I support the staff's recommendation. Other comments from the board? I'll echo Maureen and Jess. I note that they you know they do have a lot of significant amount of things about two and a half million dollars worth of carry forward from their non-refundable COVID money so there's some cushion there assuming from an audit point of view they can keep it. Their effort on navigators and I mean this being the Northeast Kingdom with a very high Medicaid population and the fact that their bad debt and free care was trending down because of their use of navigators is something I think that other hospitals might be able to learn from and another question I had but it was Maureen's discussion with them during the board in terms of their their top top line you know and you're not having any of that kind of fall to the bottom line but you know so I'm glad Maureen asked the question and I'm glad that I see that you know that question was answered. And I'm I agree with what everybody else said and I could make a motion if you're ready for it Kevin. Certainly. I move we approve North Country hospitals budget as submitted with a 1.1 percent decrease from fiscal year 20 to fiscal year 21 budgeted and PRSPP a 3.6 percent increase to overall charges and subject to the standard budget conditions that's outlined on slide 27. A second. So it's been moved and seconded to approve North Country's hospital budget as submitted and I will say as I look at my notes that and I think I was pretty consistent in my notes that this is one where I probably would have chiseled the change of charge a little bit but I've already ignored my note on a previous vote that we had I do I am concerned just as Board Member Holmes expressed her concern about the rates for Southwestern Vermont that sometimes I think it would be better if increases and change in charges better lined up with our goals of trying to hold health care growth to the growth of the overall economy but it's such a small amount that I do support this motion before I open it up to public comment is there any further comment from board members then I will open it up to public comment would any member of the public wish to comment on the motion to approve North Country hospitals budget as submitted hearing none before we vote I just want to say that kudos to Brian and all for coming in and really acclimating himself to this hospital service area and I think that the days cash on hand and the help that they receive from the federal government puts them in on pretty good footing and it's always a hospital that you would truly worry about because of their lack of drivable proximity to other areas for care so with that all those in favor of the motion signify by saying aye aye aye aye aye those opposed to the motion signify by saying nay let the record show that the motion to approve North Country hospitals budget as submitted was approved unanimously Patrick Thank you Mr. Chair next up North Eastern Vermont Regional Hospital North Country's counterpart in the North East Kingdom this is a hospital again who has used continued and growing collaboration to provide needed services in rural North Eastern Vermont again teaming up with area hospitals as we heard from the North Country presentation in February they were operating about 2% below budget at that time they had lost their ophthalmologists which was having an impact on their overall revenues their request at 3.7% it has over the 3.5% growth rate ceilings set forth by the board for the total change in charge of 3.9% they have a 1.1% COVID related change in charge in MPR if they did not have this their growth in MPR would be 3.3% budget to budget Lori if you can navigate to the operating margin page please again this is a hospital that is coming in with a budgeted margin 2% that is very very close to what they have achieved historically this year they are projecting to obviously miss that piece of their financial goals however overall their change in charge is almost on point their request with COVID is almost on point with their historical averages for change in charge so at 3.6% I should note and with that we would approve both as submitted the 3.7% requested growth and the change in charge with the 1.1% 1.1% COVID component as a part of that before we start before we start to talk about this motion I think that I have been lapsed Patrick in that you had a slide that had all the standard budget conditions we have not referenced that at that point I think it might be important for us to reference that slide and make a motion to have it apply to all the budgets that we've approved so far and then reference it on each of the motions going forward certainly yes we put this in there on the advice of our legal team it is often cited the standard budget order condition so we decided that we would put this in the slide deck for reference in the motion and I believe you want me to reach through each one of these for recognition purposes for the record or well you have in the past there was one change that we made was that has that change been reflected on here yeah that was the Lori was that the timely filing of all provider nope that was the hospital shall continue to file all requested data and other information in a timely and accurate manner before this we had it in each recommendation as an additional recommendation but to your point Kevin a couple of meetings ago there's not a time in the future where we're not going to want or need monthly data from these hospitals to analyze just given the the situation on the ground in our state so we put that in as a standard budget order condition that would be in each single motion that the board makes and clearly an important piece of each one of these is the sustainability planning so that that's part of everyone's order so is there discussion by the board on the standard budget order conditions the only thing i know it is i i know there was a reference to the standard budget order conditions in the gifford emotion i mean redundancy is not going to be a problem but um yeah i know i know it was in the gifford one i think i just want to make sure that everything is covered so would somebody like to make a motion i am moved that we approve the items on slide 27 as standard budget order conditions to be included in every hospital's budget order second that's perfect then we don't have to bring it back up again so that that is um prospective as well as retrospective correct member lunch or correct thank you and it's been seconded by member holmes is there discussion by the board if not i will open it up to public comment on a vote on the motion to approve the standard budget order conditions for each of the hospitals is there any public comment i think i saw a hand flash for a second but it disappeared hi kevin this is mark um to the last item on the sustainability planning i just want to reiterate the hospital stance on the amount of effort and the amount of administrative work that needs to go into that item and you know refer to with a boss letter that they previously submitted to the board let the record so no is there other public comment mark was it your hand that had gone up quickly and then went back down or yes it was kevin i actually thought i raised my hand then you slapped it down i would never i'm sorry i couldn't resist yes it was too much respect for you go ahead we have these on our slides for the motions like tom said um on 27 southwestern on slide 39 we made a point of making sure that that budget condition language referred to that slide okay well this will just clarify clarify it for everyone any other public comment any further board discussion if not all those in favor of the motion to approve the standard budget condition signified by saying i i those opposed signify by saying ne let the record show it was a unanimous vote patrick okay pick up where we left off with northeastern our recommendation to approve the npr increase at 3.7 and the change in charge at 3.9 percent which is inclusive of the 1.1 percent covid rate and we would turn it over to the board for discussion on the northwest or northeastern vermont hospital discussion on northeastern vermont regional hospital board members so this is robin i will jump in because this may throw a wrench in the monkey works so i'll do it early but i'd be interested in other people's perspective so it looks like northeastern is one of the hospitals that were asked for the covid increase of one percent which looks like it's about according to their one percent of charge is around 375 thousand it looks like from my notes um and they are also one of the hospitals that did not apply for the ahs funding so um but they did in my notes it indicates that they applied for fema so it seems like they would at least be eligible for that 25 percent match of their fema however much that is um so i think for me personally if there's the ability to get federal funding to support those covid expenses that would be my preference but i i also would want to um hear from other folks on the board and others as to whether or not their covid exchange in charge was meant to represent some other time period or something like that even though i think our guidance was for 2020 expenses do we have a representative from north northeast on this call yes it's bob hersey hey bob could you address the answer again right so the money that's available from fema and others goes away when the public emergency goes away and we're expecting that to go away before we have to incur these expenses so we won't be eligible the money we're asking for or showing as covid related charge increase they're going to be incurred after the eligibility period for fema and other funds and bob am i correct if i recall your testimony at hearing um weren't you talking about these funds being used for changes that are going to have to occur and continue to occur as far as patient care with screening and PPE and things like that am i wrong okay no you're absolutely right no it's the PPE the screening and the the sentries at the front entrance to screen visitors yes and the testing tent we're going to have a testing location outside of the hospital that we have the staff as well and again those expenses are going to go on after the availability of fema or the aj fund period and and were you able to apply for fema funds bob uh we are um of the opinion right now that we've gotten more already and and state and local and federal support and we're going to then we're going to be able to justify by the increased costs during this fiscal year and during the public emergency period so similar situation we did not apply because right now we're thinking we're going to have to pay money back as it is so if we apply for fema we're just going to have to pay more money back right i just robin had thought that you had mentioned that you're applying for fema in which case it would probably would have been 25 that would have been eligible for the state dollars but that not being the case robin did you have further questions for for bob while he's on the line nope that's answered my question thank you sure and thank you for being on the line bob we appreciate that sure yep other board members i guess i would just say just in line of that conversation i really appreciated that northeastern uh pulled out that 1.1 percent of their 2021 fiscal year 2021 expected COVID related charges because that would um presumably assuming we get through this pandemic at the end of 2021 those costs would sunset and so it wouldn't be baked in the base of the commercial rate or the charge going forward so i really appreciated that and i um i appreciated your answer to that bob that question you're welcome so i actually support the uh go ahead go ahead i was going to say i support the staff's recommendation on this on this budget i'd like to remember i also am very deeply appreciative that you did um put in that request and i have to believe in my heart of hearts that all hospitals have had to change their practices and will have screening and PPE expenses that will go into uh 21 and i wish that more had taken advantage of that um bifurcated rate um but that's hindsight and um with that being said i support um the staff recommendation for northeastern other board members yeah i support it as well and also want to echo that i appreciated that they separated out the COVID piece the 1.1 and i supported it well as well it seems that northeastern is on a good path in terms of competing with its neighbors at north country um in littleton um their provider tax calculation was exactly at six percent i applaud that and i can support the motion shall i make a motion that would be good okay uh i move we approve northeastern vermont regional hospitals budget is submitted with a 3.7 percent increase from fiscal year 20 to 21 budget at npr a 2.8 standard increase to overall charges of 1.1 percent COVID 19 related increase to overall charges and subject to our standard budget conditions as we've already approved i'll second is there a second i hear a second from member holmes it's been moved and seconded is there um further board discussion hearing none i'll open it up to public comment does any member of the public wish to comment on the motion to approve northeastern vermont regional hospitals budget as submitted hearing none i'll throw it back to the board for any additional comment or question and hearing none all those who support the motion to approve uh northeastern vermont regional hospitals budget as submitted signified by saying i i those opposed signified by saying nay let the record show that the uh motion carried unanimously patrick thank you mr chair next up is grace cottage hospital their budget as submitted represents a 5.3 percent increase over their fiscal year 20 budget which is in excess of the 3.5 percent growth ceiling and they submitted a 3.2 percent change in charge um as of february grace is operating about 6.8 percent below budget um we looked back at historical growth which is averaged about four percent annually and in looking at that we believe that yes there has been a history of aspirational budgeting as the board puts it however we also consider that all budgets aspire to be actual at some point so we look back in average growth rate of about four percent over these years represented on slide 54 and so we don't believe that uh volume will solely contribute to their mpr request as the hospital cited i think there's some um demographic changes that they were thinking were going to drive their volume certainly covet is going to upend um some of the demographics in this country but that is yet to be borne out and if that's the truth we would expect to see that in the years to come but probably not this year um therefore lori if you can navigate to the um motion link thank you also i'm looking back there they are budgeting for essentially a break even year operationally um so due to that because of that the logic that i've just expressed we would reduce their npr fbp budgeted growth to reflect that average year of your growth of four percent from 15 to 19 and we would approve their change in charge as submitted and of course um built into that uh reduction in npr would be commensurate reductions to their operating expenses and with that we would turn it over to the board for discussion so board members question for patrick or comments on grace cottage hospital's budget well this is one that go ahead cool um yeah i have an issue with their the npr requests that were coming out with um going back to um what they had requested um you're looking at this chart here the issue i have is um they missed their budget every year and um one of the things that we had brought into guidance before was that if the hospital um was missing their budget that we would go no higher than five percent off of their projection um and not the three and a half percent so when i look at what we approved from 19 to 20 we gave them the three and a half percent um increase year over year if i go back and calculate from the 18 735 that they did 19 a five percent increase and then take a three and a half percent increase on top of that that would get them to about a 20.4 million versus the 21 million um it's also important to note that as patrick said through february they were seven percent behind their projection um and um if we do recall last year we did make them bring it down somewhat from their budget and they were opposed to that adjustment um and they still came were coming in seven percent short of that so if i took their seven percent decline that they were trending at look at that up there on their 20 projection and then carry that forward by 1.035 that would bring them to 20.2 million um so i do not support giving them over three and a half percent increase um for their npr and if anything i would talk about should we reduce it to two percent and and i just want to really um express the rationale is because this hospital has consistently missed their top line every single year and they're and they lose money every year because their expenses are tied to that top line budget so i do not want them to pull back and not do anything or refuse services but i just don't see that they're going to hit the top line number i'm okay with the change in charge of the 3.2 um but again i i don't support i certainly don't support going to four percent uh we could talk about whether it should be three and a half percent um personally i think it should be a two percent increase because of their misses in the prior years and because of our prior guidance of saying you could be five percent off for your projection so marina i would support if you went down to the 3.5 because clearly that was the guidance um i'm a little bit concerned about going too much below that only because grace cottage uh reported um stronger numbers once the pandemic um hit and other hospitals what what they noticed in their area was that um because of their location there were a lot of second homeowners that came in and through whatever had twisted ankles or things like that um they did not see the drop in in revenue as much and part of that is because really it's different than most hospitals yes it has an er but um you know it's it's more or less a large medical practice it's our smallest hospital in the state and in some respects i i think small is nice in that respect i also have always felt bad for grace cottage being the hospital that pays into provider taxes but doesn't receive anything back but but i do believe strongly they did not make a case to exceed the guidance of the 3.5 so i would be with you on that but probably not with you on two um other board members i share moraine's concern i i note that in their budget that um for 2021 they were using um it was like 800 and $882,000 and kind of carry forward um covid money and i just worry given the growth and spending that they are going to hit a cliff at the end of 2021 they they do have some additional federal money and it's quite a bit of money at least uh i think it's like three million dollars of covid money at the end of 2021 but they're unsure whether or not they can justify keeping that and so it's you know it's like other hospitals subject to an audit they also have a very old age of um age plan at 18.8 years so i would like to tear down um i can agree that tearing down um to kind of soften the landing from the federal money to a lower npr growth rate i'd also be open to increasing the change in charge you know to kind of uh you know by you know a percent or so to kind of you know have those those uh uh you know the the um the loss of the federal money to have some support underneath them but um so that so i you know i could support um you're lowering the npr and increasing the change in charge it's such a small hospital it's not going to make or break the system and uh small is beautiful i think to some extent in townsen so i'll look in there go ahead jess oh okay i was going to say that i um i also support reducing the npr probably closer to three and a half um maybe not so far down as two but when i look at it i do think this is an aspirational budget and i appreciate that the hospital budget team looked at the four percent actual growth from 15 to 19 but 15 to 16 was the big year of growth for this hospital if you if you start from 16 and you look up 16 17 18 19 they're averaging much lower average growth rates so the more recent trends have been closer to three percent or sometimes you know less than that uh growth rate so i would be comfortable with a three and a half even maybe slightly lower than that uh but you know certainly i'm not comfortable with four i think that's aspirational and for the same reasons that morian outlined this hospital has not their expenses have exceeded their uh npr year after year their operating margins have been negative you know i think their expenses have to be in line with what they're actually going to receive in terms of revenue um and so i think this might be the year to help them on that path this is robin i'm go ahead no you go ahead no you go ahead i was i was gonna say i'm uh i i'm on board as well with reducing the npr um and uh i'm comfortable with the three and a half percent uh guidance amount um and i guess that's really all i have to say yeah and i mean i can um i i can agree to the three and a half percent because we didn't put in the budget guidance this year the five percent you know two based on um projections but um i don't think they're gonna hit so i mean it's just a caution to the hospitals because your expenses are rising significantly um up a million and a half or up a million seven from a 22.2 million budget and 20 to 22.8 million so sorry up 700 thousand um um that you know it definitely could create an issue of continued loss and you know just one thing on the four percent year over year that's on the actuals and we're now putting a four percent to the budget which they miss the budget every year so that's why i i don't agree with the four percent because on an actual to actual basis they've gone up four percent but i would then go back to their actuals for 2019 and hit them up four percent and then four percent it comes up to a much lower number when you look at it to budget but i can go ahead with the three and a half um i don't think uh a change an increase in change in charge um and the other thing tom remember on this hospital they have uh the payer mix where they really don't have a lot in commercial they have much less in commercial payers and that's one reason um you know that those increases haven't generated a lot so yeah it was 34 percent Maury would you like to make a motion sure uh move to approve grace cottage hospital budget with an npr fpp increase of three and a half percent from fiscal year 20 to fiscal year 21 budget with commensurate reduction to expenses uh 3.2 percent increased overall charges as submitted and subject to the standard budget conditions as outlined on slide 27 is there a second second it's been seconded by member launch further board discussion so um i'd like to amend the motion um i'm looking at their change in charge history and on average it's been a 4.3 percent over the last uh five years uh like the hospital that we talked to her about earlier the 5.8 percent is the one in 2016 and that falls off the table and uh i fully understand what marina is saying is that when you look at the the um uh you know the distribution um you know at 3.2 percent a change in charge yields only a couple hundred thousand dollars in commercial but i think for a hospital like this every bit counts and i i think that they put themselves you know out in a position depending on this federal carry forward money too much and um so i'd like to amend the motion to include a 4.3 percent change in charge which is their um long-term history is there a second to the uh the amendment hearing none unfortunately tom your motion to amend fails will be the first time so with that i'll open it up to the public comment on the motion that uh is before us which is to approve grace cottage hospital's budget with an npr fpp increase of 3.5 percent from fy 20 to fy 21 budget with a commensurate reduction to expenses a 3.2 percent increase in overall charges that submitted and subject to the standard conditions is there any public comment hearing none is there any further board discussion hearing none um all those in favor of the motion signified by saying aye aye those opposed signify by saying nay let the record show that the motion has carried unanimously and as i'm watching the clock patrick i notice it's 4.25 is this the logical time to stop for today and commence tomorrow at 8 30 yes i would say it is yeah and do i have that time correct 8 30 tomorrow i believe so yes great so with that um is there a motion to adjourn for the day kevin um before we adjourn can uh we have any insight as to what the next couple of hospitals might be for tomorrow i think all the remaining hospitals are what you should be prepared for tomorrow every single one it's an all-day board meeting and whatever possibly can be accomplished tomorrow should be accomplished tomorrow got it is there a motion to adjourn today's meeting sound moved second it's been moved and seconded to adjourn our meeting i'll see everybody tomorrow at 8 30 i haven't gotten to call the motion i haven't forgotten to call it i'm just reminding everybody before i do just that um we'll be back again at 8 30 so with that all those in favor of the motion to adjourn signify by saying i hi hi you opposed let the record show the motion was unanimous see everybody tomorrow at 8 30 thank you everyone