 Well, it is one o'clock so we're going to get started and my name is Kevin Mullen chair of the Green Mountain care board. I'm going to call this meeting to order. And the executive director is on vacation this week. So I'll just announce a few public comment periods that are open in her place. And the first is the board is accepting public comment July 28 through September 1st on the fiscal year 22 hospital budgets. The second comment period is the board is accepting public comment June 30 through August 10th on the proposed rules for data submission and data release to replace the current rule that governs data submission and data release for Vermont's all pair claims database. The Vermont health care uniform reporting and evaluation system v cures. A public hearing is scheduled for August 2 2021 at 2pm on this. And the final one is the board has asked its advisory committees to provide written comment to inform a potential future agreement with the state of Vermont. And CMS the board encourages the general public to comment on this information at any time so that feedback can be considered by the all pair model signatories. The governor's office, the agency of human services in the Green Mountain care board. With that, it's my understanding from legal that there we have nothing for required announcements. So the next item on the agenda will be the minutes of Wednesday, July 14th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, July 14th without any additions, deletions or corrections. Is there any discussion? Hearing none. All those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Great. So now we're at the point in the agenda for the main purpose of today's meeting. And as you recall, this meeting is about hospital budgets and Patrick Rooney, along with his team of Lori Perry and Caitlin Hoffman are going to present us with some initial analysis of the submissions and talk about hospitals that may or may not qualify for the presumptive approval and therefore dropping the necessity for public hearings on those hospitals. So with that, I'm going to turn it over to Patrick and Patrick, take it away whenever you're ready. Thank you, Mr. Chair. I will begin sharing my screen and please let me know when you can see the presentation. All right, great. Then we will get started. As the chair, good afternoon, everyone. First of all, thank you for taking part in this kickoff to the hospital budget process for fiscal year 2022. Just to start here real quick, I want to thank the team, the finance team here at the Green Mountain Care Board for the work they've done on this. This is probably the most comprehensive preliminary review that we've put together in some years. And the work of Lori Perry, Kate Hoffman and Russ McCracken and their contributions to this initial review of hospital budgets is exceptional. And I really want to acknowledge their participation. I would be the one doing all of the talking today, but I certainly want to acknowledge that the work that they've done behind the scenes is why you're going to see this perspective today. So with that, as the chair recognizes, this is the preliminary review for fiscal year 2022 hospital budget submissions. You'll note the asterisk there that these submissions are of July 19th, 2021. And part of the reason we call it preliminary is that there are usually ongoing, sometimes material, sometimes immaterial changes that occur to some of the submissions post July 1st. So some of these figures may change between now and when the board decides to deliberate. And the other reason we call it preliminary is that in a few weeks, we'll begin a very important component of this process that is the hospital budget hearings where hospitals, you should come in and inform the board to their specific situation at their organization. And there's a Q&A session to be claimed from that activity. So there's a lot of information that's derived that that goes into the deliberative faction of what we do here and ultimately leads to the decision. So I'm saying all of that because we did not do a preliminary review last year. COVID's impact gave the board reason to shift around some of their chronological ordering of this process. And so at this time last year, we did not have hospital budgets yet submitted. They did not come until August 1st. So we're picking back up with this historical process here and providing the board a high level overview of where hospital budget submissions and the data they're in are coming in for this fiscal year. And as the chair discussed, we also have nuance this year around public budget hearing exemptions and we will get into that discussion as well as we navigate the slide. I will do my best to announce slides as we go through them, but if there's a reason for me to, if you need to stop me and remind me to do that, please feel free because I want to make sure that everyone can follow along. To begin here, here is the order of operations for this process. On July 1st, we received the submissions. Here we are today, July 28th, preliminary review and the review of hearing exemptions. And in a couple of weeks, we will begin the hospital budget hearings, whereas I've said the leadership will come in and discuss the individual circumstances at their organizations. Point of order here is that on the 16th, that's actually Bennington Battle Day. That is the state holiday, so state offices will be closed. Hearings will actually start on the 17th, and we have a schedule that Abigail Connolly has graciously drawn up for us that is in this spreadsheet later on as we will wrap up this presentation. After a couple of weeks of the hearings, we will begin deliberations on September 1st and throughout the next two weeks, the board will deliberate and at some point make decisions on hospital budgets with September 15th being the deadline for board decisions. And then the two weeks after that, leading from the 15th up to October 1st, this staff here, the finance staff and Green Mountain Care Board Council will work to draft budget orders, and we will deliver those on October 1st, 2021. So on slide three, we want to acknowledge a very important piece of this regulatory budget process, and that is the public comment. The board has received three public comments to date. We are open for public comment at any time, but we will open that comment section specifically for hospital budgets after today's meeting, and we accept public comments throughout that process. So we have some links here to help facilitate some of the knowledge that individuals may want to use in addressing their comments. And then down at the bottom here, we discussed that we would like to receive your comments by September 1st so that they can be considered for that two week deliberative process that ends on September 15th. And if you would like to make a public comment, we have a link here as well to help facilitate that and be encouraged folks to do so. And all you have to do is you can access it straight through the slide deck that is on the screen here. So getting into more of the budget process components of this presentation, the board did decide in the fiscal year 2022 hospital budget guidance that MPR FPP growth will be set at 3.5% over the FY 2021 approved budgets. And that does allow for an allowance to be deduced from that potential growth that is related to the COVID-19 vaccine testing revenues that the hospitals have received as part of standing up the public good effort to get this population in Vermont vaccinated against the COVID-19 virus. So we do have a few different perspectives on relative data points as we move through this where we've manually adjusted with information that was submitted from the hospitals, some of the NPR and operating expenses in projections and budgets to help provide context around what that growth looks like. So documents and information we've collected, I would like to thank the hospital staff and the leadership for providing the information necessary for us to aggregate and sometimes de-aggregate a large quantity of information to help facilitate the board's decision making. And here is some of the items up on the screen on slide five regarding narratives and presentations. I won't read through all of these. I'll just give you the high level ones. Year over year changes as it relates to certain financial components, risks and opportunities of your organization, value-based care participation, capital investment cycle. And then this year we built out a variance analysis financial workbook to in part gather some more granular detail on some items that board members have deemed important in their decision making. But in the past we have not gathered at that specific level. But also this is where we gathered information relating specifically to COVID so that we could provide for that allowance that I've already spoken for. And also allow the board to understand how relief funds advances and whatnot have aided these hospitals in passing through this current fiscal year and the continuance of the public health crisis that is COVID-19. From our adaptive database perspective, that is the database that we collect the majority of financial information in that allows us to keep our year over year records and to provide many of the perspectives that you're going to see throughout this process beginning today. These are some of the items. These are high level. There's certainly a lot of detail that goes into each one of these that the hospital provides, but this is a high level capture of the information that we have requested from the hospitals for this budget process and most budget process under normal circumstances. Continuing on the process piece, we do have this year the potential for exemption from public hearing under Act 91 authority to open the exemption from public budget hearings to all hospitals that meet the criteria set by the board. The criteria can be seen at the bottom of this page. An exempted hospital will not have its budget adjusted by the board unless requested by the hospital in the year for which it was exempted. The board established an NPR rate request, growth rate request of 3.5% or less. That includes an allowance for net patient revenue fixed perspective payment related to COVID-19 vaccine testing. So if your initial growth came in over that and using that allowance, it brings it under that qualifies for this component of the criteria for hearing waiver, a charge increase of at or under 3.5%, continued involvement in value based care reform that is not limited to ACO participation, and then budget assumptions, the submission and content are deemed reasonable, reconcile and comply with guidance. Some considerations for the board as they hear the presentation today and as we move through hospital budget hearings and deliberations is that budget guidance and adequately justified request on NPR growth rates with an allowance of COVID-19 and vaccines. Again, we will be providing you with multiple perspectives to help you align what that growth looks like, the impact of charge on commercial rate payers, adequately justified provider transfers or accounting adjustments. As we know that can reduce or grow net patient revenue and we want to make sure we're accounting for that activity appropriately. Hospitals overall financial health due to COVID-19 including operating margin and other key financial indicators and the hospital's capital and infrastructure needs. Those asset management obligations often come with a sizable price tag and that is something that the board, we feel the board should consider as they navigate these budgets. Additionally, continued participation in the all payer model and value based care. The hospital's specific risks and opportunities is an area we've highlighted in the past few years. We should continue to look at that under considerations, cost savings initiatives and how we're suppressing costs in the system. Leadership turnover workforce as it relates to traveling staff and I would add the topic of burnout to that discussion. Given the public health crisis utilization trends and then other revenues and again this goes to the COVID-19 revenue replacement funds that have been largely taxpayer debt funded to relieve the health care system of the burden of costs that and revenue reductions that COVID has brought about and also those vaccine and testing revenues that have come from standing up clinics to get the population of the month vaccinated. We also want to call out some common themes that we've seen in the narratives thus far. These are in no specific order, but that 340b revenue is at risk. We began to hear that narrative expressed in last year's budget proceedings and it comes through the narratives over and over again that the heat is really becoming to be applied to 340b from pharmaceutical companies who no longer want to honor some of the activity that's been going on there and that's been a kind of a growth area for hospitals and their other operating revenue for several years now. And it appears that that outward pressure is being actively placed upon that and hospitals have concerned around those the future of those revenues. We have renewed strategic plans and budgets. We have several budgets where hospitals have acknowledged that they have renewed their and revive their strategic plans. Following the public health crisis and that these budgets are the first stepping stone in attaining the success of those plans. Emergency department or emergency volume are not coming back. Staffing challenges continue including burnout as we just discussed. Capital expenditures are being jump started after a period of delay given the financial uncertainty caused by the pandemic. We have increased inflationary factors that hospitals are outlining that are leading to higher expense growth in several categories going into fiscal year 2022. And the use of 2019 is the base for things such as utilization assumptions in these budgets. Several hospitals are hoping to get back to the level of care that they were providing pre-pandemic. And that FPP is not the only form of value based payments. Other reform payments totaling 5.2 million system wide. It's not a huge piece but as we continue to tie the value based side of regulation to the hospital finance side we felt the need to call this out. And oftentimes things start small and ramp up relatively quickly. So it's something that we want to keep an eye on as we move through the next couple of years in our regulatory processes. Change in charge one of the two largest decision points that the Gremount care board will make. You can see here we've applied a short history for your intake and that's on the far right hand side here on slide 12. You will see each individual hospital's submitted request and then you will see the estimated weight and average at the bottom of 6%. And that is calculated off the gross revenue to the change in charge rate. So system wide we're looking at an estimated weighted average of 6% which compares to submitted 2021 of 6.8 submitted 2020 of 3.2. And as in recent years in this process and other reporting that we've done to the board we've begun to provide a little more perspective around how each hospital. Change in charge has turned out usually a five year look so we're continuing to that we've provided five year average and a five year median. And you can see where each hospital falls in that respect. This is not necessarily directly correlated to board decisions. If hospitals ask for lower rates and the board grants them they could end up on the lower end of the spectrum as well. So this is not in any way to be taken as this is the impact of the board's decision on the whole. This is how matters have shaken out over the last five years per an average median. You'll see Porter Hospital has been zero since 2017 they have not requested an increase in their rates over that period of 2017 2021. They along with other health network hospitals have opted for a commercial effective rate increasing their margin on commercial business. So their charge master is not necessarily increased, which is why you're seeing that 0% there at the top and then being on the bottom of that five year median and average. And this view continues to be it's a big data dump but it continues to be very valuable, especially when we're considering all of the fluctuation that is still being felt from covid's impact in fiscal year 2021. We also know that budgeting last year and potentially this year is still extremely difficult given the unknowns. So we want to provide a dollars to dollars actual to budget to projection to budget look at how hospitals have fared over the last couple of years to provide again context around what has occurred. And you're going to see this throughout this presentation that we're providing different perspectives on relative data points because covid is not is making it very very difficult for us to just look at some of the standard perspectives that we have in the past so in order to call out some of that stuff. We're trying to find creative ways to project that information to assist with the board's decision making as it relates to the fiscal year 2022 budget. As I noted before, due to the allowance that we are offering as part of this process, we are going to provide a couple of different perspectives. This is a very relative look but we are extracting out the dollars on the far right-hand side here on slide 15 from projection 21 in budget 22 as it relates to vaccine clinic and testing revenues that have been or are anticipated to be received throughout 2020 the rest of 2021 and in budget 2022 so we're pulling that out of this you can see those system wide numbers shift slightly and then on a hospital by hospital basis it differs according to their specific circumstances. Again, another perspective here we're providing the NPRPP percentage change across these various categories 21 to 22 budget 21 projection to 20 budget 21 budget 22 budget adjusted for covid allowance 21 projection adjusted for covid allowance and 22 budget adjusted for covid allowance and then we're providing a CAGR there to help again try to tie some of this together as to what the board feels is reasonable growth over what is a very shaky period of activity to assess. So on slide 17 we're trying to provide a more illustrative approach to some of the information that we've gathered as I discussed early on the appendices and variants workbook became much more detailed this year. But this is how the reconciliation tables on tab one of that workbook are visualized and not everyone can look at those tables and derive from it the activity that's going on. So we wanted to take a system look and show people board members included but also folks at home who may not follow this process in depth Lee just to give the better projection of what are the main drivers of NPR from budget to budget and because the board looks at and sets a rate budget to budget on NPR growth. We wanted to visualize that for folks as to what's causing a suppression of NPR growth and what's generating NPR growth and so you can see here. We're starting out on the left hand side at 2.789 billion dollars that is the system total for approved budgets and fiscal year 21 that the Green Mountain care board approved right to the left of that you'll see a black line right here. This is important because this is acknowledging that we're not starting from zero. We're starting at that 2.75 billion. There's a whole lot of activity going on underneath that that gets us to that 2.789 billion dollars and that is the total budgets last year. This chart would be very unseemly if we were to have that in there. So we have to shrink that down to show to maximize the effect of the illustration that is this growth. So what you're seeing here is you're seeing hospitals have submitted that reimbursement and payer mix changes are suppressing revenue growth by about 23 million and then bad debt and free care suppressing it by 3.2 million other by about a million. And then we start seeing the activity that's contributing to that growth. So we're bridging or reconciling from the approved budget to left to right to the proposed or submitted budgets for this year. And so then you begin to see utilization contributing 33.4 million UVM's billing variances or what they call rate difference. Attributing almost 77 million and then the rate effect the rec the combined request the net request of that where rate impacts MPR $82 million. Now I'm not going to go into the specific UVM piece they've called it rate difference it is circumstances specific to their hospitals they are prepared to talk about that at their budget hearing. So in order not to misstate the facts as they will present them I'm not going to go into that topic publicly but you can see we wanted to call that out. It's a very major driver of how they see their year progressing from budget to budget and because of the magnitude mostly the medical center you can see that it's the second largest contributor to MPR FPP growth budget to budget. So we've taken this look throughout some of the higher level financial factors MPR other operating revenue operating expenses etc to show you what are the major drivers and our plan is to adapt this to each individual hospitals. Deliberation profile to help again provide context to board members around what is their budget requests really mean and what are the drivers and do we believe that those increases are deemed reasonable. So again we have to provide another perspective here we've carved out about $10.6 million in COVID vaccine and testing revenue here so you can see that the starting point is the same on the right. All of these numbers remain the same with the exception of that carve out and on the far right hand side the proposed budget growth drops to 2.958 and I will go back up just to highlight this. When we go to this at the bottom on the far right on slide 15 you will see that 2.958 the system total and without the allowance you will see the 2.969 system total so we're providing that bridge or reconciliation in a more illustrative way. To help folks see what the major drivers of this are from a system perspective and we will cater this to each individual hospital when we get to deliberations. Payor mix is always a major component of this process. We tend not to see a whole lot of shift on a system level and we're not seeing that we are seeing that here as well you can see there's not a whole lot of movement here. What we've seen in the past is once we get into those specific hospital profiles through deliberations then we tend to see the impact on the individual hospital. So the payer mix is important. It doesn't quite highlight the shifts that are going on at each one of these organizations because when they're all put together it kind of gets thrown out in the wash. So when we get to those individual looks you will most likely see some shifting activity year over year as we begin to dig into those more granular details. This is a perspective that we've been providing in years past. It's on slide 20 FPP as a percentage of net patient revenue and FPP. So you'll see the system total is represented by that entire bar blue and orange combined with FPP true FPP making up 14% of that 2.969 billion dollars that have been submitted for budgets this year. We do believe as we learn more about fixed perspective payment and value based payments in general that we should probably have discussions after this hospital budget process is over about how we want to portray this moving forward and how we're going to measure it. We do have an understanding that there are some accounting nuances that may not allow us to capture effectively the perspective we're looking for here. So we'll continue with it for now, but as we learn more about the interaction between value based payments and hospital finance that we may have to shift the way we look at this particular statistic. So just to give a more granular view on a hospital by hospital basis. You can see FPP as a portion of the total MPR FPP and we do have quite a variance here from zero with Grace Cottage. They do not currently participate in fixed perspective payments all the way up to a high of 24% for Southwestern Vermont Medical Center. So again, we're trying to maximize the illustrative value of what Excel gives us and painting a better picture of some of the activity we're seeing here. I do want to point out that you'll see this 66.3 million dollar reduction in specialty pharmacy. That is more of a reporting discrepancy. It's a symptom of the way we did our budget information gathering last year as most people who are familiar with this process recall we scaled back things considerably and we just had a line item for other. We did not break it out into this detailed look so when hospitals went to input their information, their approved information into adaptive in November. It was dumped into one single category for this is mostly a UVM impact into specialty pharmacy. So when you're looking at the budget to budget look as they break things out, it's going to go from a very high number to a much, much smaller number. So this is a reporting discrepancy. It's a symptom of what we experienced last year, but you can see that it has reset the expectation around where this lies. And then you can see each individual component contributing to what is ultimately almost 297 million dollars in proposed other operating revenues for the hospital system in the state of Vermont. And again, providing different contexts and perspectives on relative data points. We've been focusing on other operating revenues for a couple of years now as a growth sector for hospitals. And we know in 2020 and 2021 there's been a lot of taxpayer debt funded relief coming in to support those the revenue deductions that have been placed on these hospitals. Most importantly in 2020 with the cessation of non emergent elected procedures. And then on the right hand side, we have a different perspective of the slide we just showed you and what components are contributing to that nearly 297 million dollars in submitted other operating revenues. Again, COVID relief funding is a is been a major part of this fiscal year as it was in 2020. So we asked the hospitals to compile that data for us. Now that we have a better understanding of how this this accounting works and which we did not last year at this time. We can tell which revenues are being dollars in relief funding to help prop up those the revenues of those organizations. And then we start seeing in 2022 it really dropping off. But even last year when it came to budgeting hospitals weren't sure what the ultimate rules were going to going to deliver them. Some had money left over and they weren't sure if they were going to lose it. There was a lot of uncertainty. Most of that money is being exhausted now or they've received new funds in this year for losses taken last year as was the case with the UVM Medical Center. So it's still not clear as far as I know about what the American Rescue Plan Act will provide for the health care system. So we're not seeing any budgeted numbers for that. And we also don't know from the hospitals how they might be able to justify receipt of those funds. There's still a lot of unknown there. But this is how things stand to provide context for last year and projections for 2021. Total operating revenues that is the addition of NPR FPP plus the other operating revenues. You can see here in slide 25 that the system has now pushed over three and a quarter billion dollars in total operating revenues. And of course this also has the impact of revenue reductions from COVID or whatever. So we're going to see some shifting going on in that territory because those revenues are finite and the accounting for that has somewhat been solidified now. But we're still seeing growth areas there as it relates to the FY 22 budget. So operating expenses, we're seeing some pretty solid growth here. The system is coming up just shy of $3.19 billion as submitted in fiscal year 2022. Again, these have been skewed by factors such as the shutdown of electric procedures in 2020 and organizations having to deal with inflationary factors as they've outlined in their narratives in 2021 and 2022. We're having to continue to maintain supplies of personal protective equipment and other safety protocols that require them to bulk up on supplies. So the expenses here are continuing to grow and we're just coming up shy of $3.2 billion as submitted for this budget. And we also offered an allowance for the expenses related to these vaccine clinics. We've heard stories throughout the year about having to shift staffing and whatnot to make sure that these clinics remain well staffed and that we can keep the flow of patients and vaccines moving as a state. So that alters the projection and budget for 21 with the adjustment slightly bringing that the system totaled down to 3.18 essentially from 3.19. So not a huge adjustment, but definitely offers the perspective of what the system has borne as a cost for standing up these clinics. So again, offering the same perspective we've offered on NPR FPP and other operating revenues except for this time we're looking at operating expense growth and the major drivers. And the same logic applies running left to right where last year's budget totals left off as approved and where they are headed as submitted. So you will see that inflation increases are making up a massive component of the growth from $3 billion to almost $3.19 billion. And then following that is another category followed by new positions as we descend down back towards that fiscal year budget. Now other from a system perspective I realize is not very helpful. That is why we intend to break these down on a hospital by hospital basis because we provide a certain amount of line items that we know are going to impact every hospital. And then we give them some pretty broad ability to cater the rest of that to their specific needs. For example, an example I would give is last year during Northeastern's budget presentation they discussed that they have a drug that is about $600,000 annually. And that was for fiscal year 2021 and in their narrative this year I believe they said that single drug is up to a million dollars annually. So you'll find something like that in that other pool, but that times 14 hospitals. There's a lot going on there and to provide a deeper dive on that is not really a great use of time. That'll be more important when we start looking at individual hospitals as to what is driving that other column because it's very diverse. We did want to highlight the inflation piece because it is the biggest from the system. And so what we've done is we've broken out on the left hand side here on slide 29. We took an average of each of the groupings that we collected from the hospitals and we left this largely up to them to tell us what the inflation drivers were across which categories. So you'll see here we have some wages compensation medical staff wages compensation non medical staff they have identified those to us we wanted more of a holistic look. So this is the first year we've really weighted into the waters around inflation to help provide board members with a better understanding of what that is and what that looks like as it impacts these budgets. So we took an average of each one of those buckets. And we felt we had to have the dollar value piece also on this slide because when you look at travelers and purchase services we know there's an immense cost pressure being put on that because the demand is so high. So we're looking at an average of 52% on what is essentially $2 million. So whereas we have $33.4 million in non medical staff wages of compensation the inflation rate there is about 3% on average. So it's really to provide a perspective about what this looks like and this is something that I'm sure we will refine as we move through this process towards deliberations and decisions later on but this is kind of our first look at the system. And we'll dive a little deeper when we come to the individual hospitals and what's impacting them. So with everything above. We've been looking at this perspective really since the onset of Kobe and what kind of kicked off the staff's review of this was the shutting down or cessation of those non emergent elected procedures and what that what revenue gap was going to exist when that occurred. So as part of that we were trying to get an understanding of how much money was going to be needed to cover the suppression of those revenues by what was an essential order at the time to control the spread of the virus. So we've really taken a closer look at that and in combination with what we've seen in other operating revenues over the years we wanted to call this out to the board to add perspective to it. Other operating revenues continue to be a source of subsidization for the hospital system to achieve positive margins and mitigate loss. And then when we look at the book ends of this graph here in 2016 actuals in 2022 budget as submitted. We're seeing in 2016 that MPR fell short of covering operating expenses by about 41 and a half million dollars as budgeted in 2022 that gap has grown to 200 almost $221 million. It's important that we point this out to the board for a couple of reasons. One, as we've already discussed hospitals are telling us that 340 B revenues which have been a growth area are under siege from the pharmaceutical companies which could cause this gap, which could cause the ability to cover some of those operating expenses to shrink. And also we'd like the board to start asking more detailed questions around some of these other operating revenues especially the big categories like specialty pharmacy 340 B and get more familiar with that because ultimately there's a finite amount of revenue growth and be extracted from the current set of other operating revenues. And if that happens we might see what we've come very close in the past year where those operating expenses begin to outstrip the ability to cover them. And so that might put pressure on your MPR decisions and budget processes in the future. But hopefully also this can help inform some of the other work products that the board is actively engaged in around value based care and sustainability planning and things like that. So it's more making you aware of what we're seeing what the numbers are telling us and what's being needed to help fill that gap and contribute to some of the margin positive margins or mitigate loss on margin. So taking all of that in we want to provide that look because ultimately it's going to end up impacting some of the work that we do. So continuing of that we have here on slide 31 as budget fiscal year 2022 we don't have a whole lot of red on this table and we don't have a whole lot of red in projected 21 either so hospitals currently are faring relatively well. I don't want to overstate that in any sort of way because we are still actively involved in a evolving public health crisis and we know how quickly things can turn. So I just want to point that out that comparatively to something like fiscal year 2019 the picture seems to look a little better. Certainly there is a lot of public relief funding that is helping keep those numbers on the positive side of zero. But either way wanted to highlight that and specifically when it comes to the University of Vermont Medical Center. They did receive several months back some relief funding that is contributing to that projected margin for 2021 that they otherwise would have received in 2020 and it was real relief funding that an organization like Dartmouth Hitchcock received because they're in what CMS is designated as a rural statistical area and the University Medical Center is in what they delineate as a metropolitan statistical area. So UVM met all of the qualifications around providing care for COVID patients that otherwise would have allowed them to receive that funding. But because of the fact that they were in that statistical that metropolitan statistical area they were overlooked. And so I believe they worked with the delegation in Washington to attempt to receive that funding and ultimately they received it. And it was I believe it was around 40 million. And if there are folks from the health network who are on this call after I'm done they can correct me if I have that those facts incorrect. But I want to point that out that those revenues would have otherwise been received in fiscal year 20 but for I'm not the fact that they were overlooked. So as always provided perspective of operating margin percentages which follow the dollars perspective that we provided earlier but it gives you an idea of what that particular margin is per hospital they are relative to the revenues that come in for that particular hospital. So a different perspective in general for each individual organization is an important perspective to have when reviewing that individual hospital. And then we provide this look we started doing this when we were reporting in the middle of COVID to provide what the system looks like, and then what the system's largest hospital University Medical Center looks like and then what the system looks like when UVM is removed economies of scale are very important thing when looking at a system such as Vermont because it goes from everything from about a $20 million revenue generator to 1.5 billion with Grace Cottage and UVM Medical Center respectively. So we felt that this helps this helps detail what operating margin percentages look like when we're providing a system overview. Total margins this is activity that happens in what we call below the line. So after operating margins are calculated there is often activity that goes on beneath the line relating to investment portfolios and pension activity. And there can be some pretty big swings in that I'll highlight the Southwest and Vermont Medical Center. They are ridding themselves of their pension obligation and shifting that obligation over to an administrative company to manage from here on out that will have an impact on their overall financial picture. But I just want to highlight that because the sky is not falling for them, but they're making a needed adjustment in their finances for the long term liability of their organization and shifting pension obligations from a hospital to an administrative or insurance company is not unusual. I believe the medical center is actively looking to do that as well. So I think that pension obligations have become a big item for the financial departments of these organizations. So that is the type of activity you can expect to see under the line as we call it with total margins. So we're going to navigate now into some financial metric comparisons. We've bolstered this look this year. So we are statically obligated to look at these types of comparisons. And so the 18 VSA section subsection 9456 C individual hospital budgets established on the section shall take into consideration national regional regional or in state peer group norms according to indicators ratio statistics established by the board. The hospital budget guidance also noted fiscal metrics of the hospital including days cash and other routine and collective metrics ratios as a factor that may be considered when evaluating NPR FPP and change in charge. So I don't think that overall budgets to that in general. But I want to highlight most importantly that the purpose and use of these metrics is to provide perspective in context to the analysis and the decisions and add value to the discussions. They are not I want to highlight that not intended to be financial targets for any party and these were not adopted as specific targets for this hospital budget guidance process and to make an example of that if one of the peer groups were produced is operating margins of negative one percent. I don't think anyone of reasonable mind would say that we want our hospital shooting for a negative margin. So that's to highlight that these are not intended to be targets there instead intended to provide context and show where our hospitals may or may not be outperforming or underperforming their peer groups. And so hopefully that will help guide your your questioning of the hospitals when you have the opportunity to meet with them. So we'll go through some of the financial metrics that we've highlighted. The logic will apply to the next several slides beginning here on slide 36. So what we've done is we've taken for example here operating margin percentages. You will see a variety of colors here in the bar graph. Each one is projecting the operating margin for eight critical access hospitals on the left and six perspective payment system hospitals on the right up at the top in the title. We've also highlighted what the Vermont median is for that cohort that you're looking at for fiscal year twenty twenty two budget. So with Vermont you'll see it's two percent for critical access and one point four eight percent for PPS hospitals. And as far as the individual lines go you can see down here that the blue line represents that Vermont median. So where we have it labeled as two percent up here it falls right on that two percent line. You can see who's budgeting to outperform. You can see who's budgeting to come right in at that level. And you can see who's going to be underperforming that median. Likewise we're using the flex monitoring data that we've been using for several years now. It's really great critical access hospital financial metrics. So we're continuing to make use of that. And what we've done is we've looked at the Northeast critical access hospitals and then the nation the United States in general. And so the red line and green line show where this metric falls for those peer groups. On the other side for PPS the Vermont median is the same the blue line highlighting that. But this year we've reached out and contracted with Fitch Rating Solutions. They're one of the big three bond rating companies with Standard and Poor's and Moody's. We know of several hospitals who use their metrics to benchmark their individual organizations against peer groups. And so what we've done we've been using this for about a month now. So we're relatively new at it and we'll probably refine this as we as we go in future years. But what we did was part of their tool is that we can scale down on a more specific basis. So what we did was we extracted organizations from their portfolio for Northern New England being Massachusetts, New Hampshire and Maine. And so that cohort is where you'll see that red line fall right there. And then we did the Northeast in general which also captures states like Pennsylvania, New Jersey, New York, Connecticut, and so on. So you'll see where that peer group aligns with the green line there. The Northeast for Fitch and the Northeast for flex monitoring are not the same. There is some difference there, so please don't misinterpret that in that manner. But so this is how we're going to go through the next few slides and pegging that there is a key later on that actually gives you the numbers that these blue, red and green lines are tagged to for each of these hospital designations. So anyone following home can scroll down in the slide deck and see some of those numbers. This is fiscal year 19 information. We feel comfortable with that. It's the most recent available to us. We also have several hospitals as we've stated who are looking to establish a level of operations in fiscal year 19. As it relates to the Fitch rating solutions, when looking at their materials, they generally update the new materials in early September. So if we can get access to fiscal year 2020 information by the time we get into deliberations, we will make sure that we update that so that we can have even more current information to provide for the board. So shifting to slide 37 we have total margins. You can see there's quite a variation here for critical access hospitals. Again, this is that activity that occurs below the line. The Vermont median for critical access is 2.5% for PPS hospitals 2.71. Again, there's a pretty close clustered grouping there for PPS hospitals and you can see Southwestern Vermont being that outlier with the pension activity that they've got. We've noted that on that table so that we are crystal clear that they are not under a significant financial duress. But this is something that's naturally going to occur when they remove such a large obligation from their finances. And I believe if you want more specifics, it's laid out pretty clearly in the Southwestern Vermont narrative. So again, not to misstate anything that's going on there. I would encourage folks to go read that section of the narrative should they want to know more about what's driving that almost negative 34% total operating margin or total margin. Days cash on hand, another big financial metric that many folks like to follow. And I should state as I go through this that all of these financial metrics are interrelated for folks who don't follow finance activity in one can dictate shifts in the other. So it's really important to look at these as a group and also individually, but keep in mind that the activity there can impact the way these numbers shake out. If you don't have positive operating margins and you don't collect your receivables in a timely manner, you're going to struggle with keeping your days cash on hand up. You're going to struggle with being able to make meaningful investments and asset management for your organization. So it's all interrelated. It also impacts the way you acquire debt for asset replacement and whatnot. So keep in mind as you look at some of these that they are all interrelated. It's very important that people understand that. So I just wanted to highlight that as well. But we can see here that for the most part Vermont hospitals outperform their peers for critical access hospitals in the Northeast and the US. And we can say with some confidence that there probably is a little bit of cash hanging around in here from the advances and some of the relief funding. So we may see these numbers rollback slightly as that relief comes to an end and those dollars are either utilized or paid back. So we should put that important context out there as well. But for the most part Vermont hospitals are doing pretty well from the cash perspective. It is important to note as we do every year that Southwest and Vermont on the right only holds their days cash on hand. Their parent company holds even more so they may be underperforming their peer groups from this perspective. But they always let us know that things are much better off when we factor in the days cash on hand at their parent company. Days receivable and other very important metric when it comes to cash flow. The sooner you can push out clean claims and collect on those claims the faster you replace the money that you spend. That is about acquiring a balance for cash flow purposes. So as we can see from here Vermont hospitals do pretty well. I think it's important to point out to I'll pick on Brattleboro here on slide 39 at 60 days. It's important to get context if you have questions ask questions about why maybe they are underperforming these peer groups in the state median. If an organization is undergoing a an update to their billing and financial systems. There are always hiccups that can occur. There are always there's always activity where claims can get held up and claims hold or what have you. And that can cause billing delays and that can cause delays in collecting your receivables. So no one should jump out of their seat and be curious and be wondering why Brattleboro is underperforming the medians. There could be a very valid explanation for that or maybe they recognize that they need to make improvements in their revenue cycle management. It's all about asking the questions and getting the context. So if there's that's why we're putting this together is that if you see something like that pose the question they should have an answer for you relatively quick. We're on the spot in the case of the hospital budget hearings. But we can see here critical access hospitals generally collect their receivables in under 40 days as do the PPS hospitals. And we can see that some of the median peer groups outside of that are not as quick to collect on those. So overall the state the state hospitals are doing pretty well. Days payable paying your bills you can see here that the median is higher than the receivables for both. That's a good thing. That means hospitals are collecting getting their cash in hand sooner than they're paying it out. That's very important. You can't pay your bills with accounts receivable credit. So you need to make sure you're collecting that money in order to pay your bills. So you generally want to see days payable be a little bit higher than your receivable so that you're capturing that cash before you send it out the door. If you're sending out the money before you're bringing it in that days cash on hand is going to come whittling down slowly sometimes quickly depending on what the situation is. Point of emphasis here is that flex monitoring does not capture days payable. So all we have for that is the median. It's the only one of these metrics that they do not offer us a peer group comparison on. So we're going to stick with just the Vermont median here so that you can see which hospitals perform at under or over on the expectation around the Vermont median. Long term debt. We want to make sure that our hospitals are not overly debt burden when it comes to making investments in their capital. As you can see and I'll highlight this again. Springfield is at almost 81% again highlighting the fact that these are all interrelated. Not to pick on Springfield, but we all know the financial distress that they've been going through, which has, you know, the margin losses have put pressure on those days cash on hand, which impacts their ability to equity finance some of their debt. But also with the bankruptcy that they have now emerged from that also makes it very difficult for them to acquire debt to make improvements in their assets. And so you will see that this figure will come way out for a hospital like that. But for the most part Vermont hospitals outperform their peer groups and on the right hand side here with PPS hospitals that green line with the nice little arrow at the top. The northeast 2019 median for long term debt to capitalization is at 35% and I ran out of room on this graph when I was doing this work. So it's over in that direction for lack of a better explanation. Debt service coverage ratio. What is your annual debt obligation and how much money how much cash do you have to cover that obligation. This is always to one that to one being for every dollar of annual debt service that you have how much do you have to cover it. We can see that our state's hospitals are doing pretty good for the most part. The Vermont median for this budget is 4.64 meaning they have $4 and 64 cents of available funding to cover $1 of that debt obligation. This is where oftentimes we'll hear the word debt covenant thrown around. Lenders like to set a de minimis on this. It ranges to between lenders you know I'm familiar mostly with 1.2 or 1.25 to one as the de minimis before you start getting a little worried about their ability to cover your obligations and other obligations so overall though we have some pretty good coverage here in Vermont. And that's what we're doing from that respect about ability to cover debt service. Age of plant. This is important and we all know that the capital investments are often extremely costly whether it's an MRI machine or a new office building or a renovation to prepare your organization for the future of health care. But we can see here that Vermont hospitals tend to make do with their current assets for longer than their peer groups. That's kind of the old Vermont spirit that we all know so well, but it's obvious here that when we look at where they meet their peers throughout the key below that Vermont hospitals age of plant definitely exceeds that of their peer groups. So that's not really surprising I think to most of us who work with this information on a regular basis, but the freezing capital projects last year added to this. And so when we talk about considerations for budget approval those capital projects I think are going to be something that comes through the narratives in the presentations loud and clear that now that they have more consistency in their revenue. And so as that happens these numbers will will potentially come down in future years depending on the scale of those investments. We're migrating away now and slide 44 from the metrics to accountable care organization plan participation for 2022. You can see here that Medicaid and is nearly universal with the exception of Grace Cottage Medicare tends to lag a little bit with participation and the commercial side. We did not break out what specific commercial programs they are in. We just said that if it's related to the commercial bucket then they are actively involved in that so that can range on a hospital by hospital basis. For the folks listening this presentation. And then we have a few here who are involved in the self insured component of that mostly UVM health network hospitals here in Vermont. So this year we began to ask again for some more detailed information on the participation. So here we have the total monthly average budgeted attributed lives for calendar year 2022 because that's the time frame by which the ACO operates on which is different than the fiscal year. Of the hospitals. So we took every single hospital submission for each one of these categories and added them all up. And we have about 100 that 180,000 I believe total monthly average budget attributed lives as provided to us by the hospitals for calendar year 2022. Here on slide 46 will navigate into the exemption from public hearing. We had two hospitals qualify for that meeting the criteria set out in the hospital budget guidance. Which is a positive sign because we didn't want hospitals to create a budget that meets these criteria just for the sake of meeting the criteria. They need to ask for what they need to ask for and we need an accurate depiction of what they expect and the hospitals delivered on that. So we have a couple of hospitals here who did not set out to meet these criteria but when they began to assess their budgets fell within those criteria and they've met every single one of them. We've provided a summary of each one of these hospitals below this to provide some context, but I'll run down the numbers real quick. Gifford Medical Center MPR rate requests came in at 3.5% budget to budget growth that does include a COVID allowance. They started out at 4.1 and then once the allowance was calculated in it lowered them to 3.5 so they've met that qualification. Their charge request came in at 3.5. They are continuing to be involved to some extent in value based care reform and their assumptions, submission and content were deemed reasonable by the staff reconciled and were within the guidance provided by the Green Mountain Care Board. Northwestern Medical Center, their NPRPP rate request came in at 2% growth between budget to budget. Their charge request was at 3% which is below the 3.5. They are continually involved in several value based care reform efforts related to the ACO and their assumptions, their submission and their content for the budget was deemed reasonable, reconciled and complied with guidance in accordance with the criteria set forth in the hospital budget guidance. So we wanted to provide a brief overview, a snapshot of what those numbers look like so you can see here on slide 47 up in the left hand side here. This is a look that we've provided in the past for the individual profiles for each hospital when we get to the deliberation. So we still found that useful to help show the progression from their request, what it meant to the budget to budget growth and then taking out the vaccine dollars and showing that 3.5% growth which qualifies them for the budget exemption and giving the board a perspective of where their NPRPP is headed for 2022. A history of their charges so you can see their 2022 submitted charge is the lowest of the last five approvals that they've received. Navigating to slide 48. Here is some financial history of this organization. We can see that their 2016 and 2017 revenues went into a bit of a decline in 2018-2019 and 2020 and now we're beginning to see a return to that $54 million level. And this is a hospital who had a very rapid downturn financial distress in 2018 but has done a fantastic job at navigating out of that and has really turned the organization around financially and is looking to build on that progress going into fiscal year 2022 with their budget as submitted to the Green Mountain Care Board. Next we have Northwestern Medical Center again showing that progression here. Again, vaccine testing took them from a 3.5% down to a 2.0% so either way they were going to meet that specific criteria. And again, here showing a quick revenue recap over the last couple of years. They're largely looking to maintain the level of NPRPP as their projection this year. It is slightly higher than the revenues for the 2021 budget and their history of charges. We can see here the 3.5, 3.0% is significantly lower than what they received either last year or in 2020. So that's saying to us that they are comfortable with that rate of increase and no longer need higher rates going into fiscal year 2022. Again, a snapshot here. Their revenues have been steadily at the low 100 millions. This year they are certainly seeing a revenue spike and look to maintain that progress moving into 2020. And again, this is another hospital who has in recent years suffered some financial distress, but they are looking to continue their upward trajectory and returning that hospital to profitability in the coming year. So as part of that, the exemption from public hearing, I'm sorry, I clicked too soon. We are looking to get the board to codify this with a vote. We did warn for that vote today. So we have some motion language proposed motion language up here for each one of these organizations to approve that exemption from hearing and thereby approve that budget. If those hospitals are listening in discussions we've had with our legal counsel, we will deliver your budget orders on October 1st with all of the other hospitals. So don't look for that soon because we might be approving your budget today. We will keep that in line with that deliverable date that we have to acknowledge as it relates to the statute. So Mr. Chair, I don't know if you want to vote on this now or if you'd like me to wrap this up and then the board can broach this topic at the time they see fit. Kevin, you're on mute. Thank you, Robin. I would have completely finished by the time I realized. As usual, my neighbor decided to mow, same time as the board meeting. It's a common thing. But Patrick, what I was saying is that I think that it would be best if you wrapped up and when you wrap, finish wrapping up, bring it back to this slide. And then we'll open it up to board questions first and then public comment and then any motion. Okay, we will do that. Thank you. All right, so that concludes our presentation. We're going to wrap up here with a few process points that we'd like to make. As we started out this discussion, we showed you the order of operations, the chronological order of operations for this process. So the next step here is that hospital budget hearings will begin the week of the 16th. Again, the 16th is a Monday and state offices are closed that day. So those hearings will begin on the 17th. And here we have the schedule that Abigail has put together for us where we have each hospital locked into their presentation time. So for that week of the 16th, we will go Tuesday and Thursday. And then the week beginning at 23rd, we will go the 23rd, 25th, and 27th. And then we will, from there, we will take all of that information that has been portrayed to us and we'll begin to move into hospital budget deliberations after that. This is posted to the Green Mountain Care Board website. So if folks want to go and print an individual copy without having to dig through this presentation, you can certainly do so. And then to wrap up here, we have a history of some key financial indicators. This is just to support some of the information that was above. Here's the metrics key that I spoke of relating to the financial comparison so you can see specific figures for where these lines will fall on any of this grouping of financial metrics. And then we have a glossary of some of the terminology that we use. It's not always obvious what CAH means or PPS means to a casual observer or NPR or whatnot. So we have a very detailed glossary here for folks to follow along with as part of our obligation to be publicly transparent. So with that, that concludes our presentation. I will migrate back up to the motion language here and Mr. Chair, I will turn it back over to you. Thank you so much, Patrick. First, I'm going to open it up to the board for questions. Board members. I have a question. I just have the observation that Northwestern a year or so ago was in with a 21% request and we gave them a 13% request and approval. And it looks like they've studied the ship up there and can likely sail into the future without having to come before us and have an extended hearing. Thanks, Tom. Patrick and I did have a conversation with Northwest earlier today because as you recall, they were one of the hospitals that we have scheduled meetings with for monitoring. So we express similar comments to the leadership team there this morning. I'll just jump in and say first of all, thank you, Patrick, to you and the team. I would agree that this is the most thorough and expansive kind of pre-budget hearing analysis we've gotten. So I really, really appreciate that. And I really appreciated the addition of Fitch and Flex Monitoring and sort of allowing us to benchmark against some external sources on many of these metrics. I really, that's an added component that I really appreciate. We clearly have our marching orders here with all of the diving into all these individual budget submissions and I actually look forward to it. Can you just turn to slide 29 for a quick sec? This is the inflation table. Yeah. So actually, I wanted to just check in on this table. So this is really helpful. I think this is a new piece to the budget submissions that we added this year. I know it's a table in that workbook and it asks hospitals to break down the different inflationary components, the price-only components that contribute to their expense growth. But it's the price-only components. And I just want to make sure that we're actually capturing the price-only components. And the red flag as I'm quickly looking at this is, for example, the provider tax. So we're only looking at the price effects only. So in a sense, it's not trying to capture the base upon which the provider tax is being applied or any growth in that base. It's just looking at the provider tax. So I would, unless I'm not thinking this clearly, unless the provider tax rate itself has changed, that's the price-only effect. There shouldn't be any inflation associated with the provider tax rate. So I wouldn't have expected any hospital to report that unless they were conflating provider tax rate and the base upon which the provider tax is applied is growing. Is that right? We agree with that. That is a UVM Health Network specific entry. So I think when they come in front of the board, that's a good question to ask them is why they believe that provider tax is part of this price-effect inflationary factor that we're trying to capture here. It's not a huge number, but that does not detract from your point that it probably is not meeting the spirit of what we are looking to get out here. Okay. And the provider, I just want to make sure the provider tax rate, which I believe is 6%, has not changed, right? To my knowledge, it's 6%. Okay. And then I guess with that, I just want to make sure that that doesn't then follow over to the travelers and purchase services. Because again, the spirit of what this is supposed to capture is just the wage effect of travelers, not the fact that hospitals may need to hire more travelers. So I just want to make sure, is it possible to just do a triple check because that is such a huge growth and it's entirely possible given COVID and given the labor market shortages. It's not unreasonable perhaps to think that the average salary of a traveler could have increased or could be anticipated increased by 50%, but that's still pretty high. And if that's the wage only effect, that's suggesting that travelers' salaries are going up 50%. Not that we need more travelers, right? Like that's, I want to make sure we're not completing the two. And so when I saw the provider tax, I thought, well, I wonder, and I've seen the table and you're very clear in the table asking hospitals to submit price only effects. So it's not a question of the clarity in the table, but I do want to make sure if we're really looking at inflation, which I think is an important thing to understand because we hear from hospitals that, you know, about the inflationary pressures. And that's why the charges have to increase to cover those inflationary pressures. I really want to make sure that we're actually accurately capturing price only effects here. So I just want to throw that out there and say, is there a way to double check that the traveler's number is actually capturing the price only or the wage only effect? Yeah, well, we will look into that for context. We have heard from a couple of hospitals that what they're now paying for travelers is basically they're meeting the, they have to pay for those services. And so the companies are, their rates are rising at a unsustainable rate. I believe one hospital told us where we used to pay $80 an hour, we're now paying $140 an hour, but we'll look into that a little closer. And then maybe what we can do because this is, I know this is a topic that is important to you will extract which organizations were reporting into that traveler piece and provide you some more detail on what that is. And maybe you can work with us to help us understand if that is being captured appropriately or if we are, if something is being unintentionally misreported there. Great. Now that's really helpful. Thank you, Patrick. And again to the team, you know, this presentation is thorough and really helps us set the stage for the work we have to do in the next several weeks. So thank you. Other board members. I do have a question. So I'm interested in our definition in this process of fixed perspective payment. In rate review there, we've been looking at questions that have that relate to this land group which categorizes fixed perspective payments, basically by the level of risk associated with the type of program. So I think it ranges from level one where there's no risk to up to level four, where it's an absolute capital capitation approach, and the risk is on the provider. And I'm wondering in order, so that when we're looking at an FPP distribution here, it could be apples to oranges and we don't even know it because of the broad definition. So I'm wondering if, but one care should be able, I would think to quickly basically look at each hospital and say, you know, they know the contracts that they have with the hospitals and basically say what type of FPP according to this land LAN network categorization, so that we would have the information a little bit more disaggregated and more accurate picture of the FPP at each hospital. Is that a thought? That's on my wish list. That's one of the topics that I hope that we can work across team with the ACO APM team. So I think we can even rate review team to try to tie that information together because I would really like to get a better reconciliation within reason of what that looks like. And I know that on the ACO side, improving those definitions is at the top of their list as well. So that's going to be, you know, that is a work in progress and it's definitely a goal of mine because it's at some point we've got to bring these more closely together, especially as fixed perspective payment becomes a bigger proportion of the system's revenue. We need to understand how it flows. So that is definitely on the radar, Tom. Great, that'll be helpful. Okay, other board members hearing that I'm going to open it up to Robin, you just turned blue. I was just going to say I don't have any questions. Thank you. But I echo everyone else's appreciation. Yeah, same here. It's great. Great deck and a good lead in for the hospital budget season that's upon us now. Super. So I'm going to open it up to public comment and I'm going to recognize Ham Davis first. Kevin, thank you. I know this is maybe a bit of a weird question, but one of the things that the persistent things that strike me in this kind of thing I agree with all of the board that the work that Patrick and his team have done is better than any that better than any that I have seen. At the same time, I worry about whether the about the reform. We don't have anything about sustainability. We're just, we're looking at, we're looking at budgets, just the term from budget to budget and question whether they're acceptable. So this is an unfair question to you Kevin, but you asked about once a month. I've said this before that you're looking that you keep looking every once in a while every month or so you pop your head up and you say, Well, when are we going to see the real real benefits in savings of the reform process, shifting from fee for service, etc. So my question to you unfair is this looking just for you looking at these numbers. Are you happy with these are these giving you are you seeing in these numbers, what you've been looking for the last four or five years. So I wouldn't call it an unfair question him but I will say that as you know I'm usually never ever happy and always hoping that we're doing more and continually trying to find creative ways to push the envelope so that we get to the goals that we have with healthcare reform. So no, the answer is no, I'm not happy him. Are we making progress? Yes. Other public comment, and I'm going to go to deal hack it next and Dale welcome back we were worried about you we haven't seen you for a while. So glad to hear from you. I was on vacation visiting my grandchildren that my daughter. That's great. So couldn't couldn't resist that one been too long since I seen him anyways. Is anybody tracking this out. What are you going to do in the fall if Lambda gets going the Lambda variant or the Delta variant that actually hits schools to children. Is there any I like what you presented had to be in another room but maybe I'm reaching too much on this, but I am concerned about what's going to happen in the fall. Is there anything that you have seen analytically that you're preparing for the what ifs. So Dale, none of us have a crystal ball and what's going to happen in the fall. We've been very clear that will that we will be flexible and respond to changes in the healthcare environment as they occur. But at this point everything that we're looking at is based on today's current expectations. That doesn't mean they couldn't change on a dime tomorrow, but we're going to proceed. Okay, that's one of what I wanted to know is like you're you are aware of the fact that you know by September you could have a totally different picture and that's what you'll have to manage. That's correct. Okay, thanks. Thank you Dale and welcome back and I'm glad you got a chance to spend some time with family. Next time I'm going to go to Mark Stanislaus. Actually Kevin, I would just like to call out the board and staff for thank you for throwing in some financial benchmarks that relate to the rating agencies and my comments are more related well to them. The University of Vermont Health Network is actually rated through Fitch and the other two rating agencies. So I think a more appropriate peer group would be our rating group that we have just to share and I believe Patrick can share some comparisons through Fitch on that. And just as a comparison through one of the rating groups, I should say 99% of academic medical centers have an A rating and in my experience you never want to be in the bottom 10%. So as it relates to that I would really stress the A rating metrics is the category that the University of Vermont Medical Center and even the other hospitals. Should be rated by because that's how we are actually rated by them. So I'll just say that. And then the other thing that I would share is in all of the rating reviews I've been in, there's been a lot of focus on operating even a margin that's often referred to as cash flow margin from operation. So I would put that out there as a potential too, but you know, very nice job, very good start. It is clear to see that staff put a lot of effort in this. So I think a very good initial pass. So thank you to the board and the staff. Thank you, Mark. Next I'm going to go to Mike Del Treco. Mike. Sure, thanks guys. The team, great job as always. I just want to comment on some of the important areas that you guys have highlighted around uncertainty, 340B revenues, the inflationary discussion that was had really important components as we move forward in this process. One of the things that maybe would be nice to see, and I can talk offline with you, Patrick, is a just a consolidated income statement. So as not to have to piece all the components of that together might be interesting. And then the other area, which you really focused in on appropriately is the other operating revenues and maybe a comparative slide to illustrate without those revenues, what would operating margins look like, where they are great threaten those areas. It would be good to sort of have just a quick chart on that. But really great work and I appreciate all the front end efforts that have gone into this. So thanks to you and your team and the board. Thank you, Mike. Appreciate your feedback. Tom, can I just comment one thing on that, Kevin? Certainly. I think that is important what you're talking about, Mike, but I'm not sure we clearly have all the expenses lined up with the other operating revenue cleanly in all cases. So that that would be one thing to make sure we have that component in order to determine that because we as far as I when I've looked at it seems we've had mixed answers about it. You know, we'll hear 340B is going up. We'll hear expenses are going up relative to that and cleanly getting what fully allocated profits are for those pieces. I'm not sure we have, but I'd love to see that. Okay. Other public comment? Other public comment? If not, Patrick, if you could go back to the motion slide. I would ask if any board member is prepared to make a motion at this time. I can make a motion. I move that the board finds that Gifford Medical Center and Northwestern Medical Center each meet the requirements for exemption from public budget hearings as we established in the Fiscal Year 22 Hospital budget guidance. And that therefore we would exempt Gifford Medical Center and Northwestern Medical Center from the requirement of having a public budget hearing for their budgets and will approve the Fiscal 22 budgets for these two hospitals as presented. Is there a second? Second. It's been moved and seconded to approve the motion. Is there any further discussion? I'm glad that there were two hospitals that fit into this and it would have been nice to have been able to see a few more, but hopefully people see. Any other discussion? If not, all those in favor of the motion, please signify by saying aye. Aye. Aye. Aye. Those opposed, please signify by saying nay. Let the record show that the motion carried unanimously. Kevin, can I ask one more question on this topic, which is I know you had mentioned earlier that you had been seeing Northwestern for meetings and typically we include those sorts of conditions in the budget order. So I don't think we need to do this today, but if there was any sort of special conditions that we need to carry over from this year, we probably need to talk about those. I don't know if there are. Yeah, I don't think for these two, it's necessary to carry anything forward unless Patrick disagrees with me. I do not disagree with you. And I think. I think the discussion and all the all the remaining hospitals can occur when we're going through the deliberations on those. But they'll probably be glad not to have to meet with Patrick and I and Laurie anymore. So with that again. Thank you, Patrick. Thank you, Laurie. Thank you, Kate. You can take that screen down now, Patrick. And I'll ask if there's any old business to come before the board. Is there any new business to come before the board? Hearing none. Is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor, please signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show that the motion carried unanimously. Thank you, everyone. Have a great rest of the day and it's nice to actually be able to go outside and breathe after the last few days of very poor air quality. So let's hope that the forest fires out west and in Canada don't keep going at their current pace because it's a shame to see what's happening to our air. Have a great day, everyone. Bye. Bye.