 So good morning, everyone. My name is Kevin Mullinger, the Green Mountain Care Board, and I'm going to call this meeting to order. As discussed on Wednesday, our goal for today is to try to come to conclusion on two more hospitals. We are still waiting information on four other hospitals that we'll have to wait till next week. But I did want to use the prerogative of the chair to say a few words at the beginning of today's meeting. And I think that it's an important discussion that needs to be had. A couple of years ago, I spoke before the legislature and I talked about workforce in Vermont. And I talked about the fact that in healthcare I believed it was a crisis. And at the time, an observer in the room came over to me afterwards and asked if I wasn't being a little bit melodramatic. I don't think I was being melodramatic then because I said what I believed. And today I know that we have a workforce problem and that we have an access problem. So with that, I have committed the board to work with Secretary Mike Smith and his team at AHS and Commissioner Mike P. Check at DFR to try to do what we can to quantify the problem and to come up with specific issues. Workforces issues are not unique to healthcare. And everyone has seen the difference things that have happened in businesses that surround us. We've seen airlines cut down on the number of flights. We've seen restaurants only open certain hours of the day. We've seen businesses cut out certain service lines. And yet in healthcare, you can't say we're gonna be closed for these hours of the day. They're open and they're open for business. And the reason why they're open is to protect Vermonters and make sure that Vermonters get the right care in the right setting at the right time. So we at the Green Mountain Care Board will work with our partners. And when I say our partners, I'm not just talking about our state colleagues. I'm talking about healthcare providers around the state to try to come up with first, identifying the problem and secondly, coming up with strategic solutions to that problem. We saw throughout this process we heard stories from around the state whether it was at a nursing home that was in the service area provided from Mount of Scottney to the myriad of issues related to the Burlington HSA. But it's been consistent throughout the years that hospitals have had a tough time recruiting. If you look back over the last five years of work at the Green Mountain Care Board, there have been several panel discussions on access and workforce. Our primary care advisory group has testified in the legislature on numerous occasions about what they've seen. We've testified about the nursing shortage. We've seen some small changes. The Office of Professional Regulation made some changes. We've seen it easier for nurses from other states to get licensed in Vermont. The problem is that it's not one specific area in healthcare that we have a problem in. We have a shortage of mental health social workers. We have a shortage of technicians. We have a shortage of care attendants. We have a shortage of nurses and we have a shortage of medical providers. And that scans across all specialties in some situations. It also isn't just our hospitals. Let me be clear that the access issue affects even areas that hospitals are not involved in, such as optometrists. A recent conversation with an optometrist, he told me that for the first time in his career, he could not guarantee a patient access to him when they had pain in their eyes. And so we all have to work together and when I say we all, it's the state of Vermont, it's healthcare providers, and it's each and every Vermonter because we all can do more to try to make this situation better. And I'll use a few baseball analogies. We're not the Los Angeles Dodgers. We don't have an unlimited payroll. We have to live within limited resources but we can still do things. And we're not gonna hit a lot of home runs but if we go about it right, if we lay down the sacrifice bond, if we hit the sacrifice fly, if we steal a base, we're gonna score some runs. They won't be home runs but we're still gonna make progress. And we've seen some progress. We hear stories in every hospital budget process of things that have been done that nibble around the edges. And we've seen some things that have done even better than nibbling. So when a college went out in Bennington, Vermont, we saw that Tom Dee and the team at that hospital went out and they worked with Castleton and with North Adams in Massachusetts to make sure that the programs continued to feed them with a supply of nurses going into the future. We've seen little things happen. Like for example, at Rutland we heard about the fact that a change had been made to allow nurses to draw down on their defined benefit retirement plan while still working per diem. These weren't home runs, but they made a difference. We heard from Joe Parris about what they did at the skilled nursing facility there to make sure that they had adequate staff. We've heard from hospitals that have brought in foreign workers. These are all steps that can be taken and we must continue to take, but this is not gonna be solved. Let me be very clear. This is not gonna be solved in the next weeks or the next months or the next couple of years. This is a long-term solution and it will take partnership with our education partners as well. This is a national problem. It is not a state of Vermont problem. It does not end at our borders. We cannot get into an arms race. We cannot just continually increase compensation. That's a short-term solution until our neighbors outbid us in that war. The only way we're gonna win is to increase the supply and we have to start now and that takes years to achieve. To that end, there are a few things that the board can do immediately to begin to work on this. So at this point, I'm going to task the hospital team to work with Michelle Degree and others on the policy team to do a presentation to the board similar to the presentation that was done by the hospital team a couple of years ago led by Agatha Kessler at the time in that presentation on access. I'm also gonna ask for a report to be developed similar to the one two years ago that we can immediately share with our state partners once it's complete to help them have a better understanding of what the problem is at least from the data that we have. And again, we only have data from hospitals so it's not a complete picture. I'm really thankful to Secretary Mike Smith for his willingness to step forward and take leadership on this issue. It's an issue that's affecting all Vermonters and it's something that has to be addressed. I'm gonna task board member Jessica Holmes to work with Ina Bacchus on the vision for this joint project. But Jessica is gonna need input and help from each and every board member as we move forward on this project. And I'm also gonna task legal and the hospital team to come up with specific ideas on a specific hospital service area for inclusion in our hospital budget order and that is UVM. And we all saw that UVM is trying to do the right thing and doing everything that they feel is in their power to address this issue. This issue existed prior to the pandemic but the pandemic exacerbated that as people did not seek the proper care at the right time at the right place. And so now we're seeing an increased complexity of care. The acuity has increased dramatically. In Burlington, they were hit hard by the pandemic. They did not see a return to their hospital in the same way that places like North Country Hospital did. And so the demand built. And so you couple the pandemic related demand with the time that was lost through a number of things that happened at UVM. One was their electronic medical records implementation. Another was the air handling issues at the Fannie Allen Surgery Center and another was the cyber attack. Those all took resources and time that could have been devoted to patients away from the availability there. So anecdotally and in the information that the hospitals themselves provided to us, it's apparent that Burlington especially has been hard hit in this pent up demand for services. And so I think it's only appropriate that in the budget process, we consider certain asks such as developing a strategic plan to reduce access times. Quarterly reporting in a public board meeting that informs us and the rest of the state of Vermont on the progress that is being made. Their problems are also amplified by the fact that they are the hospital that many of us rely on for services that are not provided at our own hospital. I'm grateful to live in an area in Rutland where we have an incredible quality of care for the size of our community. But I'm also grateful to know that for those items that they can't do like heart surgery and other things, that we have a place that we can go to to get that care. And this system of not asking every hospital to do everything only works if the hospitals that we are asking to do those most complex situations can take that on. To that end, this board has made some rather quick and expeditious yet extremely thorough decisions by pushing our CON team to try to get things done in an expeditious manner as possible. When there was a scarcity of beds, we quickly approved a non-material change to the Miller Building CON to allow for 15 more beds. We have quickly voted to approve an additional 3T MRI for UVM after doing the thorough research necessary. And we also have approved a conceptual CON for new operating space on Tilly Drive. And again, that's just a conceptual CON that will take a few years in order for us to see that surgery capability online. No one should ever think that the hospitals themselves are not trying to do everything that they can. And no one should ever think that there's a benefit for people not to have the proper access to care. When people don't have proper access to care, it doesn't lower costs, it raises costs because in the long run, the type of care that that patient is gonna need is gonna be much more expensive. There have been some allegations by some that the all-payer model encourages rationing. It does not. I can assure every Vermonter that our insurance companies are not rationing care either. It is not in anyone's best interest to deny care. We have a three-legged stool at the Green Mountain Care Board. It's not just about cost containment, but access and quality are equally important. We realize through the data that we've received and through the anecdotal stories that we have heard that both quality and access are compromised right now. So we're all in this together. I would ask all staff members of Green Mountain Care Board and all board members to really think as hard as they can about any type of creative solutions that could be achieved. We don't have dollars or a pool of money that we can help with, but we do have intellectual capability that could assist others who do have resources to move forward. So I just wanna say that I look forward to working with Secretary Smith, Commissioner Pichek and our partners throughout the state because this is what Secretary Smith has asked us to do is to look at access statewide and we'll do that. But what I'm asking the board to do is to come up with specific ideas for the budget order for UVM as it is apparent that the most pressing issues in the state right now are in that hospital service area. I don't wanna slight any other area of the state. I know that there are extreme pressures on certain specialties in every corner of the state. And we will quantify the problem and we'll work towards strategic solutions. So with that, we're gonna move towards looking at the two hospitals that we hope to go through today and I'll turn it over to Patrick and his team, Patrick. Thank you, Mr. Chair. Please let me know when you can see my screen. We can. Excellent. And Kim, can you hear me? I can, thank you. Very good. Okay, we made some progress on Wednesday, September 1st. We formalized the approvals for Northwestern Medical Center and Gifford, the two hospitals that fell under the exemption of qualification from public hearings that the board allowed for fiscal year 2022 budgets. And we also approved budgets for Southwestern Vermont, Rutland Regional Medical Center, Northeastern Vermont Regional Hospital, excuse me, Mount of Scutney, North Country Hospital and Grace Cottage Hospital, just to recap some of the activities from the other day. Within the slide deck, we made some updates here based on board requests. So on slide 12, Board Member Pelham had asked us to provide a year-over-year NPR comparison and change as well as capturing the change in dollars by payer and by hospital. So you can see that on slide 12, that is a new addition from Wednesday's deliberative discussion and relative to that, Board Member Pelham also asked us to provide a similar view, but singling out FPP change year-over-year, FY21 to FY22 and by payer. So you can see that on slide 14. I'm going to fast forward to slide 137, where we met Board Member Yousafur's request to provide a history of days cash on hand by hospital so that she could reference this and other board members may reference this and making decisions today and in the future around cash balances and the ability to service in the event of for days cash on hand. And on slide 138 and 139, we've also met Board Member Yousafur's request to provide a commercial to Medicare ratio and also a Medicaid to Medicare ratio. We've broken that out by PPS hospital designation and critical access hospital designation on 138 and 139 respectively. So those are the updates since our last meeting, bear with me as I scroll to the hospitals for discussion today. And as Chair Mullen had discussed, we're going to review Brattleboro Memorial Hospital today and Copley Hospital for discussion. I will be reviewing Brattleboro and I'll turn it over to Lori Perry to review Copley Hospital. And with that, we'll get started. So in front of us here, we have Brattleboro Memorial Hospital. Year to date, as of the budget, the projection for this hospital was coming in 6.3% under their 21 budget with year end revenues forecasted at just shy of $87 million. Their budget for 21 was just over 92.8 million and if fiscal year 22 request is just about $95.6 million. So effectively budget to budget, their request would be 3% NPR FPP growth. However, from their current projection of just shy of 87 million to their $95.6 million request, that change would be 10%. They're requesting a 5.1% change. So they're a charge master. Predominantly those dollars are coming from commercial at just over $2 million. And sticking with the narrative we've had so far, if we look in the lower left-hand corner in slide 85, we've trended their 2019 actual activity forward at the 3.5% NPR growth rate that the board has approved over the last several budget cycles, which would put them around $93.1 million using that trending forecast. As you can see, their projection for 21 is coming up a bit shy from their $92.8 million, 21 budget. However, they're looking to achieve that $95.6 million that I've spoken to thus far. The justifications for that 95.6 million is that they had a very slow volume start to FY21 that has since increased. They have the expectation that in 2022, those volume levels will return to pre-pandemic levels. They've been successful in their recruitment efforts in hiring staff. They're all in on payment reform efforts and they've gone through revenue enhancement and expense production plans to help control costs and build revenues. And the result of that has also been a reduction in contract labor spend, which again, combine that with the successful recruitment efforts will help control costs at the hospital. Reconciling their budget to budget predominantly, the growth, the 3% growth that they are requesting from their 21 budget is being driven by the net patient revenue rate effect of their request, which attributes $2.2 million. So that growth and following behind that is utilization just shy of 600,000. Operating expense drivers for the hospital, no surprises here. Inflation increases are the predominant driver of those operating expenses. Brattleboro has submitted about $2 million budget to budget and inflation increases followed by new positions at $1.4 million contributing to operating expense growth. And on the other side of that reconciliation speaking to their cost savings initiatives, about 351,000 is acting as an operating expense suppressor along with the reduction in traveling staff, which attributes about $100,000 in operating expense suppression. So as Brattleboro stated to us, they had a slow start to fiscal year 2021. We can see that here in the quarterly perspective at the top of slide 88 with revenues coming in shy of 21 million. However, realization through Q2 and Q3 has been in excess of 22.3 million and they're forecasting about 22.1 million in Q4 or about a 1% reduction from Q3 revenues. And we can see the impact of that slow start that they mentioned with operating margins quarter by quarter improving. However, the first quarter had quite a significant hit for the hospital's bottom line and they've been building that back up through three quarters. However, in Q4, they do expect that to recede a bit by and suffer a loss of about 607,000. It is important to note that in the materials that they supplied to us from the base that they had for their budget for 2022 that they were forecasting about a $4.08 million loss at that time, our materials reflect that loss. However, in conversations during the budget hearing with Brattleboro and in monthly submissions since that forecast has improved and they are now forecasting a $1.8 million loss heading through the rest of the fiscal year. The history here of NPR, we can see that the hospital has not quite met approved budgets by the board over several years. Of course, 20 is a major outlier given the impact of COVID on this hospital and several others. And as we've stated so far, the fiscal year 21 projection is coming up 6.3% shy of that $92.8 million budget. And they are looking to grow that NPR coming into fiscal year 2022. And in the past year, the hospital has had several years of negative operating performance. However, in 19 and 20, the board did produce positive operating margins. And as we've stated so far, as you can see the materials that were submitted show a $4 million loss. Brattleboro leadership has informed us again that that has improved significantly. However, they do anticipate producing a $1.8 million loss for fiscal year 21. And their budget for 22, they are hoping they can achieve a $650,000 operating margin gain or a 0.6% operating margin percentage. Breakdown of the change in charge, again, 5.1% as submitted the Green Mountain Care Board which will have a $2.2 million NPR impact value of 1% of that is $435,000. They will apply that request to hospital inpatient charges and outpatient charges at 6.2 and 5.8% respectively. By payer, commercial will bear most of the load here with self-pay other contributing about $152.6,000. And as you can see, the budget to budget NPR increase just shy of 2.8, but the majority of that coming from the change in charge as we've already discussed. From approved to submitted over the last five years, the hospital has been approved at average of 4.3% and they've submitted 5.1% with some reductions coming in fiscal year 18 and 19 budget processes. Payer mix, there's some shifting activity here from year to year at Brattleboro as it relates to commercial revenue. They're seeing a bit higher payer mix percentage this year for commercial revenue at 53% compared to budgeted 47% for 21 and 22. And the last year of actuals in 2020 was at 50%. Medicare continues to remain relatively stable here across the 38, 39% aisles. And then they are forecasting an uptick for Medicaid in fiscal year 22 rising to 14% from a current experience at 9%. And gross to net collection rates, they are forecasting 22 to come down as it relates to commercial. We can see here that it was about 67, 66% as they are currently experiencing 21 projection down to 58%, which would be the second lowest on this table that we have provided here, 2018 being slightly lower than that with government payers coming in between 34 and 38% for Medicaid and Medicare respectively. So our suggestion for recommendation or options to the board, we did have a little bit of trouble seeing the $95.6 million budget being attainable given the prediction and forecast for this year being around $87 million. We think that the 10% projection to budget growth was excessive in this case. So our suggestion to the board would be to reduce it to reduce their MPR to the 93.1, 3.5% trend that we have forecasted on the first slide of this hospital's profile. And that would be an effective 0.3% budget to budget increase. However, projection to this new MPR level would be 7.1% growth if you were to accept this $93.1 million NPR FPP top line. And we feel that the 7.1% projection to budget would be ample growth for the hospital going into 2022. We could not justify from what we heard that they would get to the 95.6. And so we wanted to be a little conservative. There are a lot of unknowns out there. That said, we would offer you two options on rate. As you can tell by their five year average and five year median, they are around 4%. So we could see reducing the rate by 1% down to four for this hospital to align with what the board has historically provided them. However, given the times we could also recommend to approve as submitted. So if you were to reduce it, it would have about a $435,000 impact from the budget they submitted which would lower the delta between the 93.1 that we've provided and the reduction of that charge on that top line NPR. However, if you approve as submitted, then they would have to find the space to reduce their NPR from what they submitted to what we are recommending here. And again, as additional recommendation, the continued improved timely and accurate submission of financial data to Green Mountain Care Board staff would be an additional recommendation. And on the next slide, we have laid out those options within the motion language. So with that, Mr. Chair, I'll turn it back over to you and your fellow board members for discussion on Brattleboro Memorial Hospital. Thank you, Patrick. At this time, I'll open it up for board questions of Patrick or comments on Brattleboro Memorial Hospital's budget. Board members? Right, I'll go first. I'll just address a couple of things. First, Patrick, if you can go back to the recommendation page. First, speaking to the projections. This is another, this is a hospital. We just wanna make sure that their top line projection is achievable. And then they make corresponding adjustments to expenses. What we're looking at here is if we look at their budget for 2021, it was 92 million and they're coming in about 87 million. And we do hear they're gonna beat that. But because their expenses have only gone down modestly with that reduction in revenue, they were projecting a $4 million loss. And that should hopefully improve to I think a $1.8 million loss. When we look at, yeah, this chart that shows where they're projecting their NPR to go on that blue line. And if we compare that to, if I look at all of the other hospital requests and look at their projection to budget, because at this point budget to budget is meaningless because we know where we're coming in this year. So that the projection to budget except for each of the UVM network hospitals and for Springfield, they even with their reduction to what we're projecting they would then be the next highest hospital. And we do hear and expect Springfield will be reducing their request from projection to budget. So even at the, I think we're coming out about a 7%, they would rank as one of the highest hospitals from a projection to budget. So it seems that that's probably more realistic and reasonable, they haven't shown how they're gonna get to a 10% increase over their current trend. So I'm very supportive of what you're recommending for the NPR and just wanted to point that out when you go to the recommendation page and we talk about, when you look at it from a it says the 3% request is under the budget to budget growth rate guidance with COVID allowance growth is 3%. I would point out there that it's, they're requesting a 10.2% to their current projection. So that's really what I'm looking at there. It's not so much looking at, oh, they went under. I appreciate that, but it's pretty significant. So again, it's, we want the hospital to be successful. It's not saying, stop the utilization and saying, are you really gonna get there? When we talk about the charge increase, I will point out that last year when they had a 4.9% charge increase, 2% of it they identified as related to specific COVID expenses within their submission. And this year at 5.1, the combination of those two years, the 4.9 and 5.1 put them on the higher end of the rate requests, looking at both years together. So certainly want to hear what other people think about whether there's a reduction of the 1% or approved as submitted, but that certainly is a consideration for me that kind of two year combination, which would be 10, you know, 10% over two years. And just to continue on the cash balance piece, they did start with 1.8 million in 2019. They have a projection of being at about 10.4 in the 21 projection, but they have told us they're gonna improve their bottom line by a couple of million dollars. So that should translate to a couple of million dollars of higher cash that would also go into 22 where they were projecting 6.4. So they're probably gonna net out, you know, closer to over 8 million of cash from a 2019 starting point of 1.8 million. So I'll pass it on for other board members. Well, I have just a couple of observations. I think I can support the recommendation of the staff in terms of the adjustment to NPR and the reduction to the change in charge. But, and for me, there was a couple of items that caught my eye that might align with that. The first was that in their payer mix profile for 2022, they show a reduction in Medicare revenues of $480,000. And so that is a factoid. And another is that in 20, by the time they get to 2022, they say that in the 2021 cycle, they will have paid off that 6.3 million in Medicare Advantage, that there's 12 months where there's no interest and so they'll play that out to the end of the 12 months. They started repaying it in April 1st of 2021. And then when they hit the point where the interest rate goes up with cash, they'll pay off the rest of it. So I kind of look at that Medicare number for 2022 and think if the Medicare Advantage advance is paid off by then, why is it a negative year over year? So that's just a question that is in my mind. And another is again, looking under pillows in the provider tax, they have budgeted a 6.53% increase, although for 2021 over 20, 2021 projection over 20, they're looking to pay 6.3%. But to me, if you drop that down to 6%, that saves about $451,000, which coincidentally is about equal to 1% of each percent on their charge. So that's my call on this is that I think the staffs and building on Marines inside as well, I think the staff's analysis is a very reasonable one. Other board members? And supportive of the reduction in the MPR, again, to Maureen's point, we're hopeful that their volumes will return to prior levels, of course, but it does seem unrealistic to think they're gonna get that big a jump, even with pent up demand. And I'm sort of torn on the change in charge. It is high and it has been high the past few years, which concerns me on the other hand, given all of the uncertainty and given the soft volumes that they were seeing, and the financial issues with the operating margins, it is a sure way to get them through the year. So I'm kind of torn on that and can go either way right now. So I'd love to hear other people's continued thoughts on that piece. Well, I guess it's up to me then. Well, Kevin's still too. I agree with the staff recommendation. I think, you know, and I also agree with Maureen, to her point, we want this hospital to be successful. I do worry that they won't achieve the MPR they submitted, given their projections where they are this year. And that would leave the planned expense growth too high and more losses for next year, which again would be a problem for sustainability. So I think whenever we're thinking about reducing MPR, we're really trying to say, please let's also reduce the expenses underneath that so that we can ensure operating margins. We're not trying to stop volume or access. We're really trying to make sure that what we're seeing in terms of realistic expectations for NPR are met with realistic operating expenses underneath that. So I agree with the staff recommendation to reduce the NPR. I think the 93 million roughly there is a target, is a good target. It's in line with the 3.5% annualized growth since 19 and actually still allows for 7% growth over their projection for 21. So for me, it's allowing some return of volumes still, but it's not aspirational. As for the rate, I wouldn't reduce it below 4%. I would support 4.5 to the degree that this is a hospital that needs some margin, needs some, you know, perhaps some rate support. I will also remind everybody this is a hospital that's all in for the all-parent model. This is a hospital that's doing the delivery system transformation that we hope to see. And to the degree that they need some dollars for that transformation, I would support it. So I too agree with the staff reduction. I agree with both the reduction in the NPR and a reduction in rate. I would support a 1% reduction in the commercial charge, but if others feel strongly that 1% reduction is too much, it's not going to prohibit me from voting positively on this, but I do think that there is room for a reduction not only in the NPR for all the reasons that have been said by my colleagues, but I also think that the message should be clear that we can't be every year approving high rates. We did that last year to make sure everyone was sustainable. Fortunately, hospitals for the most part are not in worse situation than they were a year ago. And so for that reason, I would also support the reduction in the change of charge. Is there any member who is prepared to make a motion at this time? As always, I'm sure we'll have Robin to make the motion, but I think understanding all the conditions and the fact that they are all in, I could support doing a 1.5% as well. If you want to start with that motion, maybe Robin and the reduction in NPR. Sounds good to me. So I'll move to approve Broward Memorial Hospital's budget as modified hereby with an NPR FPP increase of 0.3% from fiscal year 21 to fiscal year 22 budget, a 4.5% increase to overall charges and subject to the standard budget conditions as outlined in slide 36. Is there a second? Mr. Chair, before we move on, we had talked about reducing the rate, half a percentage point, which would make it 4.6, not 4.5 as motion. That's what I thought was the... Sorry, I will amend it to 4.6, sorry. And Patrick, I see that you're trying to trick me by changing the slide number. So instead of my usually saying slide 34, it's now slide 36. You can blank legal for that one. Okay. Was there a second to the motion? Jess, you're shaking your head. Did you second it? Yes, I couldn't get to my mutant time. Yes, I seconded. Okay. With that, is there further board discussion before I open it up for public comment? Hearing none. At this point, I'm gonna open it up for public comment on Broward Memorial Hospital's budget and the proposed motion in front of us. Does any member of the public wish to make a public comment at this time? And I do see a hand raised and that is Ham Davis. Ham? Thanks, Mr. Chairman. I don't have an opinion at all about the Broward Memorial but I'm trying, I would like to know when the appropriate time would be to offer a comment if that's allowable on your opening statement about the overall situation. Ham, if you'd like to offer that comment, go ahead. Okay, thank you. This whole thing could go on for 10 years and it originally started 35 years ago and a lot of stuff has happened, a ton of water has slowed under the bridge. The situation we have now is extremely difficult and extremely important for the state of Vermont and I just wanna say that in spite of whatever coffee you drink that your statement was terrific that it was one of the very few really balanced, insightful, gutsy statements about where we have to go with this whole thing and I thank you for doing that. That's the end of my statement. Thank you. Today I'm drinking half-calf from Green Mountain Coffee. It's better than your, that's not your normal, right? No, normally it would be McDonald's which I actually think is made at the same place but. Well, I think you should keep going out market, Kevin. I'm happy where I am, Ham. I believe in living within your means. That's a terrible idea. Other public comment, I see a hand raised from a phone number. Actually that may be, Ham are you on here twice? Are you on a phone and it must be because when I lowered your hand it went down. So, okay, is there any other public comment? Hopefully on Brattleboro Memorial Hospital's budget and the proposed motion. Russ McCracken. Thank you, Mr. Chair. It's Russ McCracken, staff attorney with the board. I wanted to ask a clarification on the motion and that was whether the board intended to include the expense-worth piece. Expense-reduction piece, so part of the motion. I have been consistently not including those because of the previous discussion on Wednesday about allowing for a little more flexibility this year with the travelers issues. But certainly people should feel free to disagree with that in individual hospitals or in general. Yeah, as it stands now, Russ, the motion does not include that. Someone could offer to amend the language but at this point it does not include it and thank you for keeping an eye on us because we are capable of making mistakes in motion. So thank you, Russ. I think what it does is it gives the hospital flexibility to hopefully reduce their expenses. We are seeing growth in their expenses from their budget from $95 million to $99 million. From their budget from $95 million to $99 million. Obviously they can't sustain a loss. What we're trying to look at is that we don't see the volume growth that they're putting in here to support it and if that doesn't happen, then they are gonna have a several million dollar loss. So hopefully they'll be monitoring that weekly, monthly to see if that volume is occurring. But we're still expecting this to give them a 7% volume growth, which is significant. And they need to be monitoring their expenses in line with their volume. But I think we are willing to give the flexibility to allow them to manage that rather than to mandate it. Is there any other public comment? If not, the motion in front of us is to approve Brattleboro Memorial Hospital's budget as modified with an NPR FPP increase of 0.3% from 21 to 22 budget and a 4.6% increase in overall charges and subject to the standard budget orders as outlined on slide 36. All those in favor? Kevin, Dale has his hand up. His hand up. Oh, Dale, you snuck in on me late. Go ahead, buddy. That's true, I am late. So I'm just asking a question that may have already been answered. I'm not looking to cut utilization based on demand with any of this. This sounds favorable as a quick review, which is all I'm a chance to get. I'm not. So, Dale, it's not that it's trying to cut utilization. It's looking at the historical growth and the net patient revenue and factoring in some what we believe to be pent up demand and trying to calculate what it would actually be versus an unrealistically higher number. Everybody's projections are different and that's where the board is headed on this one, Dale. Okay, thank you. And that also includes trying to get people in if they're understaffed. That's a different expense, but allowing that they may have to spend more to actually get a workforce sufficient for needs. There's no question that the greatest cost driver in this year's budget is the pressures on workforce. With that being said, that really was not a factor in this motion, Dale. Okay, all right, thank you. Is there any other public comment? If not, all those in favor of the motion signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Let the record show that the board voted unanimously to approve Brattleboro Memorial Hospital's budget with the modifications as presented in the motion. With that, Patrick, I'm gonna turn it back over to you. Thank you, Mr. Chair. We will move on to Copley Hospital and I'm gonna turn it over to Lori Perry to walk the board through the information on the slides ahead. Lori, all yours. Thank you, Patrick. Before us is Copley Hospital and they are coming in at 5.5% over their 21 budget to projection and their 21 budget was about $76 million. Their projection is over $80 million and they're requesting $86.4 million for their 22 budget. The 22 budget is 13.4% over their 21 budget and it is 7.5% over their projection. The 13.4% is over our guidance of 3.5%. The hospital is requesting a 5% overall change in charge and this is made up of commercial of just shy of $2 million and Medicare of $1.6 million and a little bit of self-pay and other at $90,000. Their trending for the 3.5% chart that we've been supplying is the budget is $12 million more than the trend that we are showing or 16% and their projection is $6 million or 7% more than the trend. This is a little bit of context there. The hospital's justification is they have, they're wanting a reasonable margin to rebuild their cash reserves and make overdue infrastructure improvements. Their infrastructure are showing an average age of plant between 12 and 13 years. They want their budget because of the inflation or in staffing pressure. They are making a shift to Medicare due to aging population and they're adding neurology and podiatry services and they have increased FTEs by 24 and a pay increase of 4%. They are planning to participate in the commercial ACL plan for this coming year and their volumes are expected to research comparable to 2019. They are continuing to have coordination with their community partners in their community health next cycle. Thank you. This hospital is requesting a provider transfer of a podiatrist and it is worth a little bit more than $300,000 to their MPR and $500,000 to their expenses. And it is worth, this was effective April, 2021. This is in effect a minus 0.7% to NPA. The next slide shows basically what, excuse me, that was not podiatrist, this is neurology. This particular provider was in their the Moyle Community Health Services, they call it Chesla. And this particular provider was a Copley employee back in the day and now wants to come back to Copley. They will be bringing another FTE with them in this practice. We're asking the board to acknowledge this provider transfer. The hospital is from the 21 budget to the 22 is an increase of 10.2 million dollars. And the major drivers are their rate effect of 3.2 million. I'm sorry, Lori, can you just start that over? You were echoing a little bit and I missed something. Okay. Thank you. The MPR drivers for Copley from the 21 budget to the 22 is worth 10.2 million dollars total. And the major drivers are their rate effect of 3.7 million. The utilization is worth 4.2 million. The reimbursement payer mix is worth 3.1 million. Then they have additional bad debt and free care of 1.7 million which reduces the increase of their MPR. And then the previously shown provider transfer which was worth 300,000. And they are adding an FTE to podiatry which is worth 400,000. And then Copley plans to increase their ACO participation in Medicaid by 157,000. Next slide, please. Copley's expense drivers from 21 to 22 budget. Their increase is 9.8 million and new positions make up 2.8 million. The inflation is 2.4 million. The salaries and fringe combination is worth 0.8 million. Their supplies and other purchase services are each around a million. Drugs and provider tax have increased about, each of those have increased about 0.6 million. And then their depreciation is worth about half a million dollars to the large drivers on this chart. Copley's operating performance this last year, they have the first three quarters have been between 20.5 million to a high of 21.5. But they're projecting a decline in their last quarter which is about 13.8% or 17.9 million for their last quarter. Their operating margins, the first quarter was about 3.4% which included the COVID relief funds. And then the positive operating margins kind of leveled off for the next two quarters, but the fourth quarter declines due to projected decline in NPR FPP. Copley's historical performance, they exceeded their budget in 16, met their budget in 17 and exceeded their budget for this year's projection but they did not meet their budgets for 18, 19 and 20. Their operating margins broke even in 16 and 17 and expected for projected 21 to break even but they had losses for three years in a row from 18 to 20. Next slide please. So Copley's overall change in charge is 5%. The NPR due to change in charge is approximately 3,700,000. The value of 1% change in charge is 734,279. They are having their overall change in charge of 5% to both to all three inpatient, outpatient and professional services. And as mentioned before, the change in charge is worth 1,900,000 for commercial, 1,600,000 for Medicare and 90,000 for self-pay other. Their NPR change from 21 is $10.2 million and then as mentioned their change in charge makes up $3.7 million of that change. This hospital has had a rough start in 18 and 19 for their rates or change in charge. So their five year average is 2.6% from 17 to 21 is what was approved. And then for submitted their five year average is 5.1%. Copley's collection rate has been about 56% for the last few years. For fiscal year 22, their commercial is 68%. Medicaid is 53% and Medicare is 41%. The hospital's NPR and FPP payer mix has shifted between 20 actuals and 21 budget but has leveled off for 21 projection in 22 budgets. This hospital has been receiving FPP for Medicaid since fiscal year 20. So that might be causing some of the shifts in this payer mix. Next slide. And we are suggesting that the NPR be reduced to 12.4% driven by 1% reduction in the rate requests, which would reduce NPR by 734,249 growth rate with provider transfer making that 12%. The change in charge, we would like to change it from 5% to 4%, which is a reduction of 1%, which reduces the NPR 734,279. So if I may, Mr. Chair, step in. Kim, this is Patrick again. Regarding the NPR growth piece, this is a hospital given its proximity to Chittenden County and your opening monologue around wait times inclusive of a very popular and successful orthopedics program at that hospital, we can see this NPR coming very, very close to what they budgeted. And that's one of the reasons that most of that NPR request budget to budget remains intact with this recommendation. We do feel however, that as I navigate back up to the rate slide that's the last several years, the board has been extremely fair to this organization in which the organization has, for lack of a better term, basically received back some of those cuts that occurred in the mid-2010s to their rate. And as you can see, 4.5, 9.86, and whether the board agrees today at 5% or 4% that we've recommended, that would increase that five-year average substantially as that FY 2017 rate falls off this perspective and we add in what FY 22 would be. So the staff feel that trying to control that rate growth a little bit is important with some of the rates that have been provided in kind of the COVID era as it's become to known. It is possible that COPDLY has not yet maximized all of the revenue off of those rate increases due to cessation of procedures and folks not seeking care. So eventually that will return and they will reap the benefits of that. So that's one of the reasons behind our cut to that charge and also the logic behind why we can see NPR actually achieving the growth, almost the growth that they have forecasted for the FY 22 budget. And with that, we'll turn it back over to the board. So before I go to the board, I just want to ask legal a clarifying question. Russ, if you could tell us, I doubt there's any controversy whatsoever on the handling of the practice transfer language. And I'm wondering if that needs to be separate motions or included? I would suggest doing it as two separate motions. So the first motion would simply be to approve the provider transfer. We usually acknowledge the provider transfer recognizing that we don't approve it. First say. Well, we're approving the change to the NPR, but acknowledging is fine too. Robin, are you prepared to make that motion? I am. So I move, we acknowledge Copley Hospital's request to adjust its fiscal year 21 budget request to reflect acquisition of one neurologist along with one non-provider FTE from Community Health Services of Lemoille Valley effective as of April 1st, 2021 with an impact to Copley's fiscal year 21 NPR FPP of a negative 0.47% and conditioned on required notice to patients pursuant to Act 143. Is there a second? Second. With that, is there any board questions about the provider transfer or any comments that someone wishes to make before I open it up for public comment just on the provider transfer motion? Hearing none, is there any member of the public who wishes to speak and offer a public comment about the motion before us regarding a provider transfer? Hearing none, is there any further discussion from the board? Oh, Dale, you're tricking me every time with that late hand, go ahead. This increases capacity to handle utilization. This is a practice that had been elsewhere that was in danger of being lost to the community and so the hospital has taken on the responsibilities of that practice. And so it's not adding anything more to the system that already existed when the practice was elsewhere, but it is acknowledging the fact that it does increase their net patient revenue because it's now booked through the hospital rather than elsewhere. Okay, yeah, that's a contradiction that I picked up on at times. And all right, thank you, very much appreciated. No problem, Dale. Is there any further discussion from the board? 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 regarding the provider transfers has been approved. With that, let's turn our attention towards the discussion on NPR and change in charge and who would like to lead it off for the board in that discussion? I wanna go first through a clarification. If you could go to the change in charge chart that you had because I had different things in my notes about what 1% was worth. And when you look at their charges, commercial is up by 1.9 million and Medicare up by 1.6 million. So if we were only impacting the commercial piece of this, I think the 1% change in charge would be like 400,000 because I'm not really sure. I don't think what we would do would really impact the Medicare rate. So just wanted to ask that because I had in my notes that 1% was 400 or is it 734 was the question because part of it is if you just take the commercial rate at the million nine at 5%, that's not gonna equal the 734, it's the total. So I'm thinking that what we're gonna discuss and impact is really gonna be impacting just the commercial piece of it. I know at hearing they had thought that that 1% resulted in 3.8. As a follow-up to a question, we asked they lowered that to the 3671. Patrick, do you have additional information on that? Nope, we requested 1% of the value of the charge from net revenue. So that would be the 734. You're right, the overall NPR was 3.8 and the leadership at Copley corrected that and said it's actually 3.67. So the 1% value has not changed from their submission. Okay, so I guess my question is if we're doing a reduction in rate of 1% going from five to four, is that going to impact Medicare? Because I'm thinking it does not. And so if not, then I think the 1% charge we would be, if any 1% charge we would be impacting would be on the commercial piece. I'm just trying to clarify, because we're gonna- As much as we would like to be the arbiters of what gets spent in the Medicare program, anything that we do here is not gonna make that change. Correct. Well, except that they're a critical access hospital, so their Medicare payment methodology is connected to the charges, the cost report. So there is like, I think there does have some impact based on the Medicare methodology, but because they have to keep their charges the same across all payers. But the methodology is what it is. So to your point, Kevin, we can't influence that. I'm just trying to clarify. If we take a 1% reduction in charge and or for every 1% reduction in charge, is that really gonna be a $734,000 impact on their NPR? Or is it gonna be about a little over half of that because commercial was a million nine and Medicare was a million six? Most of the other hospitals we've been looking at they've had Medicare at zero, at least on this schedule. So when we did, 1% was truly for commercial. I don't know, does anyone else wanna weigh in? I'm thinking it's half, I'm thinking it's 400. Well, I hate to make assumptions. So unless somebody is on the phone from Copley that could make that, unfortunately, my recommendation would be for the team to reach back out to Copley and get a firm answer and for us to come back to this next Wednesday. You have a hand raised from Copley, Kevin. Oh, great. That's even better. I'm not sure who it is, but if it's Joe, go ahead. If it's Jeff, go ahead. Yeah. So it's actually, it's Jeff. And I go back to what you said, Kevin, with the Medicare methodologies. We're critical access hospitals. So the 1% of 730 does include Medicare. Medicare pays on costs, since our costs are going up in proportion to our rate increases, we would get that net revenue from Medicare as well as commercial. Does that answer your question, Maureen? Well, we're talking costs or expenses and rates. So I guess, Jeff, are we saying if we cut, if we make a determination to cut your change in charge by 1%, then you're saying that'll be across both payers and it'll be 734, 734,000? Yes. Okay. Yes, that answers my question. Thank you. Maureen, did you have other comments or should I turn it to the next board member? I know I have other comments if you want to go to the recommendation. I'm fully supportive of the recommendation that the staff has put together. This hospital has shown a significant increase on their NPR even through the pandemic. They're one of the only hospitals that showed an increase from 19 to 20, going from 67 million to 69 million, but their 20 to 21 is going from 69 million to 86 million projection, I'm sorry, 80 million projection above their budget by $4 million. So we are seeing pretty significant increase year over year. We know we had heard elective surgeries were suspended in many places obviously during the pandemic, so they may be picking that up and that seems to be continuing through 22 budget. This is clearly going against the 3.5% guidance that we had given to the hospitals, but with so much uncertainty in all the hospitals right now, I think that's something that maybe could be addressed later because this hospital clearly is on a trajectory to be showing utilization a lot higher than what our recommendations have been, but that said, they're again going from 21, 76 million to, I'm sorry, 69 million to 80 million, so pretty significant increase, and now they're 21 projected to budget is going from 80 to 86, and based on what they've been doing, what they told us, their staffing increases, that does seem realistic. So I am supportive of that. Looking at the change in charge last year, they did get a 6% change in charge of which 2% was looked at to be related to, potentially related to COVID. I'd also say looking at their balance sheet and what they have still on their balance sheet, their cash increases as well as their PPP money of over $5 million that they still have hung up on the balance sheet, some CARES money that they still have hung up, they've gone from a 7.1 million cash in 2019, they're sitting on $23 million of cash now and projecting that that goes down to 8.5 million, but there's about $10 million between the CARES money and the PPP that most likely is not gonna be paid back, and so that would increase that pretty significantly. They've also shifted a bit, I think believe on the commercial payers, so they need to balance here, their expenses and looking at cost saving opportunities with this tremendous growth in top line, I feel it's warranted to reduce the change in charge by the 1% and I do support the NPR. Thank you, Maureen. Comments or questions from other board members? Sure. I'll go with Tom first. So I'll jump in here and I think that the staff recommendation is more than reasonable. I might've been a little bit harsher when kind of looking at the history in terms of the growth of expenditures over the last four years, 2019 to 2022, it's about 7.1% and obviously, the change in charges have been, I think, reasonable, but their operating margins are not good. And so I do think that this is a problem that needs to be solved internally at the hospital level. And one other area I noted in addition to the 1% Marine profile is if you look at their four-year trends 2019 to 22 budget for bad debt, it's at a 34.9% annual rate increase and free care is at a 23% rate increase annually. And when asked about that in the hearings, we were told that those increases were tied to the increases in gross revenues, but over that same period, the average annual increase in gross revenues has been 10.7%. So that there's not really a tight connection at all between free care and bad debt and the growth in gross revenues. So I can support the staff recommendation and I'll leave it at that. Thank you, Tom, Jess. Thank you, Tom, Jess. Yeah, okay, so I'll support the staff recommendation on both NPR and the change in charge reduction, noting that they're adding podiatry, they're adding neuro, both much needed services, particularly neuro, which I know is an excess demand all over the state. So I applaud them for taking that on to prevent its loss to the community. I suspect also that they are seeing some rising ortho demand because the shortage is in Chittenden County. This is a high margin service, which should actually help their bottom line quite a bit, but they are taking on probably excess demand from other areas in the state. So I'll support the NPR, given their 21 projections on these added service lines. I also support the staff recommendation to reduce the rate to 4%, given the very high increases in rate we've approved over the past three years and also their strong pair mix. As a critical access hospital, these costs that they're seeing will be covered by the Medicare beneficiaries to the degree that it's a critical access hospital and they're getting 99% of their costs reimbursed. And a 4% change in charge will more than cover inflation for their commercial beneficiaries and they have a pretty low Medicaid population. So there's less need for a cost shift than other hospitals. So given the rate increases we've approved over the past three years, which are substantially higher than other hospitals in the state, I would support the 4% more than cover inflation. And I agree with the others statements around NPR and those projections. So Robin, would you like me to go first so that you could possibly make a motion at the end? Sure. So I support fully the staff recommendations and I would just say that hospital CEO should know that we listen to what they say and Joe was quoted either last year or the year before is saying that they can't continually go back to the board for high increases. And so I think this shouldn't come as a surprise to him. He's a seasoned veteran. They should expect the fact that the board is recognizing that although we would want them to be in even stronger financial position, they have made vast improvements. There is money on there that we don't know for sure would have to be returned. And now is the time to make an adjustment. And I think it's a reasonable adjustment, the 1%. So with that, I'm supportive of the staff recommendation. Robin. Thank you. I agree with what everyone else has said. The only other comment I would just make is just a reminder that the reductions in, I think it was 17 and 18 were actually enforcement actions because of the coply exceeding its budget in prior years. So just a reminder that that is why those were negative. So I am ready to make a motion. Patrick wants to move ahead to my cheat sheet or whoever's driving the slides. Thank you. I move to approve Copley Hospital's budget, including the acknowledged provider transfer. I think you'd get rid of that, but. Okay. I move to approve Copley Hospital's budget as modified hereby with the NPR FPP increase of 12% from fiscal year 21 to fiscal year 22 budget. A 4% increased overall charges and subject to the standard budget conditions is outlined on slide 36. Is there a second? Oh, Mr. Chair, I just want to make another point of order here that 12% that Robin cited effectively does include that provider transfer. Otherwise it would be 12.4%. So I think that we do need to include that language in the final motion. Russ, can you speak to that at all? Yeah, thanks, Patrick. I was going to ask if I could make the same clarification. It would be an NPR FPP increase of, and Patrick, correct me if I'm wrong. I believe what the board was discussing is a 12.4% increase from FY 21 to FY 22. If the provider transfer is given effect in that calculation, it becomes a 12% increase. I was just looking as being redundant, Russ, since we already had made that motion, but if legal tells me that that should be in there, it should be in there, and I'm sure that Robin will consider a friendly amendment and so will the sector. Yeah, legal is fine with either phrasing, either to reference the provider transfer and a 12% increase or not reference the provider transfer and a 12.4% increase. So I will reference the provider transfer and stick with the 12% in my motion. And does the seconder agree? Yes. Okay, is there further discussion from the board? Hearing none, I'm going to open it up for public comment on the proposed motion regarding Copley Hospital's budget. Is there any member of the public who wishes to comment at this time? Jeff Thiemann. Thank you, Mr. Chairman. My remarks are not really specific to Copley, so if you want me to hold them, I can do that. No, you can go right ahead, Jeff. Okay, great, thank you. I just wanted to say a couple words and thank you for your comments this morning, Kevin. I think as I've said throughout these hearings, and you've heard our hospital leaders say, this is a really difficult time for hospitals and for healthcare providers, really for all of us. So I think it was important and timely this morning to acknowledge our workforce pressures to underline them and for all of us to try to make sure we continually understand how far-reaching and expensive the implications of that problem are. And I also wanted to say that the Hospital Association stands ready to help the Green Mountain Care Board with this important conversation. We've been in this work for a long time. The Rural Health Services Task Force with Robin and many people from the hospital community and other partners examining every option we have to recruit and retain the people we need. So please know that VOS stands ready to help with whatever tools and data and assistance we can bring to the table. And I just think one message for the moment is to know how important it is for this board to approve the budgets you're reviewing so that hospitals can manage this growing challenge as effectively and quickly as possible. And of course, it's my view that any cuts to these budgets threaten hospitals' ability to do that. So I don't completely understand, especially given remarks this morning, making cuts at such a delicate and important time. I think hospitals need the room for creative solutions, for recruiting strategies, for college partnerships, for compensation incentives, you name it. So they have to be able to pay for these things so that Vermonters can get the care they need when and where they need it per the points that were made by the chairman this morning. So agree completely, none of us can do this work on our own, we have to work together, we stand ready to do that and thank you for listening as always. Thank you, Jeff. Is there any other public comment? If not, I'll refer it back to the board. Is there 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 it was a unanimous vote to approve the motion. And Patrick, it's my understanding at this time that we are not prepared for a thorough discussion on the remaining hospitals, is that correct? That is correct. We are still awaiting some very material followup information from those budget hearings as requested by the board. So just for some housekeeping, I wanna be clear to everyone that although we may be able to accomplish a few tasks next Wednesday, I expect that we will not be able to accomplish all. We put out several questions to UVM of which we have some answers back, but not all. And depending on the timing of that, it's unlikely that we'll be able to proceed on Wednesday with the network hospitals. But with that being said, you never know. Maybe we'll get the information first thing Tuesday and we'll be able to. But if not, we'll probably likely just be tackling Springfield on Wednesday and coming back to UVM the following week. Do I have that correct, Patrick? As the situation stands right now, that's correct. Okay, so board members, please be prepared to discuss the network next Wednesday, even though we may not get there. Hopefully we'll definitely get through Springfield and we'll just keep moving along and I just wanna thank the staff and the board members for the progress to date. We are moving along. And although we have some pretty big decisions yet to make, we're on the right path. So is there any old business to come before the board? Hearing none, 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 of the motion signify by saying aye. Aye. Aye. Any opposed signify by saying nay. Thank you everyone and have a great Labor Day weekend and we'll get right back at this on Tuesday of next week with our meeting on Wednesday. Thank you staff. Thank you board members. Thank you public.