 With that, we're going to reconvene, and Patrick, if you could take us to the next hospital. All right. Porter Medical Center. Their FY21 request for NPR FPP represents 2.7 percent growth over their fiscal year 20 budget is below the 3.5 percent growth rate ceiling set forth by the board. Their change in charge represents a 0.0 percent overall change in charge request and a 5.75 percent commercial change in their effective rate. They have not but a risk reserve in the coming year as they are rolling over their reserves related to the ACO from prior years on their balance sheet. Their justifications include a need to balance and manage expense growth and that it is necessary to support the nursing home. This is a hospital who also has had some pretty solid budget management over the years and has produced some relative margins in recent years. Most notably, they had a 5.2 percent margin in their fiscal year 2019. This is a hospital that's affiliated with the network in fiscal year 2017 and the years leading up to that that are not visible on this had some financial difficulty but has since rebounded from that and in fiscal year 20 here they are projecting a 2.8 million dollar, excuse me, bottom line operating gain and their budget includes a 4.5 percent operating margin which is equal to 4.37 million dollars. So moving on to the 2.7 percent request as previously stated is within the 3.5 percent guidelines. We would accept their overall change in charge of 0.0 but reduce their commercial effective rate to 3 which would have an impact on MPR reduction to 1.8 percent in change in charge. We would look for the hospital to have commensurate reductions to expenses as we stated for other hospitals where we have recommended a reduced MPR and I believe we ran some calculations late yesterday that with the staff's recommendation this would bring their operating margin down from 4.5 to 3.8 just to give you some context around what that decision does for that margin because we do believe that the margin overall was not fully justified. So with that we turn it over to the board for discussion on Porter Medical Center. Sure thank you Patrick and I'll jump in first. Your closing statement really focused on my concerns here in that I worry about equity in the process when a number of hospitals come in with a budget that's requesting an operating margin in these uncertain times that's just above zero and here we have one that came in at 4.5 it was the highest one that I think I'd have to go back through and look at them all again but it was the highest budgeted operating margin and even reducing to the 3.8 I think it still keeps it at the top of the list on that operating margin so that's my biggest concern about this hospital in that I just worry about equity in the system so with that I'll turn it over to other board members. Yeah one of the things I'll point out is I do think that their top line number that they came in with may be aggressive it is under the three and a half percent so I'm not saying that we actually should adjust that but they were trending I believe seven percent down through February and you know their request year-over-year 2.7 seems low relative to that and even with their change in charge requests which I believe in total was 1.2 million my concern would just be that they may not hit their top line so I would just put that out as caveat I'm not going to reduce their top line because it's within the three and a half percent but it is a hospital that where they were trending was below the 5.75 commercial is on the higher side definitely would look at talking about bifurcating the charge into potentially two pieces and whether or not it's as high as 5.75 or a reduction to the three percent that the staff put and you know whether it's three percent base and a one percent covid or something like that I mean I do think that the margins they're reporting are high we know that they've benefited from being with the with UVM and that's good and they've reflected in the past you know lower rate requests because of that but this year the 5.75 is you know much higher than what they've requested over the past five years and obviously there was discussion about how important and the need to support that I don't dispute that how important needs to be supported it's just is that at the backs of the commercial rate payers in order to provide a higher margin that's then able to support support that how important as well so yeah my observation is that orders presentation was a very good presentation and they have been and are probably out of a recovery mode at this point in time the only wrinkle for me was the the nursing home and the kind of Kevin was talking about the equity between say Porter situation with their nursing home and I do note that the rich operating margin is a is offset to some extent because it includes a mouse do then flow to the nursing home and I think in reading the staff material that they looked at the order financial statements of the nursing home in the hospital or the hospital for the last three years and there's been an increasing amount of transfer to the nursing home I think the most recent one was over three million dollars which which means that the net operating margin for the hospital itself will be diminished quite a bit in 2021 but I do think that that is an equity issue that has to be sorted out maybe not in this budget cycle but there clearly isn't an equity there that needs to be addressed but I can support the staff recommendation on this on Porter. So I'll jump in here a couple of things this one's an interesting hospital to be thinking about they have rebounded but I would say that their days cash on hand are still below the state average so the rebound has taken some time but we're still not even at the state average I think that the chart that you have up now is really an important one if we look at the approved commercial over time or the approved overall but I think the more relevant one is the approved commercial it's 2.17% over the five years so this actually has changed my mind a little bit on this hospital given that the adjustment has been made to this chart in the sense that this is well below the median change in charge and they are a low base hospital as well so their commercial to Medicare ratio is low I think it's the third lowest of all the 14 hospitals so their base is low and their growth rate has been low so I do think that their margin is high it is your right Kevin it's the highest of any hospital and it's I think the second highest would be the end with 2.5 so it's a big delta between where Porter is coming in at and where the next closest hospitals margins coming in and that you know did stand out to me as well I think the issue with the nursing home is something we have to grapple with and I think that there are every hospital has services within its mix that are cross subsidized so hospitals that have mental health you know in patient beds are those I'm sure are probably being cross subsidized by something like orthopedics so we have to think differently I think going forward about how we want to treat the nursing homes it's a separate tax ID number if I understand correctly so it is treated as a separate entity but it is being funded largely by the by Porter hospital so I understand the equity concerns but I also would recognize that there's a lot of cross subsidization happening at many hospitals depending upon their service mix and it is a resource in our community here in Middlebury that I know people rely on so I would worry that if we cut them off this year because you know there may be some compromise of services offered there but it's something we need to think about look at carefully and think about how we want to evaluate but I think we need to do that in the next budget cycle I'm not sure this is the budget cycle to do that so I guess where I'm landing is I think that you know their base is low their growth rates have been low and below the median they have some room with their margin although it's not as large as simply shown here because of Helen Porter which we do need to address I do think that the NPR might be high and so I would worry about them even making that margin if their expenses are being calculated based on an NPR that they may or may not hit to Maureen's point so I also worry there so where I'm landing is I think you know we have been giving commercial rates of increases of 3% you know to many of these hospitals I'm comfortable I would go above the staff's recommendation of a 3% commercial rate I might do 3% plus a COVID or straight up frankly 4% for this hospital for all the reasons that I outlined Yeah I can support a 3 and a 1 as well but I just could you go back Patrick to the slide that was showing the commercial changes I don't maybe someone needs to explain to me on 16 how we can have an approved overall and a submitted overall of 5.3% rate correct and then approve commercial of zero that just seems to be inconsistent I think I can probably explain that I think when Porter so I don't think that Porter is reimbursed as a percentage of charge for commercial payers they're reimbursed on a negotiated schedule and so the change in charge may not actually impact the approved commercial at all I'm right about that and remember too since they've joined the network they've begun to ask for that effective rate that medical center asked for so this is only taking into consideration if they broke that out that's it before they came under the affiliation with the network they were requesting overall changes in charges and as you can see that is not been the case they've instead changed their tactic to request a commercial effective rate so that's just capturing that they don't bleed over into the other one I thought maybe 16 and I was trying to go back and pull up the documents from 16 to see what they got because I don't recall I wasn't here then but I'm not would be surprised if it was zero if they had a 5.3% overall which is then factoring into that blended year 5 year average but I'm okay with what Jess had suggested which was the 3% and 1% or 4% but I think separating out of COVID piece is more flexibility and I'll just jump back in that I think even at the staff recommended level there's still the highest approved budget with the highest operating margin and so anything over the staff recommend I think I will oppose but we are a 5 member board so that's what makes us beautiful can I just ask a quick question on that note Patrick and Laurie if you could answer this or some other board member can answer this the 4.5% margin what is it once you include Helen Porter that was in the narrative and I don't have that in front of me I just want to make sure that I understand what that actually is what you mean included do you mean the distributions they've been making well there was I don't have it in front of me but there was an adjustment or there was a there was a point that they made once they included the distributions right what their margin would be that I don't recall again this is where not being able to understand what's happening with the finances of the nursing home in 2021 we need to cover the shortfall in operations over there so I see it looks like Jen Bertrand just raised her hand so she may be able to weigh in on that I can speak to that it brings our margin down to 2.5% the budgeted subsidy to Helen Porter for FY21 is approximately $2 million and I can elaborate on that during public comment for the board this one's a little bit tough because I can see both sides of the issue and I am sympathetic given a lot of the nursing home issues we have in the state for the need to maintain those services in the community I would however say that Medicaid does have processes where nursing homes can request modifications in their rate because of financial difficulties I don't know how that plays out in this situation so I'm hesitant to rely on that knowledge and the other thing that is a little bit problematic is we don't know the CRF funds that would fall or not fall to the bottom line and we're quite frankly I don't think going to know that because I don't know that we want to wait on this budget until effectively next week so I'm struggling a little bit I guess with whether I would land with Kevin or whether I would land at the 3% plus 1% COVID I'm definitely in that range I'm just going to continue thinking while other folks make comments and we hear from the public yeah I'll just put a little context too so what was recorded in their charts is that the value of 1% charge on commercial is $278,000 so if we were to go to 4% that would be a $486,000 reduction and assuming for sake of argument that just fell to the bottom line that they didn't have cost savings which I always think are available to look for more cost savings and efficiencies but that would be half a percent on their operating margin which would bring them down to their reported margin of 4% where Jenna just said it would be $2 million to Porter that would bring them down to I think 2% operating margin and a higher total margin just to put into context what it would be for a 4% and I do think because of the uncertainty I understand what people are saying with potentially a 3% but I think with the uncertainty of COVID if we put in a COVID allowance we then can review that next year again I think we've said mid-year and at year end there will be a lot more clarity on what happened for 2020, what type of funding they received where they are on their balance sheet and then we could look to make adjustments if necessary or continue with that so I'm willing to go on the higher end because I think it gives us that flexibility on the COVID piece and with just so much uncertainty with this whole process 1% is $278,000, $7,000 and they certainly even though maybe they hadn't documented completely there are COVID related increases whether that was in PPE slower losing volume etc. that's impacting that so that's where I land but that's definitely helpful Maureen so thank you for sharing those thoughts I think for me now having thought about this for another minute or two this is the hardest part for me during the deliberation is sometimes I need a little more time to think but I don't want to slow the process down I think I have gotten myself comfortable to the 3% and a 1% COVID for the reasons that Maureen and Jess have explained and also I would note Jen has done a fantastic job as CFO she's been a leader in figuring out the critical access hospital issues so I trust that she if she sees something going differently than expected that she will communicate that because that has been the pattern in the past so I think I think I would be comfortable to share and people are ready I can make a motion anytime you're ready okay so I would move to approve Porter Medical Centers budget with a 3% standard increase to the effective commercial rate and a 1% COVID-19 increase to the effective commercial rate is commensurate modifications to the NPR FPP subject to the standard budget conditions on slide 27 is there a second it's been moved and seconded to approve Porter Medical Centers budget with a standard commercial change in charge of 1% for a total of a 4% increase in the effective commercial rate and commensurate with the appropriate NPR FPP that staff will calculate and subject to the standard budget conditions as outlined on slide 27 did I accurately portray that Robin thank you further board discussion hearing none I'm going to open it up for public comment and I heard Jen say that she wanted to offer some additional comments and public comments so Jen the floor is yours thank you Chairman Mullin I appreciate that I just do want to clarify a few things for the board and speak specifically to a couple of expense items as well as Helen Porter and I know that there was maybe some discussion about our COLA or cost of living adjustment for our staff and I did just want to make a couple clarifications there that the total wage increase for Porter was actually 1.4 million and not 2.1 million that 2.1 excuse me includes all of our inflationary expense increases that's benefits supplies and pharmaceuticals in that dollar amount our cost of living for the staff actually is $485,000 and we have some required market adjustments for our provider group per contract that's about half a million dollars but one of the biggest things that's in that dollar amount I wanted to touch on is our wage compression issues and we have about 420,000 in our budget for that so we're we are significantly behind market and our wages I'll be honest in 2018 our compensation consultants had reported that we are behind the market in Vermont by 5% and we've not been able to really adequately address that deficit so our budget does attempt to incrementally do this and we're going to do this over a multi-year timeframe but I just want to touch on cutting those expenses is really a need for this organization that 2.5% cost of living adjustment for our employees you know to talk about that relationship with the margin target would really continue to put us further behind market and that is would perpetuate further I'll be honest a very strange recruitment retention issue that we have here at Porter so I just did want to touch on that for a moment and secondly I did want to mention as critical access hospitals for all of us we build our budgets based on expenses and revenue working in tandem with one another due to our cost-based reimbursement so when you're cutting expenses to balance any kind of commercial rate reductions or just expenses in general that will have additional adverse impacts on revenue especially on that Medicare reimbursement side so I did just want to mention that and lastly actually before I talk about home quarter for a moment for our piece of this for just a moment to shed some clarity what Porter is requesting is for the fixed perspective payment reconciliation and those dollars are $778,000 that we're currently requesting as you heard yesterday it is still pending right now and I wanted to mention that but just candidly that's already reflected in our current 2020 projection because we will essentially just be writing that check over to one care and paste to the MS so I just did want to make that clarification there too and lastly the conversation regarding Helen Porter and I certainly appreciate and understand that this is not regulated this part of our business and there are certainly reasons why we are separate EINs and this is really from a cost-reporting perspective both entities do have to file discrete cost-reporting especially when you have a parent organization but the reality is that the hospital does have to subsidize them in order to keep their doors open and I really wanted to kind of expound upon what the hospital what would happen at the hospital if we didn't leverage that current transition to care that is really candidly made more efficient by having them being part of our organization and simply the cost of care to the system would increase with patient transfers those would actually be delayed under a traditional transfer model and this is a little shocking sometimes when you put these numbers to it it's a 350% difference in the daily rate between the hospital and the nursing home and if you look at that in dollars it's $1,400 per patient per day which is why we've leveraged Helen Porter so much as part of our population health initiative and being part of our success in population health and we talked about that last year during our presentation too about how we leveraged Helen Porter in that transition to care to save overall dollars to the system and I just wanted to you know kind of point out too that this would actually have an unfavorable impact on the cost shift because if we kept those patients in the hospital there's certainly an impact to that on the cost shift side of the equation so I did want to mention that and the last thing I think is the rate request that we have from a percent standpoint I mentioned this during our hearing is certainly looks higher but in fact the dollar amount is relatively low and that does strictly cover the majority not all of the hospitals and the inflationary factors so I did just want to mention that and kind of give some real context to Helen Porter and you know maybe there's some discussion that we can all have about how we can roll them and present them in the future because it does bring our margin down significantly and I will say they are if I start nursing home and it does take a lot to maintain that quality level from an expense standpoint I really appreciate you all letting me speak today. Thank you Jen I see that Thomas Thompson has his hand up as well Chair Mullen thank you if you recall I presently serve as the interim President Chief Operating Officer for Porter Medical Center I raise my hand probably a little prematurely because I know Jen covers every single topic as you well know and gotten acquainted with over the years we have a history here of submitting very responsible budgets and the only one piece of Jen's that I want to build on is the one that's related to the workplace and the workforce planning requirements of our budget which I think just start to capture the issue that we need relative to the marketplace and wage competitiveness so as such we have a 5.75 commercial rate request that really is helping us support a budget that's just starting to get at our issues and why we submitted the level that we did and again appreciate the work hard work you guys do the only other thing I just want to add to her comment on Helen Porter just quickly we've just completed and our board just approved our strategy map for a three-year window to take us into the future here in the Center and that plan has a very very strong emphasis on value and as you know we have I think the highest as far as percentage patients served on the value-based model in the state it's something the organization has taken some pride in and will only continue to prove in and Jen can certainly get at as she just did dollar impact of our long-term care and rehab service at Helen Porter upon value delivery here but as far as obviously the patient and resident experience it's also instrumental in serving the community and so with that I thank you for your service and this opportunity to address the group this morning thank you Thomas other public comment hearing none the motion before the board is to approve Porter Medical Center's budget with a overall 4% increase in the effective commercial rate with 3% allocated to the standard change in charge and 1% to a COVID related change in charge with staff preparing the appropriate NPR FPP numbers for the change from FY 20 to 21 budget with this being subject to the standard budget conditions as outlined on slide 27 is there further board discussion if not all those in favor signify by saying aye aye all those opposed signify by saying nay nay let the record indicate that it was a four to one vote Patrick I think the record needs to reflect that votes of each individual board member under the open meetings law so that would be all four board members except for the chair voting in favor and the chair voting no correct okay the next hospital up is central Vermont Medical Center their NPR request for fiscal year 21 represents 8.7% growth over their fiscal year 20 budget request which is an excess of the 3.5% growth rate ceiling their change in charges they are requesting a 6% overall change in charge and 8.5% commercial effective rate change in charge they have justified this request by noting that their expenses have exceeded revenues since 2016 and the main drivers of this have been salary and pharmaceutical costs a higher collection trend and increase in volume of 1.5% is driving this as well fiscal year 20 very year and finally we have calendar rollers majority voting due to shift in power mixed growth for unprideensible volumes as of February 2020 they were operating at�様 3% above budget and others you can navigate thank you very much as we are over the course of those years with FY20 being kind of the anomaly given what we know. This is a hospital also who has seen several years here of negative operating margins, including they are projecting to lose $4.5 million as of this budget submission. And this request produces a nominal margin of 0.5% for a value of $1.2 million. Again, we broke this out. We discussed it with Porter as member Holmes noted, so we figured we should probably spend a little more time here on that breakout as we kind of addressed it pretty quickly yesterday. So approved and overall change in charges 2.4 and 2.5%. Approved and submitted respectively. And they have also shifted towards the commercial effective rate request. However, they do continue to ask for approved overall change in charges in coordination with those. And last year you can see your approval was at 5.9%. Which is what they requested and 3% overall change in charges, which is what they requested. So here we focused on the change in charge. And we did this as we expressed in the review of this hospital earlier. We believe that the provider tax was budgeted at a rate that's too high. And Laura, if you can navigate to slide 134 so we can spend some time on that. We did receive a response yesterday from the network which does help clarify why the figure was budgeted where it was budgeted for essential Vermont. And this also applies to the UVM Medical Center. And what they've said is that they've received advice from their auditors that they haven't been appropriately accounting for it with the accrual method of accounting which tells them that they need to realize the tax at the same time they realize the revenue upon which the tax is based. So if they earn $100 million in the month of October 21 then their tax will be essentially 6% of that or $6 million that month. Which is fine and appropriate because they need to do their accounting in accordance with guidance from their auditors and gap, et cetera. However, we still disagree with the increase here because Giva is going to assess their tax differently than the way they are going to account for it from our perspective. Giva is going to look back at the month of October 2019 through March 2020, they're gonna take those revenues, multiply it by two, divide it by 12 and they're gonna assess a nine month tax based on what the hospital brought in during that time. And then in the spring, April through June when they received the audited financials for fiscal year 2020, they're gonna true that up and they're gonna base their tax for the rest of the year either up or down the revenues that were actually generated from the medical center in this one, specifically Central Vermont. So they are accounting for it in a way that is appropriate and they factored that into their budget but the actual tax they're gonna realize is still going to be on 2020. So that we believe there's still going to be a discrepancy there between budget and what they actually pay. And we are willing to back away from any hard number suggestion for the board but when we're looking at the trend analysis here it also does not connect the dots for us and we respect the accounting methodology and the explanation that they've provided but we still don't feel that that is actually gonna come to realization. So we think there's room for a cut here in that rate allow them to keep that expense structure to fall to their bottom line so that they can maintain a bottom line relative to what they need because with all due respect it's pretty slim at 0.5%. So with that we turn it over to the board for discussion on Central Vermont Medical Center. Thank you Patrick board members. Patrick I just want a little more clarification on the provider tax as far as what number you're saying it should be. I went back and was reading some of the transcripts and some of the other information about what the hospital had said at the time and then looked at what they sent us where it does seem as you said they're changing their accounting methodology that they've been doing it wrong. I've been through many audits and it's surprising that an accounting firm as well as the staff would be doing it wrong every year and that it wouldn't be noticed or talked about. Usually you show your work papers and that's a fairly straightforward calculation. You either did it on the prior year or you did it on the current year and I would imagine they would have work papers to show that and if now they're changing that methodology to reflect a change in 21 budget which I believe I know for UVM would have been about a 2% relative would equate to about a 2% on the tax rate and I'd like to get that for CDMC as well because either they're gonna get the benefit then in 20 which they haven't fully reflected or they're gonna get it in 21 although now they're gonna it seems like they're changing how they do this and someone had to have calculations on how this was done and it was either clearly done off because they said it was delayed three to six months on the lag on the provider tax because of the information that they would then receive from Diva. So it seemed like they were always chewing it up to what they owed in that year and so therefore they were accruing for when the taxes were owed and paid which was the year after. So I do have an issue with a change in methodology at this point doesn't seem like that's the time to make that change and if they've been doing it wrong all along that is surprising that their work papers wouldn't have been reviewed by their auditors because it is stated in the audit, the provider tax there is a comment in the audit about provider tax as well. So I guess maybe Mark wants to respond to that but he's got his hand up. Yeah, if possible, I'd like to keep discussion to the board until we open it up to public comment. Actually Kevin, I was just gonna speak to the specific accounting component that Maureen had, not public comment but I'll follow whatever practice you would like to take. Yeah, I think Mark, if you could hold off because I am confused on this and just to prepare you for when you speak under public comment, we did receive a letter from the network today acknowledging a $430,000 reduction in the calculation for that. So if you could address all of that during the public comment period, it would be good. Okay, thank you, Kevin. Thank you, Mark. Board member comments? I think relative to the provider tax, there is, you know, there are some hospitals that don't even do it in conjunction with Diva. Northwestern, when we talked to their CFO, had said that she was totally unaware of Diva ever being involved in giving a prospective amount for a future fiscal year. And I worry a lot about taking one accounting method and inserting it surgically into this process where that same accounting methods might apply to other elements of the hospital budget process. So we're on a budgetary basis. There's been a traditional approach across most hospitals as to how to calculate that tax. And it's 6% of the prior year's NPR. And, you know, if you kind of look retrospectively, that's what the numbers come out with when you kind of look at what hospitals have been paying under 2019 tax. So I worry that we're kind of, we get into a situation here mixing and matching methodologies for one particular item, but not kind of scrubbing the whole process to make sure that everything is perfectly aligned. So just to jump in on that, my point of view is a little bit different. I think that all hospitals should be doing it on an accrual basis. And the tax should be applicable to the period in which it was literally incurred because it's based on the revenues for a given year. And I would prefer if all hospitals did accrue it. So that's a simple 6% of the revenue that it's based on that's in the budget. But with that being said, this is very confusing because it still seems even with that to be beyond what that is. So we'll get further explanation in the public comment period, but it is troubling. Other board members, if not then I'm gonna go to the public comment because I think a lot of board members really wanna hear what you have to say, Mark, as we try to grapple with this issue. So the first person I'll call on is Mark Stanislaus. Okay, thank you, Kevin. I will speak specifically to the provider tax and reserve the right to come back based upon further conversation. But as it relates to the provider tax, the reason why this is so glaring in the FY21 budget is because the revenues have been more stable previously and the impact that COVID has had on the NPR in FY20 has raised this to a materiality level that would fall within an auditors will review threshold. Because when auditors do the annual review, it falls within thresholds and dollar amounts. And so like we had said before, previously we haven't been using the accrual methodology, but because the revenue flow has been so stable and consistent, the materiality level of the difference hasn't raised to the threshold. Given the impact on COVID or the impact of COVID on the hospitals and how it has impacted NPR, which is the driver behind the provider tax, like so many other things this year, we had to sharpen our pencils on a lot of calculations like the debt service calculation. We had to sharpen our pencil on that like we had never had had before. So, well, we do acknowledge that this has been a change in accounting practice. It has not been a material impact that would be flagged under audit. The decrease in NPR for FY21 based upon the accrual accounting methodology and like you had said, Kevin, with a matching principle, the downstream of the provider tax decrease would be recognized in FY20, okay? And so hopefully that speaks to some of the components that Maureen had had. The reason why CVMC, if you just look at the FY21 budget numbers, appears to be slightly over 6%. If you just did that calculation, I think it was Tom or Kevin that had mentioned it is because that includes the provider tax, well, for Woodridge, which is about $750,000. So if you were to remove both components of the revenue and the tax related, well, to Woodridge, you would see that it falls within that 6% corridor that we had discussed earlier. So I will stop there. This section of the public comment that I was only using to respond to the provider tax question, but I would like to end by saying, you know, booking the provider tax in the year that it was assessed versus the period that it's built, because that's what the difference is. There's about, and I'm using very, very broad references, but there's about a 12 month lag in which Diva bills on. That's the cash basis accounting methodology on when you pay the bill, it is booked in your statements. On the accrual methodology, to stay consistent with our overall accounting practice is under the accrual methodology, you know, we believe in FY21, the provider tax is stated correctly based upon those accrual accounting methodologies. And we also are reporting FY21 in the same manner. So, you know, that's going to be subject to audit by our accountants. So that's where, you know, that's where our perspective stand on the provider tax discussion. So, Mark, I appreciate the explanation and maybe I'm just thick, but I'm trying to reconcile it to the letter that came in this morning from Dr. Brumsted. And in that letter, there is the statement that as requested, we met with Green Mountain Care Board staff and came to the conclusion that our fiscal year, 21 provider tax should be reduced by approximately 430,000. So help me understand that. No, well, I mean, in all of these conversations, I think like what we said before under public comment was that we would speak with staff and we would recheck our FY21 calculation. And when we recheck the FY21 calculation based upon that accrual accounting methodology and the actual revenues in the FY21 budget, the number would be 430,000 less, Kevin. So this probably is one that maybe the staff may need some time over lunch to do some crunching on because it's clear that you're in agreement that it was overstated by 430,000. So, board members, do you have further questions of Mark on this issue? I welcome, I became chair of Central Mon Medical Center in January. So I figured it would be good to help give the board some perspective or my perspective from a board level in regards of where we are at with Central Mon Medical Center and our affiliation with the network. I'll start off by saying, the numbers Mark can answer any of those specifics, but I really wanted to give the board some understanding of the impact that moving away from in our budgeted presentation would have on the local community. We're being asked, in essence, we're at a critical phase, I believe here in the turnaround phase for Central Mon Medical Center. We're looking to really just break even at this stage. I think getting back to the Porter discussion in regards to our nursing home, we absorbed that under our own TIN and we've turned that around in the first phase of this turnaround story. The last numbers I saw were their break even. To go from losing $3 million a year on a nursing home platform to really being break even now, I think that really impacts our overall number. The second aspect of it is our pair mix. Moving away, we really have a significantly different pair mix from Porter and I think that really affects our budgeting process. I really think affiliating with the network as we have over the past number of years and has really prevented Central Mon Medical Center from being a really disaster story over the past couple of years. We could have been facing huge margin losses, significantly more than we're showing here. I think the turnaround over the past couple of years really is a testament of the work that has been done and I'd hate to see that momentum end. If we're asked from a board perspective to come up with $2 million, it's gonna seriously impact access to care. It's gonna seriously impact our ability to participate in the psychiatric inpatient facility planning. It's gonna really impact our ability in regards to budgeting for that margin level. So I would really ask the board to seriously consider that where we're at in this process, give us another year, really look at what the network has put together here. Our rate requests, I feel was reasonable. I feel if the board goes with the staff recommendation, it's gonna weaken our position to really participate and it's gonna make healthcare in central much worse. So with that, I thank you and would be happy to answer any questions. Thomas, how long have you been on the board? I've been on the board since 2014, 2015. I really started as chair of the board this year though. So I've just recently joined the UVM Health Network Board this current year. So I am chair of the network investment committee and I've been chair of the CVMC board for the past seven months. It's tough in COVID to have physical meetings. We had a meeting this morning to discuss this. It's not the same as being together. I think Anna and team have put together with Todd's help. We've had some struggles getting in a long-term CFO. So we've been relying on Todd's work in dissecting some of these issues. But I think we're really at that phase where a year from now, two years from now, three years from now, we can really show significant improvement. And then we can be really good partners with the state on helping with the psychiatric inpatient issue. So that's our goal. But I'm excited where we're at. I just would hate to see us go back and have to cut access. Well, I hope that you can somehow shorten the timeframe on starting to address the psychiatric inpatient issue. But I understand these are trying times. And unfortunately, much of what will happen depends on what happens with COVID. So... I understand we're committed to working with the network to help solve in partnership with the state the psychiatric issue because it is a significant issue for our emergency room. And we are committed. We just, from a financial perspective, we really partners in that with the network as well as with the state. And so to take on a $100 million project from a negative margin perspective would be very difficult for our board to really go after. So I'm hopeful that we can re-institute those discussions on the site center. But without the margin, I just think CVMC really has to look at other areas and I'd be very, it'd be very difficult for our board to push that. However, we are significant, we are committed to working with the Green Ramp Care Board and the state on that topic. Thank you, Thomas. Other members of the public who wish to comment on Central Vermont Medical Center's budget. Hearing none, board members, is this something that you would prefer that staff get some time over lunch to crunch what the numbers might be with at least the 430,000 agreed to amount from the network? Or do you feel you have enough information to proceed now? I think, you know, when I look at the 433, I believe if we look at it as 1% value of commercial charge is $621,000. And so 433,000 or 430, that would be about a 0.7 reduction to the commercial rate ask just for that component. I'm not sure that the staff is gonna do any more, you know, any more than that with it, you know, that's what it translates to. I tend to agree with you Maureen, but I don't know. Well, I think the range, I mean, it's 430,000 and we have that number. So I think from, you know, I don't need anything more from the staff right now on that to continue discussion, you know, relative to that one component, it would be 0.7, which would be a factor in the discussion. But I think we haven't really talked about looking at the commercial rate, you know, bifurcating it as we have other hospitals. I think for the most part for other hospitals, the barring one, you know, 4% was the highest that we've done as the base rate barring Northwestern. And then adding a COVID component on top of that. You know, I think their total rate requests would have been what, 8.5? So if we took away the 0.7, you know, we would reduce that component and then, you know, is there additional that people would want to look at for that reason? The 7.8, you know, I mean, I think my 4% is where I'd wanna go for the base commercial rate and then put a COVID rate on top knowing that, you know, certainly that could carry forward. This hospital has been a hospital that historically has missed their top line and exceeded their expenses in the past several years. I think it was in 19, their actual was the 228 for expenses. Well, let's go to the top. Their budget for NPR was 211. They came in at 208. Their expenses were budgeted at 221. They came in at 228 in 18. Their NPR was budgeted at 198. They came in at 194. Their expenses were budgeted at 208. They came in at 216. Now, if we just look at their expense growth from 19, a 228 to what was the budget of 234 and now in 21, a 253. Their expenses have are increasing significantly year over year. They continue to miss their budget, missing top line and exceeding expenses. I don't know what to do about that, but I just wanna lay that out there. And that's really the reason for those large declines in 18 and 19 was that combination of missing the top line and then having significant overages and their expenses. Question for Patrick. Before you go, Robin, a question for Patrick that I have and you may wanna work on this while Robin speaking, but I just wanna to make sure that the 0.7 is accurate. And what I'm concerned about is that with the breakout between the overall change in charge being requested at six, but effective commercial at 8.5, I just wanna make sure that we're getting these numbers accurate. So I'm just throwing that out there and I'll turn it over to Robin. So wait, one moment, what is it you want? So what we're talking about in their request was a 6% overall change in charge with an 8.5 effective commercial. With that reduction of the 430,000, what do those two numbers end up with? And are you in agreement with Maureen's calculation? Okay, and I wanna clarify too about the 430,000 because it sounds like it's being stated that the staff agree with the network on that. We don't. We were not actively involved in calculating that. We actively listen to their explanations and encourage them to submit their written response. So I just wanna clear that up that we were not in agreement with it because we didn't walk through the calculations with them. So we have really no way of verifying that 430,000 mentioned, but we will certainly walk through what the reduction would be with the 430 as the network laid it out and also Maureen's conversation as well. Well, I'd be interested and then also, and I think we're gonna end up coming back to this after lunch on this one. I'd like to know the differences between your disagreement and trying to get to the core of this matter so that I mean, if there's no basis for the 430,000 number, then that's troubling too. I took Mark's explanation at its words, but again, I have not seen the math behind that calculation. So. And Kevin, I can just clarify, you know, on the dollar value that was put in for commercial was 5,283,000 and the value of 1% was 601 and that does work out to be 8.5%. So if you take 5283 divided by the 8.5, so those were the calculations that we had before. Did you calculate in the overall what it reduces the 6 to? No, but we're approving the commercial rate, correct? Well. It all depends on what the motion is. Yeah, but I think we're focusing on the commercial. But any analysis of the system does look at the overall change as well. So I just wanna make sure that four years from now somebody's not looking back at this and scratching their heads on what was done here. Kevin, I'm just gonna make a suggestion. If we're, if we are gonna break for lunch and the hospital budget team is gonna kind of look more deeply into this for CVMC, I guess I would suggest if they could also do the same calculations for UVM to the extent that there was also, I believe, wasn't there a reduction in what the UVM in Dr. Bromstead's letter or in the calculations, which I don't have in front of me. But I think that there was, am I right? Yes, I have to pull up the letter. We just received it this morning. That's the trouble with this last minute. I guess if there was an adjustment as well for the medical center, then it might help if they're gonna be making some calculations. Yeah, there was an adjustment in the letter. 570,000. Yeah. So I'm just thinking if they could do the same thing, it may be food for thought for our conversation about the medical center. I'm not sure. So I'm actually gonna suggest then that we break now and give staff some extra time and come back at 1.15. And hopefully at that time, we can go back to Mount of Scottney and then proceed with Central Vermont and UVM. Does that make sense to everyone? It does. Can I say one thing before we break? Yeah, sure. Because I think it may need Mark or someone to do a public comment later, which is I'd be interested to understand the impact of the 8 million in CRF funds that they'll be getting to the bottom line and whether Jen had mentioned that some of their CRF funds were already included in their 20 budget and I just don't know whether these fall to the bottom line or whether these are already accounted for. And do you want that for UVM as well as CVMC? Yes, that makes sense. And so for giving Mark things to explain public comment this afternoon, I certainly will be looking for an explanation of why in the budget hearing, they were expecting about 12 million in CRF and they got 32 million, which was $20 million higher. So just some homework for Mark and some homework for our staff.