 Good morning for the record my name is Pat Jones director of health system finance with the Green Mountain care board just a quick recap on what transpired yesterday. The board voted on budgets for seven hospitals today will discuss northeastern Vermont regional hospital Brattleboro Memorial Hospital Northwestern Medical Center Springfield Hospital and then the three UVM health network hospitals central Vermont Porter and University of Vermont. So we'll start with northeastern Vermont regional hospital. They have come in with a proposed budget of almost 81 million. They represent about 3.1% of the system total. They do have a physician transfer adjustment and that brings their MPR growth down to 4.8% should the board approve that adjustment. They do in fact offer health care reform investments at the amount of 0.4% of their MPR and their fiscal year 19 rate were classed as 4% with 1% valued at just over 384,000. So preliminary decisions were made with regard to northeastern Vermont regional hospital the adjustment to the fiscal year 18 base the staff recommended accepting that and the board's preliminary decision was to do so as well health care reform investments the same staff recommended acceptance the board's preliminary decision was to do so as well. The MPR growth rate again with that adjustment is at 4.8% and the options there to accept that rate of growth or to reduce it the commercial rate increase at 4% the same options accept or reduce a significant update for this hospital is that since we met last week they they're board voted and they are planning to participate in the ACO Medicaid program for 2019. So that's a significant update. If you were to reduce their rate from 4% to 3% the estimated MPR growth would become approximately 4.3% as opposed to the 4.8%. So I'll stop there and let you ask questions or discuss the questions for that. As I look at the notes from last week it looks like the board was tentatively focusing on a 2.5% to 3% range. Does anyone wish to make a motion or have any discussion? I would say that I would start. I would be at the higher end of that range given that they are now participating in the ACO Medicaid for all reasons we talked about yesterday giving them some operational room to implement the shift from deeper service to fixed payments. Their MPR is still going to be above our guidance at that point even at 3% and 4.3% but given the demographics in their area given that they are likely probably having some new venture revenue in that MPR and given their movement into the ACO I'd be comfortable with the higher end of that range so 3%. Does anybody wish to make a motion? I'll make a motion. I will move that we set the MPR growth rate at 4.3% with a commercial rate increase of 3% and we accept the adjustment to the base for the provider acquisitions and the healthcare investments. Is there a second? Second. So the motion is to set the MPR at 4.3% commercial rate at 3% to accept the adjustment to the fiscal year 18 base of 129,700 and to accept the healthcare reform investment of 300,000. Is there a discussion? The only discussion I would have is I was at 2.5 before but I as well would go to 3% because they are participated in the ACO. I do think this is a hospital we have to watch as far as the MPR growth because they've had consistently over the 3% for the past couple of years and I think it's actually whether it's New Hampshire residents coming in or it's Vermont people coming back I think we may have lost Vermonters out and they're coming back but you know either way that's what's driving the growth and it is something we'll have to watch for this hospital but I do agree with the 3% now. All those in favor signify by saying aye. Aye. Any opposed? Okay. So the next one is Brattleboro Memorial Hospital. They are coming in with a budget of almost 84 million. There's a number of hospitals that are in the same range. 3.2% of the system total. They had recommended an adjustment due to an inadvertent decrease of their MPR last year. The board preliminarily agreed that that adjustment should be made so their MPR growth rate with the proposed adjustment would be 4.8%. They also indicated that they had health care reform investments that exceeded the 0.4% allowance. They are one of the smaller hospitals that is participating in all three ACO programs in 18 and indications are that they will do so again in 19. Their fiscal year 19 rate request is 4.9%. The estimated value of 1% is 392,000. So four decisions for the board here as well. The adjustment to the fiscal year 18 base preliminary decision was to accept that health care reform investments here. There was one investment that they indicated that it was the hiring of a neurologist. And the staff did not see the direct link to health care reform for that investment. But staff recommends allowing the remaining and even with taking the neurologist out of the health care reform investment amount. They still would reach that 0.4% allowance. So we recommend that you accept those. MPR growth rate again 4.8% with the adjustment. The options are to accept or reduce that. And the rate, the commercial rate increase at 4.9%. If that were reduced to 3.9%, the estimated MPR growth would be 4.2%. A couple of items I would just like to point out. One is that reducing Brattleboro as you can see has an operating margin in fiscal year 19 of just 0.3% projected in their budget. So if they were unable to identify some spending cuts, reducing would potentially result in a negative operating margin. Obviously the expectation would be that they find some ways to cut expenses. The other thing I just wanted to note is that this particular hospital, when you look at their charges on the Vermont Department of Health website, they definitely come in as one that virtually all most of their charges are below the state average. So I just wanted to point that out as well. Okay, as I look at the notes for last week it looked like we were focusing on a range between 3.4 and 4. Are there any questions for the hospital budget team? Is there any discussion? I actually would just like to say that for Brattleboro I have changed my mind in this week to the extent that they are all in. They're all in last year, they're going to be all in again, and they are currently with operating losses and projected deficits. I am concerned about reducing their commercial rate, such to the point where they might have a negative operating margin that concerns me. They do have days cash on hand, they've got a little question there, but I would be voting against a rate cut at this point because I'm concerned. Yeah, I have a little different perspective on that. I'm definitely concerned about this hospital. I would also put this in the category of Copley as a hospital we should be bringing back in. They've been showing losses for the past 2017 and operating loss of 2.4, 18. They're now looking at operating loss of 2 million, 19. They're coming in with a 254, showing a 254 that most likely that will turn to an operating loss. The reason I say that too is they're trying to fix this by rate. They're actually taking a 7% commercial rate across most all categories. Last year they asked for a similar high rate increase. They need to change how they're doing their business and get in control of their expenses in line with what their revenue is. Also showing if we look at what this forecast is, a 7% growth, 6.8% growth over their current projection. We did say they could adjust to the issue we had last year where they had an understated NPR, but they really don't need it. They're coming in on their budget, their original budget. This one is a hospital in trouble and I understand what you're saying, Jess. If we cut their rate it could put them in deeper trouble, but I also want to push that they need to change how they're running their business. They have been doing this for several years. Their utilization is down and they're putting in high increases. I had been at a 3.5% which would give them 5% across the board on the things that they're requesting increases for. I don't know how we fix it and whether or not we end up not cutting rate and giving them another year, but it doesn't work to keep losing money and to keep running. I believe right now their NPR estimates are too high even with giving them a 4.8% increase over this adjusted budget number. They're not going to hit that. I don't believe because they're not getting the increases and we're going to be back here next year. Even if we give them the 4.9%, I would believe on this one we're back here next year with them at a $2 million loss unless they change what they're doing. I can appreciate that Maureen, but one of the things I think we have to take into account is everybody is not starting with the same base of charges. The fact that they are pricing their services at least on the charge master below the average for me gives them a little bit of room to say, okay, this year perhaps you can increase your prices to some extent basically because the offset of some of these operating losses and deficits. I agree with you that perhaps we need to think about how they do their business model. They are all in. They are switching gears from fee for service into fixed payments and I think it's going to take some transition time. But since their prices are not already above the state average, I'm willing to give them some wiggle room there. I say like what we don't know enough about it. I understand the price part, but whether their discount off those rates is lower. Because when most hospitals are getting reimbursement at 30% or so for Medicaid and Medicare and 70% maybe for commercial, we'd have to really look at that. So it's like what are people really paying? So it's hard to say. I just have a real concern of giving high rates and letting them continue. On this path, when they were here, I said they're in trouble. What can we do to help? I don't think fixing it is just increasing rates. So I think where I'm sort of in between I would say Maureen and Jess, I would cut the NPR growth rate because to Maureen's point, they are almost 7% below from projected to budget, 18 projected to 19 budget. But I would leave the rate for the reasons that Jess articulated, particularly given that this isn't a critical access hospital, which means they have a less like their Medicare reimbursement isn't as protective or as volatile, but still. And I do agree we should ask them to come in and monitor and push them on the issues that you raised, Maureen. So that's how I would handle it. I don't have a number in my head for what to cut the NPR to, but I would cut it since they're not going to hit it anyway and it's high. I would cut the NPR, keep the rate and bring them in. Tom, you didn't weigh in last week. Are you bearing this week? Well, this one is, confuses me a bit. I think where I end up is that I would leave the NPR alone, that if they earned it, great. And I think there's some potential for them to do that, given their payer mix, which I'll get into in a second. And I would, in order to give a message to them that their spending trends have been excessive over the last four or five years, cut the rate by just one point, which is $392,000. I look at their request for, their requested increase and they are looking for a 29% increase in their commercial revenues from 32.2 million to 41.7. They are basically flatlining their Medicaid revenues from 10.3 million to 10.4 million, even though 41% of their NPR base is Medicaid. And they're actually looking for a drop in their Medicare revenues of $4.3 million from 35.6 to 31.3. And I'm not close enough to the ground to totally understand that, but it seems that there is some upside potential in Medicare and Medicaid. And if they achieve that, I would give it all to them because they need it. But in order to send a message that, as Maureen has made the point that this kind of going to rate increases in order to survive another day, is something that the board is aware of and is not encouraging. So I would support the minimal decrease in NPR or no increase in NPR request at all, but a 1% rate reduction to give the message that cost-shifting this onto the commercial insurers, which is what their plan outlines, is not the best way to travel. Just to weigh in, I haven't changed my position from last week. I was at 3.9% for a commercial rate. I do think the NPR should be dropped down to at least 3.8%. So this one, there's some variance here. Is anyone prepared to make a motion? I'll move that we leave the NPR as requested and that we cut the rate to 3.9%. Is there a second? So hearing no second, would somebody like to make an alternative motion? I'll move that we make the NPR grow 3.2% and we go to commercial rate of 3.9%. Is there a second? I can second that because there is another bite of the apple if their NPR does, if they are successful in bringing in their NPR next spring when we review these. And I'm happy with 3.9% the rate cut message. I just want to remind, I'm not sure if everybody remembers, but this is the hospital that had tremendous access issues with health care. They had new patient appointments of 120 days for their primary care services and so they brought a bunch of family practices on board and so part of the NPR growth is delivering care more appropriately, particularly primary care, which is the kind of NPR growth you want to see. Okay, is there further discussion? If not, I believe I understand the motion to be to set the rate increase at 3.9%, the NPR at 3.2%, health care reform investment at 776,000 and restore the fiscal year 18 NPR reduction of 1,323,198. Further discussion? If not, all those in favor signify by saying aye. Aye. Aye. Those opposed? Aye. Those on 3 to 2 vote. The next hospital is Northwestern Vermont Medical Center. Their budget request is almost 113 million. They're 4.3% of the system total. They had recommended a number of adjustments related to physician transfers and we were able to obtain more information on those requests, which I'll share with you in a moment. If you were to accept those adjustments, their NPR growth rate would be 3.2%. They did suggest health care reform investments at the 0.4% allowance, which the staff is recommending acceptance of. They are another hospital that's been participating in all three ACO programs and 18 and indications are that they will do so in 19 as well. Their fiscal year 19 rate request is the lowest of all hospitals this year at 2% and the estimated value of a 1% rate increase is almost 530,000. So the adjustment to the base, we had, there's already been approval for the 1.7 million in the occupational health transfer and the staff had recommended that you accept that last week. We are recommending acceptance of the remaining three transfers as well. They are for a surgeon. There's an independent surgeon who's retiring this month and NMC has been able to hire a surgeon to replace him that is now hospital employed. ENT services, there was a retirement a while ago and there have been some access challenges in the ENT world and NMC has been able to successfully recruit an ENT that person is starting this month as well. And then neurology services. That was the one that we had the most question about. There is, you know, a wait time I think of about a month for neurology services up in St. Albans. But we, a couple of board members had raised the issue of business and new service. What is happening with the neurology services that UVM will be sending a neurologist one day a week to St. Albans. And so I spoke with both NMC and UVM and with that neurologist coming to St. Albans, revenues will decline accordingly at UVM because that person won't be practicing at UVM that one day a week. So we are comfortable with recommending approval of all three of these transfers. In terms of health care reform investments, again the staff recommended approval and you all made a preliminary decision last week to accept that recommendation. NPR growth with the adjustments comes in at the board's target in the guidance at 3.2%. The staff recommends acceptance of that. Commercial rate increase at 2%. Again, the lowest in the system this year and the staff recommends acceptance of that. So as I look at the notes from last week, it looks like four of the five board members had tentatively accepted the staff recommendations. Is there any questions for staff or any discussion? Yes. I will move that we accept the staff recommendations for the acceptance of the provider acquisitions, the health care reform investments, the NPR growth rate at 3.2% with those adjustments. I would second that. It's been moved and seconded to accept the provider acquisition of 3,249,654 health care reform investments of $424,513 to accept the NPR growth rate combined with 3.2% and rate increase of 2%. Is there any discussion? I'm going to support this, but I just want to note that of the requested increase, 90% of it is falling to the commercial payer. 17 is a 17.9% reduction in expected Medicaid revenues and a 27% increase in Medicare revenues. And this is on top of a five-year expenditure trend of 6.2%. So, you know, I think that the hospital's proposal is reasonable and fair, but there are some red flags kind of in the numbers that we should watch as time goes on. I appreciate those comments, Tom. And as I've said to you before, it's kind of hard to call it an all-payer model when not all payers pay. I'll leave it at that. Any further discussion? That model was branded into my brain. Thank you. All those in favor of the motion signified by saying aye. Aye. Any opposed? So, I'll let the record know. That was unanimous decision. The next one, I believe, is Springfield. That's correct. Springfield comes in with the fiscal year 19 proposed budget of just under 60 million. They represent 2.3% of the system total. Their MPR growth is at 1%. They did not request healthcare reform investments. And since they're well under the target, they are not needed. They are one of the hospitals that is participating in all three ACO programs in 18. I should mention that about Northwestern as well. And all indications are that they will do so again in 19. Their fiscal year 19 rate request is 5%. And the estimated value of a 1% rate increase is 319,000. So, last week, so the two decision points here are regarding the growth rate for MPR and the commercial rate increase. And the preliminary decisions last week were to reduce the commercial rate to 4%. A note that that's about 40, just under 40% of their operating margin. And then their estimated MPR growth rate if the MPR were to be reduced according to the rate increase reduction would be 0.5% of MPR growth. Are there questions of the staff? In my notes last week, Pat, I had a preliminary decision on the 4% rate. I do not see where there's any discussion on MPR. Any discussion? I've changed my mind a little bit on Springfield since last week. Again, because small critical access, terrible demographics that they're struggling with, including the opioid epidemic all in on the ACO for all three programs. It does, and I would appreciate Maureen's thoughts on this, it does look like they are one of the hospitals where their growth, they're at 5% from projected to budget. So I could see some sort of adjustment in the MPR for that. But I would either leave their rate alone or do a smaller decrease, particularly with the 40% of their margin being 1%. I'll add to that that I don't think they're necessarily going to get their MPR growth, but it's only 1%, so I wouldn't necessarily cut that. Another hospital in trouble, another one we should be bringing in more frequently, they lost $3 million or $4 million in 2017. Their budget for 18 was to make a million, they're losing a million. Last year we gave them a 6.5% rate increase. I think we had similar conversations last year. We didn't cut their rate because they need to fix some things. Their budget is right 5% year over year. I don't know that they're going to get that increase. I've been for a rate cut to 3% to 4%. I just don't think we can, I almost think we're rewarding hospitals with high rate increases year over year when they need to change how they run their business. I understand their critical access, but there has to be changes made or we're just going to continue this. It's not sustaining for a hospital to lose money year after year after year. I think we need to force that conversation with some of these hospitals. I know they're struggling and I want to work with them, but I also think they need to realize that some of them said we put this rate increase just to make money. They're not talking about cost savings or changes. I'm okay with their NPR and I'm willing to maybe go to the higher end of the rate cut at 4%, but I think we need to work with these hospitals and make sure we're getting them in here and figure out how they're going to switch to making somewhat of a low margin at some point. I generally agree with what Marine has said. There are some aspects, so that kind of make me just to, you want to wish them well and not basically go with their request. And those things are that if you look at their NPR trend and expense trend over the past five years, they've been very meager. It's not like they're living year to year on expansive growths and revenue and spending. Their NPR trend has been 7.1% over the past five years and their expense trend has been 2.3%. In terms of their request for increase in NPR, it's very balanced with 783,000 coming from commercial 338,000 coming from Medicaid and 1.56 million, which is a 7.5% increase in Medicare. So I think it is a hospital that's in trouble. I think that they need to find new ways to manage toward their population, but I don't see, you know, and kind of cutting them would reduce an already very thin operating margin and total margin. So I'm not inclined to cut anything here. Does anyone wish to make a motion? I'll make a motion that we accept the sprinkled hospitals proposed by the NPR growth rate of 1% and the commercial rate increase of 5%. Is there further discussion? If not, all those in favor signify by saying aye. Aye. Those opposed? No. Let the record know to as a 4-1 decision. Anyone who's motion sick should not look at the screen. I said anyone who has motion sickness should not look at the screen right now. We are back to the University of Vermont Health Network Hospitals, which we discussed for the first time yesterday. So we'll start again with Central Vermont Medical Center. They asked for some transfers. There is the issue of the ACO accounting change, which you all discussed at some length yesterday. And there seemed to be a feeling that we should somehow adjust for that whether it's in the 18 base for ascertaining NPR growth rate or making some changes to 19. Their fiscal year 19 proposed budget is at 211 million. They're 8.1% of the system total. NPR growth without any adjustments 6.5 with the staff recommended adjustments related to transfers 6.3. And if we were to go with the ACO accounting change, it would be in the neighborhood of 5% NPR growth. They also requested health reform investments and like all of the health network hospitals, they're participating in all three ACO programs in 18 and plan to do so as well. In 19, their fiscal year 19 rate request is at 2.8% with 1% of the commercial rate increase being worth about 675,000. I believe that yesterday, and we haven't updated these slides to reflect yesterday's discussion, but my recollection is that the board was leaning to accepting the adjustments, accepting the health care reform investments. In terms of NPR growth and commercial rate increase, I believe there was discussion and in fact even a motion made, which was then withdrawn of a potential 2.3% rate increase if I'm remembering correctly. That's what I have in my notes as well. For the questions for the staff, would anybody like to make a motion? For members, our discussion was from, even though it was just yesterday, I actually don't remember what we were discussing about NPR. Does anyone else remember? Was it with the 2.3% or was it reduced to NPR? So my recollection is that we weren't reducing the NPR, but we were only talking about the rate. Yeah, I think the reason we had talked about not reducing the NPR is their concern when they came in, although I think they've revised it somewhat, is their 2018 is coming in hot, was coming in hot. They may have brought that, I think they came back in and brought that back down, although at the meeting they did still say it was 217 versus 212. So the change is 3.6% against their projection. So that was, assuming their projection was correct. I think some of the discussion we had on the rate was really related to the fact that they did in fact, they are in fact coming in hot, so they're asking for a higher amount, and do we reduce their rate? This is another one, hoping that under the network, they're going to be able to get their profitability aligned. They did lose $2 million in 2017, and they're 18, although they're up on top line, they're still making money on the bottom line, but it's going the wrong way. So their top line increases are being more than offset by higher expenses, which is not what we want to see. If you go up by five on the top line, and your expenses go up by seven, that's a bit of a problem. So I think what we say, I'm willing to take the NPR, put a motion for NPR at 5% and commercial rate, I think we said was 2.3. Yes, and I think, as I recall, Robin, the discussion really was about the fact that similar to Porter being part of the network, we're actually hopeful that people are being put in the right settings, in that we would want them to be in a more cost-affordable setting than in a more expensive setting, and we'd also want them closer to their families and their support group. So I think that's why we had tentatively left the NPR at 5%. So I think that that's where I land with the NPR. I think the NPR, I'm fine with it, given that I think more care is being delivered in the community centers, and I'm also comfortable with the commercial rate increase of 2.8%. So that's where I would like to leave it personally. So thinking about the rate increase, I think I said this yesterday for somebody, some hospital, but for me, I would deal with the coming in hot as part of the enforcement, and so I understand that that obviously has a slower impact, but I think if we want to start enforcing things differently, we should address that in the enforcement guidance so that there's a clear path for that. So I'm still thinking where I am on the commercial rate increase, but I'll probably land where Jess is. Real-time thinking. We'll see how it flies. So I will move that we accept the adjustments to the base, as the staff recommended, the healthcare reform investments that we allow the NPR growth rate to be 5% with the acquisition and ACO accounting adjustments, and the commercial rate is 2.8%. I'll second it. So it's been moved and seconded. I'll just say that I agree with 3 out of the 4 pieces of the proposal, but I will be voting no to the final proposal because I do think that the rate should be reduced by the half point. So any other discussion? I'm probably going to vote no on this too for a similar reason but I think a rate reduction from 2.8% to 1.8%, that amounts to $674,000. And I look at that in the context of their long-term spending trend, expense trend, which is 5.4%. And so there's some very favorable things though in this proposal that their payer mix proposal is very well balanced. They are not relying so much on commercial, they're expecting increases in Medicaid of 37% and Medicare of 18%. And I think that's a good thing, but I think the spending trend is a little excessive. And so I can support the NPR increase because if they earn the revenue then they get to keep it but I think a modest reduction in the rate proposal would be appropriate. Any other discussion? If not, those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Nay. I believe that the motion has failed. Would someone wish to make a substitute motion? I would make a motion for the 5% NPR and 2.3% in the commercial rate. And would you also add the adjustments in the HCR investments? And the adjustments in the HCR. Is there a second? Second. It's been moved and seconded. Is there any discussion? If not, all those in favor signify by saying aye. Aye. Those opposed? Nay. So let the record show that it was a three to two vote. I would just like to clarify regarding healthcare reform investments as well. I'm not sure that was covered in the motion. I believe it was. Okay. Thank you. Okay. The next hospital is Porter. There are some complexities here as well as we touched on yesterday. The proposed budget for Porter is almost 85 million. They're 3.3% of the system total. They're another one of those 3% or a number of them. They did request the adjustment, the same type of adjustment for the ACO accounting change that the other two network hospitals adjusted and that you just voted to approve for CBMC. With that adjustment, their MPR growth would be 3.2%. They have requested healthcare reform investments as well at the 0.4% level. And again, they're participating in all three ACO programs. As with CBMC, their commercial rate increase is requested at 2.8%. And the value of 1% rate increase is 295,000. So yesterday, we discussed all of these items. And another item that we discussed is this question of how Porter is accounting for its reserves. Kelly reserves for downside risk related to participation with the ACO. Kelly yesterday had spoken to the fact that ACO accounting in general is new territory and there really aren't standards at this point around how to account for ACO related revenues, participation fees, expenses, and reserves related to downside risk. And I believe you all saw a letter from Porter and from the UVM Health Network, two letters that came yesterday describing the rationale for why Porter is reserving for downside risk. So we spent some time thinking about this after yesterday's meeting and I wanted to offer a suggestion and see if the board is open to that. What the staff would recommend is that you approve the budget for 2019 for Porter that allows the hospital to net its reserve for downside risk against its fixed perspective payments. That's how they submitted their budget. But then that you also encourage Porter's staff to participate in discussions that our staff is planning to have after the budget review process is over, not only with Porter but with other interested parties. And our goal of those discussions would be to develop guidance for fiscal year 2020 for hospitals that would give us more standardization around how they account for ACO related revenues, expenses, and reserves for downside risk. In addition, we think it would be wise to ask Porter to work with the GMCB staff to keep the board informed about how their actual experience with downside risk is impacting their reserves as information becomes available about that so that you can have sort of a way of monitoring what's happening there. Now, I'll say directly that final information on how hospitals are performing in terms of downside risk is reliant on claims lag. So for October through December of 18, the first quarter of the hospital's fiscal year, we won't have information on their financial performance until the third quarter of 19. And similarly for January through September of 19, the remainder of the fiscal year that we're discussing here, we won't have information on their financial performance. We won't have final information until the third quarter of 2020. You know, there will be some interim information, but we really won't know for sure. So I just wanted to make sure you were aware that while monitoring is a possibility, it will not be final information until a ways down the road because of claims run out. So I'll put that out there. I can walk through the remainder of the items or if you'd like to stop here, Chair Mullen, to discuss the reserve issue. I'll let you determine that. I think we really should decide that issue first. And my understanding is the staff recommendation is to accept Porter's submission as is with that adjustment. And are there questions of the staff or discussion on that? I guess just the question is we certainly do need to resolve this. I mean, the number relative to the $2 million on $19 million is a significant percentage for reserve far higher than the risk quarters that I was at least understanding under the ACL that the maximum risk a hospital would be taking would be about a 3% up. So if in fact this is the case, I think it bears for a lot of the hospitals who may be in the program if they really have to take such a high reserve. So I'm still really challenging the reserve calculation, but I don't believe we're going to have it resolved and understood today. So I'm willing to accept it for this hospital. But I'm definitely concerned of the implications of it in total and how do we look at this in the future and wish we had more time to resolve it beforehand. But there's a lot of inconsistencies in the way the ACO is being handled throughout the hospitals. I'm kind of in the same boat of reluctantly accepting it. I think we do have to get to the point where we have common what I would call GMCB accounting standards. And I think I'm confident that the staff will be able to work with CFOs around the state to develop a proposal moving forward. So I would let it be, Jess? Yeah, I agree. Thank you for the staff recommendation. I think it's clear that we have a lot to learn about ACO accounting in our hospital budget process. This is a new territory. I don't want to be rash here. And so I think taking the time to figure it out over the next year and having standards for our next budget cycle will make the most sense. And I think at the end of the day, we want to be encouraging ACO participation. So we want to make sure that we're allowing for the type of risk-reserving that is necessary. So I'm comfortable with the staff recommendation. And if the downside risk is not realized, we can adjust next year in the budget if that comes up. Is there further discussion? I'm fine. Would somebody like to make a motion? Everybody's in a jumpy mood this morning. I can make a motion. I've made many motions today. And do you want to, Kevin, just on the ACO adjustment? Yeah, just on the ACO adjustment. I move we accept the staff recommendation of the, I'm going to actually do the accounting adjustment in terms of how we discussed it before, the issue of the reserves and the health care reform investments. Okay. Is there any further discussion or questions? Or a second? Oh, that would be great. Judy fell asleep and didn't correct me. I'll second it. So it's been moved and seconded. Is there any further discussion? If not, all those in favor signify by saying aye. Aye. Any opposed? Signify by saying nay. No, I'm not. I'm not. Okay. So we resolved the first couple of questions. Yeah. Is there a motion on the rate in NPR? We should have discussed in our motions. Well, you can discuss or move whatever you'd like to do. Yeah, I would like to discuss this one a little bit. I have a pretty strong rate challenge on this one to be 0%. But when I look at it, this is a hospital that's doing really well. They've, you know, joining the network has been a benefit to them. And, you know, I know we've talked about them struggling, but I see that as in, you know, in 2015, they lost a million seven. In 2016, they lost, I mean, they made a million five. Their total margin was 5.9. Their odd margin was two. In 2017, they were 2.2. Their total margin was 2.7. Going into this budget, they believed they were going to lose 203,000. But they gained what I see as a bit of synergies with the hospital network, and they're actually now projecting 6.2% at operating margin and 6.8% at an operating loss, I mean, operating total operating margin. Their 2019 budget is coming in at 3.7% odd margin, 4.1% total margin with which I believe is a conservative $2 million in for the reserve, for the ACL. I know we accepted it and I'm okay with that, but, you know, I believe some of that should go to the bottom line. When we look at their history in rate, they've typically, they were 5% in 2015, 5.3% in 2016, 5.3% in 2017, 3% in 2018. So, you know, I'm looking at this as, yes, they're doing well, but we need to look at hospitals that can come in and say, I don't need a rate increase. It would be about a million dollars. It would knock them down to a 2.5% operating margin, a total margin of about 3.2, and again, with what I believe to be about $2 million in conservatism in there. So, you know, they joined the network. You know, we should see the benefits of that. So, I'm not trying to punish this hospital. I think they're doing a good job. But I also think, you know, we need to look at rate increases and in past for other hospitals, we've given them zeros and negatives and things like that. So, you know, and we didn't do anything when they came in over in 2017 because we wanted to see how things were shaking out. So, you know, that's why I'm pushing to really go for a 0%. I think it's because I'm looking at totality within the network and the synergies that they're getting, which they should get for their getting on supplies, their saving for supplies. But when that happens, when are we able to give that back to the rate payers? And I think this is a case where we can. So, that's why I was going for the 0. So, Maureen, I think you've made an excellent argument about why it could be 0. And I'm just going to offer a little bit of a contrarian opinion on this one and that. I look at Porter as a hospital that's really almost a case study in leadership. And we saw Porter really struggle for a few years. And fortunately, someone stepped forward to take the helm that was able to get buy-in from all sectors of the hospital community. Someone who, you know, was equally greeted by maintenance staff, nursing staff, provider staff. And this is an institution that is going to be going through a change again, unfortunately, because time pressures have forced a decision not to continue in that leadership position. And I think that, yes, you could argue for the 0%, but I think they're on the right trend. I look at that historical trend moving down from closer to a 5% historical trend down to 2.8, I think is something that should be applauded. And hopefully it continues to move in that direction in the future. So, I would be willing to accept it as is. So, I agree with everything that you just said, Kevin. Having watched their days cash on hand go from in the 30s up to 133 over the past five to seven years and watched the loss in primary care physicians be replaced, the margins are positive now. And I think we can look at that as a major positive trend in their trajectory there. NPR is growing because more of the care is coming back into the community. We have more primary care providers in that community. And the efficiencies that have been gained through the network affiliation are causing economies of scale. And yes, they're creating margins now. Their days cash on hand are still below the state average. They're all in and all three payers. A 2.8% commercial rate increase is medical inflation. That seems to me to be a reasonable rate request. And I think they're moving in all the right directions and I would support accepting their budget as given. Yes, my take on this is closer to Marines. I had kind of worked my way into thinking that a reduction in the rate from 2.8% to 1.8% was appropriate. But I could live with a 0% increase. I note that their margins have been improving since 2016. So it's not just a turn that happened last year. But it goes back to the only negative was in 2015. And then I'm looking at the distribution of the rate increase. And here again, we have one that is heavily weighted in terms of commercial of the total increase they're looking for. Porter's looking for 5.3 million of it is associated with the commercial payers. A negative 541,000 is associated with Medicaid payers and a negative 2,142,000 is associated with Medicare payers. So given that the burden is being aligned and that's not necessarily where it will end up. But that's what the alignment is right now. I thought of 295,000 cut, which is the 1%, would be appropriate. Maureen's proposal, if she makes it, would be an $826,000 reduction on an $89 million budget, which is 9 tenths of 1%, which I don't think is that burdensome given the healthy margins that this hospital has been generating for a few years now. For the reasons articulated by Kevin and Jess, I'm also comfortable with accepting the proposal of 3.2% MPR growth, which comes in at our target and the 2.8% commercial rate increase at medical inflation. I do think that another area of leadership that Porter has demonstrated is they were the first critical access hospital that jumped into the all-pair model for all three payers, even though there's significant uncertainty about how all that works, quite frankly, as a critical access hospital and they've taken a leadership role in working through that with Medicare and Medicaid. I think that as their fixed payments continue to grow, that they also are going to have to continue to innovate, and now that they've achieved the economies of scale, that's going to be operational innovation, which I think could really provide a lot of leadership for other critical access hospitals. I would love a motion. I will move that we accept the Porter Medical Center proposed budget. We did the accounting adjustments and everything else. So it's just the MPR growth of 3.2% with the adjustment and a 2.8% commercial rate increase. Second? We moved and seconded to accept the 3.2 adjusted MPR growth rate and accept the 2.8% proposed rate increase. Is there further discussion? If not, all those in favor signify by saying aye. Aye. Let me do that one again because I didn't hear. I don't think. All those in favor signify by saying aye. Aye. Okay. All those opposed signify by saying nay. So I believe that's a three to two vote. So the final hospital for discussion is the University of Vermont Medical Center. They're 19, well first of all they've requested the same accounting adjustment that the other two hospitals requested in the network. Their budget comes in at 1.28 billion. They are 48.8% of the system total. Without the adjustment, their MPR growth over a rebased budget would be 1.7%. Their MPR growth with the adjustment would be 1.1%. They've requested more than the 0.4% allowance in healthcare reform investments. The staff recommends approving the investments at the rate of the 0.4% allowance. They're participating in all three ACO programs. The rate request is 4%. And 1% increase on the commercial side is worth 4.5 million. So the adjustment, I'm presuming that the board will want to go the same way that you've gone with the other two hospitals. Healthcare reform investments, the staff is recommending acceptance at 0.4%. The MPR growth rate yesterday's discussion included some concern or interest in the 1.7% or 1.1% if the adjustment. Accounting adjustment is accepted given their historical MPR growth rates which are quite a bit higher than that. Much of the discussion yesterday centered on the rates. My notes show that we had four different rate proposals. 2%, 2.5%, 2.8%, and 3%. And there was some discussion. The only difference in my notes is that I had it at a 2%, a 3%, a 2.5%, and then two identical ranges of 2 to 2.8%. Okay. I'll go with yours. So there was discussion also about, you know, maybe reducing the rate but not reducing the MPR because of the relatively low growth rate there based on history. So I'll stop there and let you discuss. Are there questions of staff? Okay. Discussion? I'm inclined here to support the 1.7% growth in MPR or as adjusted 1.1%. But I would like to see a rate reduction here. Again, we have a proposal that is obviously the largest hospital in Vermont and they have a big footprint. And relative to 2018 projected to 2019 budget, they're looking at a commercial increase of $16 million. And 18 of that, in other words, I think the projections are based going down, but 18 of that is from the rate increase. And a $1.7 million increase in Medicaid and a 9.9 increase in Medicare related to not so much affected by the rate. We're not at all according to the documentation affected by the rate. So I could support a 2% reduction in the rate from 4% to 2%, which amounts to about $9 million, which would take their total margin down to 4.6%. And their operating margin down to 2.2% and would amount to 7.10 of 1% of their projected $1.273 billion budget. And again, as I did note yesterday, that that result is in the range of their projections of having to do with the operating income, the operating statement that they submitted as part of their EPIC budget, where presentation, where they projected with EPIC, that their excess revenues over expenses would be about $61 million. So my ending result is totally consistent with that projection, which was a year and a half ago. But again, both their total margin remains very healthy with a 2% rate reduction and their operating margin remains healthy. And this is a large, even with the reduction hit on the commercial rate payers, which as we know in the end falls to those who pay premiums. So three yesterday, I could come down to be more consistent with where Jess and Maureen and Kevin are. So maybe I'll just throw a motion out there and we'll see if it flies unless people really want to say something else before I do that. I was at between 2 and 2.8. Yes. And I think Jess was 2 to 2.8. And another thing just to add to what Tom's saying, their expense increases. If I look at their NPR growth, their expense increases are coming in, whether we go budget or projection. And this one you really need to almost look at projections since they were rebased. They're 2% on the NPR versus 2.8 on expenses. And that extra 0.8 is about $8 or $9 million. So they're trending higher. We know they're putting in the Epic and Miller in here, but we also know that's not supposed to be going against rate payers. That was part of the agreement there. So I'm along with Tom too. I could maybe go a little bit higher to the 2.5, but I definitely see the ability to have a rate cut here. Any other discussion or any motion? So I move that we accept the accounting adjustment, the healthcare reform investments that we hold the NPR growth rate at 1.1% with that adjustment. And that we introduce or allow for a commercial rate increase of 2.5%. Is there a second? I'll second it. Is there further discussion? Seeing none, all those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. So I believe that was your unanimous. That would complete the review of all the hospital's budgets. Okay, do you have any words of wisdom to share with us before I turn the mic over to some other board members? No, I just would like to thank all of you for your really diligent review of the information. I'd like to thank the hospitals for their responsiveness to the many questions that we sent their way. And just, it was, I think, a thoughtful process. So thank you very much for that. So the real thanks need to go to you and the hospital budget team. And I'll just say, Pat, that in your first year of leadership of the team, you have met and exceeded all expectations. And so we're going to raise the bar for next year. Awesome. Thank you. And many, many thanks to the entire team, Kelly, Lori, Tom, and Agatha. And I'm just a tremendous group of colleagues, really. Okay. With that, I know that a few board members, or at least one board member, would like to say a few things. So I'll turn it over to Dr. Holmes first. And so I'll echo that. Thank you to the entire team and actually to all the hospitals. I know we've put a lot of hospitals through the ringer on this. And I actually would like to say one thing actually reminded me. We're always about process improvement. So at some point in the future agenda, I would love to see, let's talk about this process and think about how we can improve this process and streamline it and make it easier on all entities. So at some point, maybe Susan and Kevin thinking about future budget date, future agenda date. But a couple of things that I wanted to propose to the board that we add to our standard budget orders, based on some of the questions you probably heard me ask many of the hospitals. And so I wanted to add language to every budget order that asks the hospitals to at least work with vital to explore the possibility of implementing the electronic consent in their EHRs to add patient records to the V-High. Many of the hospitals seem to open to that possibility. So I guess I would like to have just language that asks the hospitals to start to have those conversations about those possibilities. Similarly, I'd like to add language to the budget orders for those hospitals that are participating in the ACO to have them explore the possibility of attributing their self insured employees to one care. Again, just exploring the possibilities, not a mandate, but exploring those possibilities. And the other piece I think that came out of some of the health care advocates questioning that I would like to have our language be clear on if other board members agree to this, is that language in the budget order should say that the commercial rates that we've just decided are a ceiling, that we fully expect negotiations to commence between hospitals and the carriers to reflect underlying costs and market rates for comparable services. In other words, we're not dictating rates, this is a ceiling. And so we still expect some conversations to occur between the carriers and the hospitals. And so I want to make that clear in our budget language. So I don't know if we need a motion for that or I just wanted to throw those three ideas out there. I think you do need a motion. Okay, so I will move. Now we add language to each budget order that asks the hospitals to work with vital to explore the possibility of implementing electronic consent to add patient records to the V-High. Add language to the budget orders for those hospitals participating in the ACO to explore the possibility of attributing their self-insured employees to one care and making clear in the language in the budget order that these commercial rates are a ceiling and we expect negotiations to continue between hospitals and carriers for the best of their abilities. I have a question about the enforceability of the last one. So when you're talking about the rates and so we have a zero increase, I'm not sure if we want to, if we're able to put that on as a necessarily or that it should be considered a ceiling and make the language not mandatory because I'm concerned with the ability to do that. I ask a question about what Judy just said. Yes. You mean the requiring negotiation as not mandatory or? No, they, well, they should negotiate with that considered a ceiling, but I think that's saying the language that it is a ceiling and that they may not go over. I think in some of these we have a very low increase that may prove problematic. What would you suggest with the language that considered to be a, I'm just trying to figure out what is the language that we can convey that this is not, we're not setting this, we're setting that to be a ceiling. Right, but I don't know if we, when we were talking about some, if we're talking about say a zero increase or a very small increase as a ceiling, I am concerned with the ability to say that that's going to be the cat through negotiations. There may be reasons it is not for. Well, I hope that I'm not hearing you're saying that there should, there could be reasons why it would be exceeded though, right? Well, you know, saying this broad language and saying it applies to all commercial rates, we have out of state insurance, we have other reasons that that might not be feasible. We can work with the language. I think that you could say that it should be considered a cap and all efforts should be made to achieve that, but I would be concerned. That's fine, but that language that you just described is fine. I would actually ask for one more friendly amendment in that one of your, one piece of your motion was an encouraging piece. There was no mandate whatsoever. That is the part of your motion that relates to encouraging hospitals to look at their self-insured population and you had limited that to those participating in the ACO. And I would just say that since it's just an encouraging piece, I would, I would ask if you would consider a friendly amendment to encourage all hospitals to take a look at that. I accept that friendly amendment. Although I don't think we've had a second yet, have we? I'll second. Okay. With all those friendly amendments. Okay. Is there a further discussion? If not, all those in favor of the motion signify by saying aye. Aye. Any opposed? Okay. Is there any other board member who wishes? Tom. Yes, I would just like to underscore my concerns about the cost shift. And just to three or four quick points I'd like to make. As we went through this process, we started the process by looking for $80 million in additional NPR. And only 3.9% of that was proposed to us for Medicaid by hospitals. 76% was a proposal for commercial insurance, which means premium payers. And 20% was associated with Medicare. So clearly here, even in the increments that we're dealing with on top of a very $2.6 million base, the increments underscore that the cost shifts exist. I think in the long run, the cost shift can have some very bad outcomes beyond those which already exist. We've seen from hospital presentations that it influences bad debt and free care. We know that it causes high commercial insurance rates. I worry about it affecting the all-payer model and our efforts on reform in one care. If we have a bunch of premium payers that are just with their pitchforks concerned about the high premiums they're paying as a percent of income. And so as we head into the next budget season with the state, I just want to note that if you go back to 2017 through 2019, the increases in Medicare in Medicaid have been at a 7 tenths of 1% growth rate. And that clearly is not enough to keep pace with even background inflation, much less medical inflation. And yet in the last session, the Joint Fiscal Office showed that there was a $78 million surplus that was moved into the Human Services Case Load Reserve, which is significant. So I'm hoping that we can work or the hospitals and the VASA can work in the legislature to at least get appropriations associated with Medicaid to keep pace with inflation. The money is there, taxes don't have to be raised to do it. And I think it would just calm the waters as we move to 2022 and the conclusion of the all-payer model. Do you also like to say anything? So I just want to conclude with this morning at least, since we are going to adjourn until 1 o'clock this afternoon to talk about a different subject. I just want to say that one of the more poignant points in the hospital budget hearing for me was a testimony from the lady who had had surgery at Central Vermont Medical Center. And it really brought home the fact that why I think this board is here, which is to try to make sure that Vermonters have affordable care. And I think that all of us, including the hospitals, have to further discussion on how we can make it more affordable for people who are struggling to pay their bills than yet are in life-threatening situations. So I think that this board will take some criticism for looking at rate increases. But I'm not going to apologize for that. I think it's the proper role of this board. I think it's a role that was definitely intended by the legislature in creating this board. And so I think that, at least myself, I'm very proud of the way this process has been conducted this year. I'm proud of the GMCB team and proud of my fellow board members. So with that, is there a motion to adjourn until 1 o'clock? Second. All those in favor, signify by saying aye. Aye. We'll resume our meeting from this morning. And the first item on the agenda this afternoon is a presentation from Team Awesome. So Kukua or Sarah, whichever one of you is going to start it off? Sure. I'll kick it off here. So this is, we're trying to do a better job of providing information. And this is like, I don't know what you call the appetizer to an appetizer of a more comprehensive decomposition analysis. This is just kind of a very targeted look at a set of very consistent procedure codes over time to kind of introduce some of the challenges that we're going to have when we're trying to do a more comprehensive analysis. So this is going to feature Kukua. It's really all her work. And yeah, super proud of what she's been putting together. Okay, so why don't we talk about the composition looking over the office visit that we have. There are some few questions that come into mind that I would like to think about. So firstly, probably would like to think about outpatient visits with utilization rate changing over time. Do we have the length of visits also changing over time? The other question that one could ask him or herself is how are prices changing over time? So that is the inshara paid amounts changing over time and what about the member responsibility amounts to? Lastly, one could probably say that do the payer types probably differ because the changes that we see over time. So to analyze the office visit over time, we first look at the evaluation and management codes that we have using the CPT codes. Basically, it's divided into two groups. There's the new patient and the established patient. But in 2014, we had Medicare changing over to just a single code to represent all the patient types that they have. So be it a new patient or an established patient, they just use the single code. And with a CPT code, usually you can tell the length of visits in the office. But just using the one code as a G code, you can't really tell if the office visit length was 5 minutes, 10 minutes or 45 minutes over the time. And we are going to decompose it into three main components. That's the utilization, which we refer to it as the office visit per member per year or office visit per member over the time period. Then we'll look at price. There's the changes that we see in the insurer paid amount and the member responsibility. Lastly, we have the intensity rates. That's the typical office visit length that a member receives during the hospital visit clinic or the facility visit that he or she attends. We have five major payers that we are looking at. So the major payers are Medicare, Medicaid and Medicare Advantage. But when it comes to commercial payers, we just split it into two. So we look at the fully insured plants and the self refunded plants. Our analysis mainly is based on the claims database that we have. That's what we call the VCRs. And this slide shows the overall population that we have from 2012 to 2016 by payer. If we look at the table, we could see that over the year between 2012 and 2015, our average population was about 570,000 per year. But 2016 we see a slight decrease from 570,000 per year to about 497,000 per year. This will be visualized on the next slide. So our next slide shows the average memberships that we have for each payer. That's the bar graphs that we have. And the straight line on top, the black straight line on top represent the total population over time. So we can see that there's a slight increase in the total population over time from 2012 to 2015. But we see a decrease in 2016. This was actually probably due to the government decision that happened in 2016 and we lost about 46% of our membership and mainly it was with the self-funded plants. So our first decomposition looks at the office visits over time from 2012. Just to be clear, what we're talking about is that it doesn't track the population of the state as a whole. It's really the population that we're talking about are those that are submitting the data. Yes. So our first decomposition looks at the utilization rate or office visits for the time period 2012 to 2016. If we look at the graph, we observe that there was a slight increase over time from 2012 to 2016 for about four visits per member per year to about five visits per member per year by the end of 2016. Our second part of the office visit decomposition looks at the office visits per member per year but then by payer type. So we have the payer type as Medicare, Medicaid, Medicare Advantage, then fully insured and self-funded plants. For the total office visits, for the fully insured and self-funded plants, it's remained constantly stable over time with approximately three visits per member per year. So that's the first two bottom lines that we see on the screen. For Medicaid plants, it was also consistent from 2012 to 2014 of our four visits per member per year but in between 2015 and 2016, the total office visits per member per year increased to about five visits per year. For Medicare Advantage, that's the third line or the light blue line that we see. The office visits likely dipped in 2014 but after that we saw a rise in the office visits per member per year. Last but not the least, if we look at the Medicare patients, that's the green line or the top most line that we have. The total office visits for each beneficiary increased from 2012 onwards from about eight visits per member per year to about nine visits per member per year by 2016. Just to interrupt for a moment, keep in mind that there's nothing special to say. This is a post-operative office visit. An office visit is an office visit so you wouldn't want to look at this and say this is equal to primary care. Our next major decomposition looks at the prices or the average prices between 2012 and 2016. This first graph represents the average price for what the insurance pays and the average member responsibility share amount. So the very first line at the bottom that's the red or the pinkish line represents the average member share amount and the average paid amount is represented by the blue line. For the average member share amount, we did see an increase of approximately $16 to $17 from 2012 to 2014 and in 2016 this average share amount decreased to about $14 per member over time. Similarly, if we look at the average paid amount, it did increase in 2013 to approximately $64 in 2013 but in 2012 it was around $61. Between 2014 and 2016, the average paid amount decreased from $64 to $58. Our next slide also looks at the average price by payer type. At this time around, we are looking at the average allowed amount by payer type. So the allowed amount here represents the sum of what the insurance pays and the member responsibility. So for the average allowed amount for the fully insured plants, we saw an increase over time. That's the red line. That's the second from the top. The average allowed amount for the self-funded plants also did increase from 2012 to 2015 but then decreased in 2016. This is likely due to the co-paid decision that we had in 2016. But then by 2016, we realized that the self-funded and fully insured plants were the same. The average allowed amount were the same as compared to the earlier years from 2012 to 2015 where the self-funded average allowed amount was way higher than even the fully insured plants. So looking at just the average member responsibility, excluding what the payer pays, just the member responsibility over time from 2012 to 2016, the cost sharing for Medicaid and Medicare plans remain relatively stable. That's the first two bottom lines that we have but we see more variability in the Medicare Advantage plans. That's the light blue or the third line from the bottom. But the average member shared amount increased at a similar rate for self-funded and fully insured plants from 2012 to 2014. Then the average cost sharing for the self-funded plants or members with the self-funded plants, we see a decline from 2012 to 2016 and this will probably be to the co-paid decision that we saw in 2016. So yeah, the self-funded who are still around are a pretty distinct subset. They're governmental plans such as the state of Vermont employees that don't have the option not to submit their claims to be cures. So if you look at these trends, even though the fully insured were paying a higher price, the member responsibility, or lower price rather, the member responsibility has historically been higher until we kind of winnowed it down to this subset where we're seeing some definite changes in the population. That's going to be a big challenge in any kind of longitudinal look we take at these numbers. Would you be able to pull those out of the history and only show that? Yeah, so it's possible but a little bit tricky because there's not really always a clean way to be like, this is a governmental plan without an arrest exemption. But looking at group names, we can certainly identify state employees, most of the educational plans and similar governmental plans, but it's not going to be perfect, but that's one thing. It's going to show a different line. What you just said makes a lot of sense given the actuarial value of those plans which tend to be higher than the marketplace. Lastly, composition looks at the intensity over time. That is the typical visit length each member receives at the hospital per year. Since Medicare decided to use just one code in 2014 to represent all its visits, whether a new patient or an established patient, and how long the visit takes, it's just one code we can really determine if the office visit was probably five minutes or 10 minutes or even 60 minutes. Sorry, we did take it out from the intensity measurement. So we don't have Medicare and Medicare Advantage plans with this analysis, and also the code for the G code is also taken out. So this includes just the commercial plans that's fully insured and self-insured and Medicaid plans. So over time, we saw that there was a slight increase from 2012 to 2015 in the visit length per member, but then a slight decrease when we got to 2016. As I said, we did take Medicare and Medicare Advantage out because of their single code in 2014. So looking at intensity by payer type, we do not have results for Medicare and Medicare Advantage. So beneficiaries with Medicaid plans, that's the top most that we have. That's almost like, that's the green. They had the highest office visit length per member amongst other payers over time. And then Medicaid plans, or members with a Medicaid visit length also increased about five minutes between 2014 and 2016. So initially it was around about 74 minutes per member per year to about 79 visits, visit length per member per year. Also the visit length increase for commercial plans does the fully insured and self-hundred plans. But with the fully insured plans, we did see a slight longer average length in recent years. So the self-hundred plans or the self-insured, I'm sorry, the fully insured plans, it's being represented by the red line. And the self-hundred plans, it's being represented by the blue line. To summarize, although we've seen or observed in our analysis, there are a few questions that we posed in the beginning and what did we really see? So are outpatient visits utilization rates changing over time? Yes, we did see that the utilization has been increasing steadily since 2012, but then it's being driven by Medicare. Rates observed for Medicaid and commercial plans also relatively remain stable over the time. The other question was, are the length of visits also changing over time? We did observe that Medicaid and commercial plans showed increases in typical visits length of about five minutes from 2014 to 2016. Then Medicare intensity, we can't measure it from 2014 to 2016 because of the cold change that we had. But then we could probably have other measures to measure it, but it becomes a challenging. And it's a great example that we will see that if we have the payment reforms, when measuring changes, it becomes a bit of a challenge. Actually, a capitation. Last but not the least, how are prices changing over time? That's what the insurer is paying and the member responsibility. Medicare did show relatively stable allowed amount over time. The average Medicaid allowed amount showed the most variability over time. Then changes in average cost appeared similar for commercial plans. That's the fully insured and the self-funded plans. But then the self-funded plans demonstrated higher average allowed cost prior to 2016. The go-bet decision changed the population of the self-funded plans reporting to BQS and this remains a challenge when we have to measure any changes over time. Last but not the least, our next step to further and decompose our results is to expand the decomposition to include medical services by categories such as inpatient, outpatient, and pharmacy. And also include variables to account for changes in demographics, e.g. age or gender. So for the age, for instance, we could probably try and see if the younger population member responsibility going up than the older population or vice versa. And also to include disease prevalence. Some diseases might be more expensive over time than the other. And that's it. Okay, are there questions for Kapua? Yes, I have one question. So as we move forward through the all-pair model, my recollection is that there's some sort of a flag now in BQS to identify ACO populations so we might be able to kind of compare between groups. Is that reasonable or is that pie in the sky? I would say that will be reasonable but depending on how everything goes and how the results looks like. Thank you. Well, this is getting, this is interesting stuff. I mean, and you can see it's going to get more and more interesting as time goes on. Good job. A couple of quick questions are on the second or third slide where background population is, I'm just trying to figure out to give those bottom line numbers some context. Would the bottom line numbers be the population of the state of Vermont if everybody, if this was an all-in analysis? No way. Who are missing? Uninsured, federal employees. Yeah, so. Military. Yeah. Military. Yeah, yeah. And also, so one of the, so in order to help preserve the risk of re-identifying people, all the live identifiers such as the, what we call clear text name has been hashed prior to its being encrypted and if your algorithm's any good, J-O-H-N will look nothing like J-O-N. So doing any sort of fuzzy matching is impossible. Therefore, we're positive that we have too many identities in V-Cures. So they do their best to try and cluster people both over time and across payers to one ID, but given the limitations of that, it's certainly imperfect. So this is going to be an overestimate of the true number of people that are represented in the clean student base. And so in terms of the payer type, where would free care or bad debt fit into this? We do not have those claims today. Other states have dealt with this by trying to incorporate what they often call pseudo claims. So they try and mimic what you would see for uninsured or uncompensated or self-paid care. But to get that utilization, I would highly recommend the hospital discharge data set, which is a true census of care delivered at a hospital. Thank you. I think you lost me when you said hashed prior to your credit. I had a question on how the time of visits is measured and you know, I know if I if I look to myself, you know, you get pulled into the room and then you sit there for a while. And then the nurse comes in and then they leave and then you sit there for a while. Don't quote me on any of that. You know, and then at the end of the day, you know, you might be there for an hour, but you actually saw the doctor for 10 minutes or 15 minutes. So I was kind of surprised at the 50 minutes and 80 minutes from a time and just wondered, you know, how is that measured? Because it's certainly there that long and I know there's other steps have to take place. Right. That's a great question and to be clear in the CPT manual, it's like a typical visit length. So it's kind of supposed to be a proxy for the intensity of care. One of my dreams is to... I think I've heard Mike Del Treco talk about the triangle of validation and really sit down with someone who submits the claim from the provider side, someone who processes the claim from the insurer side, and see where V-Cures comes within that triangle to figure out exactly that sort of scenario. Because administrative data is not the same as a medical record. Yeah, and that's a perfect example of one of the challenges. You're saying there's some double counting and I understand that, but if we went to 2016, it shows about 40% of the population are kind of in the insured world and then kind of 30 to a little under 30 between the Medicaid and Medicare Advantage and I know this isn't representative of what we see in the hospital budgets per se, but certainly the costs when we see how that's paid out the insured peak, this insured and self-insured paying so much more of the way, if you will, to kind of talk about the cost shift there. So it's kind of interesting to track that too. Can you go to page 9 for a second? On this one, I had a little bit, so it's the second line from the top, that's the insured, fully insured, because I know you guys, your summary takeaway was kind of that it was they were all moving pretty similarly, I see more of an upward slope in the commercial line and a little more of a downward slope certainly in the Medicaid line and a flat, so I mean my observation would probably be a little bit different that the commercial, other than the self-insured where I know there's some things going on there because the population changed and I'm thinking if we hadn't changed that population, the self-insured last bubble probably would have been trending up too. So only because we're talking about in other ways cost shift and things going up and it seems like things are fairly stable, but just looking at those costs too are interesting to see the 100 plus dollars charged on the commercial side versus the 50 dollars on the Medicaid side and if we ever were able to start marrying up their actual expenses to those costs knowing that there's not a lot of profit throughout the system it really would show the cost probably somewhere around the blue line and the difference where we're being subsidized for the Medicaid, the Medicare and then paid out on the other side. So I know we don't know that profit piece or the expense piece but it's certainly going to fall above I would think a green line. So it's very refreshing to see something that's 2016 versus 2012 which is what we were looking at for a number of years and I was wondering if you might want to share with not only the board but with the public, what changes have occurred that have allowed us to get more timely information and what do you see going forward so for example, when do you think we'll be looking at 2017? Sure and to be honest, we could have included 2017 today one of the challenges there is that's the first year of the ACO pilot with Medicaid and we're still trying to figure out a meaningful way to deal with shadow claims and true costs and that's all kind of contingent on the settlement and the final numbers coming out of that program so the changes though I think are largely due to capacity so we finally have an in-house data team that is getting up to speed on how to directly use our claims database we've also had some improvements in the timeliness of the Medicare data which was a big leg in the past especially for the expenditure analysis so to get a final action claim for Medicare I think it's 8 15 months of run out at this point before they'll even deliver that file but we're able to get quarterly contracts these days and we're further trying to accelerate that timeline by a different delivery mechanism with our vendor so yeah so so if somebody asked me the question I would say the biggest change is that we have Sarah Lindbergh I think it's more Kakuha honestly and David and Kate and the entire 18 that's right but there wouldn't be an entire 18 if it wasn't for Sarah Susan Barrett I think it was the really extra act directly related to you yes absolutely yeah and you know we welcome feedback of this type of thing it's helpful and like I said this is like the pre-appetizer to a much more in-depth analysis but you know a lot of the challenges aren't going to go away and for instance we know that or we think that the PMPM for the self-funded overall not for office visits probably went up by a hundred bucks so I think this is a higher utilizing population left so that's going to be a major consideration of anything that we're looking at anything else from the board okay at this point I'll open it up to the public for any comments or questions be quiet after noon okay thank you very much and again thank you for the great strides you have made in your tenure here and keep it up yeah so that is the only item that we had on the agenda for this afternoon is there any old business to come before the board is there any new business to come before the board if not is there a motion to adjourn so moved it's been moved and seconded to adjourn all those in favor signify by saying aye any opposed thank you everyone it's a much earlier day than we had anticipated just a reminder in case anybody had forgotten it but tonight is the memorial for Con Hogan at Vermont College starting at 530 so hopefully we'll see some friendly faces there