 Good afternoon everyone and welcome to the Green Mountain care board. My name is Kevin Mullen chair of the board and we're about to get started. And the first item on the agenda is the executive director's report Susan Barrett. Thank you. Thank you Mr. Chair. Just a scheduling announcement that is is on our website on our press release and our meeting schedule but this evening we'll be meeting with the primary care advisory group starting at 5 p.m. and that is via Teams and all of the sign-in information is there. And then the ongoing public comment I will just remark on it again for anyone who wants to provide public comment on a potential next agreement with the state of Vermont and CMMI or CMS. Please share your comments with the board and there is a portal on our public comment section. We will share those comments with both AHS and the governor's office as they are taking the lead on the negotiations for a potential next agreement. And that is an ongoing comment. We don't have any other public comments at this time. I'll turn it back to you Mr. Chair. Thank you Susan and I just want to remind everybody that the Green Mountain care board is has made a decision to disable the chat function just so that there's no distractions and no inappropriate use. After each presentation we always call for public comment or questions and the way to do that is to raise your hand or to speak up. And with that we're going to move to the minutes of Wednesday May 12th. Is there a motion. So moved. Second. It's been moved by Maureen and seconded by Tom to approve the minutes of Wednesday May 12th without any additions deletions or corrections. Is there any discussion. Hearing none. All those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show that the motions were passed unanimously. The next item on the agenda is we're going to have an interesting presentation from support and services at home the SAASH program and I'm going to turn it over to Kim Fitzgerald and Melissa Southwick. Kim. Melissa. Welcome. Right. Yes. Thank you. Thank you so much. We're so excited to be here today and appreciate you having us here. I'm Kim Fitzgerald. I'm the CEO for Cathedral Square and I've been with Cathedral Square about 20 years going over actually over 20 years now and I am joined today by Melissa Southwick who is our new SAASH Director. Melissa has been with Cathedral Square and SAASH for the past six years but stepped into the director role this past January. So I should add that Molly Dugan is still with us just in a different role. So that's why you have two of us here today. So our goal for today is to give you a quick overview of the foundations of SAASH and update on SAASH in Vermont currently. An overview of our funding through the years challenges in funding as we move forward some current results we have and a wish for expansion. So I know that some of you have heard us present before and others have not. So we figured in order to level set in a really quick hopefully efficient way we wanted to start out with a little quick video that we have. It's actually less than two minutes giving kind of the overall foundations of SAASH. So I'm going to go ahead and share my screen to be able to show you that video. I'll go ahead and start it. I should ask if you can all hear that. I don't think we have time. Yeah I think. Okay so I'm sorry I'll try that again. It's not giving me. Is there a button on the bottom Kim I thought I saw. Yeah I'm going to have to I'm sorry about this. Let me just pull you back up. There it is yeah. Health care spending is growing at an unsustainable rate while the health outcomes are at best stagnant. The SAASH model takes an intuitive approach at improving care and slowing the growth in health care spending. SAASH is a coordinated partnership of nonprofits including affordable housing, home health, agencies on aging, community mental health centers and the SAASH participant working together to keep each participant healthy and at home longer. This model puts participants and their families in the driver's seat. They set goals around their health with the support of their local SAASH team. This collaboration simplifies life by providing transition support from hospital to home self-management skills for better health and person centered care coordination. Costs for eligible adults are covered by a Medicare demonstration grants and partner housing agencies. Funding supports a SAASH housing-based care coordinator and wellness nurse creating incredible efficiencies and improved effectiveness. SAASH operates out of 22 non-profit housing organizations throughout Vermont improving the lives of 5,000 participants and their families. The model's proven successes include reduced falls in hypertension, increased rates of immunizations, reduced Medicare expenses and a 40% increase in advanced directives saving millions of dollars per year. Not only are participants happier, healthier and living longer lives by taking a population health approach, the SAASH partnership also boosts the entire community's health and well-being. For more information, visit. And so now we'll move to share a powerpoint with some more information. So for background Cathedral Square was created as created SAASH in 2009 with help from residents and local service agencies and we had some really great initial success with our first community which was Heineberg and so we added to the blueprint for health in 2011. We quickly expanded statewide in every county of the state with almost 5,000 participants in 140 housing locations and 68 partner agencies. So yes, it's hard to believe but 2021 marks our 10th anniversary of SAASH services in Vermont. Since inception, we have served over 9,000 participants throughout the 10 years throughout Vermont and in addition, we have just started our fifth year of SAASH in Rhode Island and our third year in Minnesota. We are also currently working with Baltimore, Maryland and potentially California. We have been rigorously evaluated over five years by RTI who published four evaluation reports on SAASH with the final one coming out in July of 2019. The U.S. Department of Health and Human Services and HUD contracted for this multi-year evaluation and each year, SAASH was shown to reduce the growth of Medicare expenditures as compared to other Vermont residents living in similar situations, controlling for similar health conditions and age all based on claims data with the only difference being SAASH. The evaluations focused on Medicare because that was our funding source and the final report released in 2019 did take a look at Medicaid at our request and found that SAASH was also reducing the growth in Medicaid expenditures as well. We are currently working with UBM and hope to secure funding for another evaluation in the not too distant future. So we're working on that now. Our demographics have remained pretty consistent through the years with our ages ranging from 22 to 104 with the average age of 73. Although the majority of our participants are Medicare, again, based on the funding, we do have young disabled with 25 percent of our participants being duals and especially those living in public housing settings. Our top three chronic conditions are hypertension, arthritis, and chronic pain, which probably don't come as a surprise to any of you, but we do see the full spectrum of conditions. What many don't realize is that our participants have a high rate of chronic conditions with a median of six per person. Three or more is considered high risk and we have 75 percent of our participants with three or more chronic conditions. Statistically, those with lower incomes tend to have higher levels of chronic conditions and we definitely see that play out with our participants. Our funding through the years, so in our initial years, Cathedral Square provided the startup funding for our pilot and we did get some foundation funding as well as a legislative appropriation. And then again due to the success, by 2011 we were added to the blueprint for health and started receiving funding through MAPCP, which probably many of you know, but for everybody, it's the multi-payer advanced primary care practice, the CMS Medicare demonstration. Our original request for funding was to support 62 panels or around 6,000 people, but that was decreased to 54 panels due to funding across the state and we served 70, about 70 to 100 people per panel. At that time, our budget was $70,000 per panel. The MAPCP funding covered direct services only, so the wellness nurse and SASH coordinator time onsite only. Dale covers the programming training, partner agency support, regional support, and statewide administration. Diva has covered funding for the management of the SASH data and we've worked with Vermont Department of Health, VDH, very specific programming initiatives. Housing organizations have funded the GAP and found different grants to help support them in doing so. Our funding did not increase at all during the first seven years. In fact, we actually had a 2% reduction due to the federal sequestration, so housing organizations have had to cover more and more through the years as costs have risen. By 2017, the five-year demonstration ended and the blueprint was added to the all-pair model. In that first year, we continued to receive our direct service funding directly through the blueprint, but by 2018, we have a direct contract with one care and now we'll receive our funding directly through one care. 2018 was the first year we actually received a 3.5% increase. In 2019, we received a 2.5% increase plus a 1% increase for lead care coordination through one care. We received no increase in 2020 and in 2021, we received a small one-time increase, which we're so appreciative of the Green Mountain Care Board staff for recommending and for you for approving, but it was directed to be used in high-risk areas, not statewide, and was only for one year. So we had eliminated our options, but we did choose to add supportive staff positions to help transition our trainings to be virtual, something we've learned through COVID and to support staff absences around the state so there is no lapse in services. So our funding challenges, you know, we do worry about our future funding. The Diva HIT funding ends this June 30th, so that's 205,000 that we will not have and we have no replacement for that funding, you know, at this time. Our DALE funding totals 974,000 and is set to be reduced by 541,000 as of July 1st of 2022 due to legislative language stating it should transition to one care. Yeah, one care says they do not have the funds to cover this, so we have no resolution and this funding would actually need to be in one care's 2022 budget based on the different fiscal years. Although the legislation gave us three years to work through and make this transition, I've been meeting regularly with Ina Bacchus, Susan's been joining us as well as Vicki Loeder separately, but we don't have a solution yet. And lastly, of course, we're unsure about the future of the all-parent model and really the correct placement for SASH within health care reform in the state of Vermont. So that's my part and then I'm going to turn it over to Melissa. So, Chair Mullen, I would leave it to you if you want to stop there to ask any questions or if we should wait until the end of the presentation. I think we'll wait until the end if that's okay. That is great. And then I will turn it over to Melissa. Great, thank you so much, Kim. So I wanted to start off just by sharing with you our experience during the COVID-19 pandemic. It was quite a shift to bring our largely in-person program to one that could be offered remotely. We did this through enhanced staff support. Since March of 2020, our SASH admin team has hosted over 30-hour-long trainings for SASH staff on COVID-specific topics. These trainings provided up-to-the-minute information on the pandemic how SASH specifically was impacted, guidance to keep staff and participants safe and a chance for peer learning. The SASH admin team developed a phased-in approach for SASH staff to follow based on positive cases in their building and communities. Cathedral Square's emergency response team led the way in planning for the impact this pandemic would have on congregate housing and we were able to share that information and guidance with all of our SASH sites. Participant education and support SASH staff offered new options to participants to share information on the pandemic including increasing their newsletters, posting and sharing flyers, as well as offering group phone meetings and additional mailings. SASH staff were able to utilize their close working relationships with SASH participants to make sure each individual participant was receiving information in the best way possible for them to receive it. SASH staff also completed individual COVID-19 plans with participants, helping them plan for how to get their needs met during lockdown and preparing for support and resources that may be needed should they become ill. Vaccines Through the federal pharmacy program, we were able to host on-site clinics across many SASH sites with great reception, averaging over 85% of residents getting vaccinated at those clinics where clinics could not be offered or for those SASH participants living in the community, staff assisted with scheduling vaccination appointments and arranging for transportation. Increased connections through technology has been a big focus for the SASH staff over the past year, as I'm sure you can imagine. At the end of 2020, we received 270 iPads from state COVID relief funds provided to VPQHC, the Vermont Program for Quality and Healthcare, to create lending libraries at all SASH sites across the state. Each SASH site received tablets, several tablets to loan out to participants. These can be used for telehealth appointments, remote mental health appointments, SASH programs, and socialization with family and friends. Our SASH wellness nurses have been able to assist with telehealth appointments in many ways, including providing technology support, sharing vitals with the provider in real time, and we even have some nurses piloting point-of-care A1C testing right now. During the pandemic, many SASH programs were offered remotely with great success. We had a very popular bone builders program in Lamoille County, for example, that doubled in size when it switched to a remote program. Learning from that experience we're currently using the additional one-care funding for 2021 that Kim mentioned to convert other SASH programs to ones that can be done in a hybrid model, in person with a remote option for when that's preferred. With funding from One Care Vermont and Howard, as well as in-kind donations from cathedrals- I've never done that. We are now in our fourth year of the pilot embedding a mental health clinician at SASH sites. The embedded mental health clinician provides support and discussion groups, education groups, and one-on-one counseling. She's supporting individuals as well as the building as a whole, reducing stigma and increasing awareness and empathy. She's supporting previously homeless individuals and is also helping with housing retention efforts. In both sites, we have seen a steady reduction in ED presentations since the embedded mental health pilot began. The SASH staff and participants at each site are very pleased with the program as you can see from these quotes that were obtained in our end of year program survey conducted in December of 2020. SASH works with participants in a variety of ways to lower blood pressure, including hosting regular blood pressure clinics, loaning blood pressure cuffs, one-on-one and group education classes on hypertension management and prevention, as well as communicating with PCPs. There have been 3,610 SASH participants that have had a Stage 2 blood pressure reading. Among those participants, we've seen a decrease of 16.1 millimeters of mercury in systolic readings. And for the 2,063 SASH participants that have had a Stage 1 reading, we've seen an average reduction of 5.23 millimeters of mercury in systolic readings. This is enough of a decrease to bring both of these levels into an elevated or managed range. We looked at all of our SASH participants that were active in both 2018 and 2019, and then we filtered out for high ED utilization as defined by four or more visits per year. We had 325 people that met these criteria. In 2018, these 325 individuals accounted for 2,221 ER visits. In 2019, these same 325 people accounted for 1,320 ER visits or 901 fewer visits. This is a median decline of three visits per year. It's estimated that the average cost of a basic mid-level ER visit is $843. So this reduction in visits could amount to over 750,000 in healthcare costs saved. We also saw a median reduction of three ER visits between 2019 and 2020, but we didn't include that figure due to the potential impact the COVID-19 pandemic may have had on the numbers during that time frame. As we mentioned, we've been capped at 54 panels or roughly 5,000 people for the last 10 years. We have growing wait lists in all of our drill regions across the state, and we have no additional funding for services when the new age-specific housing opens up. We'd like 10 more panels across the state. Our mental health pilot is so successful. We would love to expand this to at least two mental health clinicians at each of the six drill regions across the state, especially given the impact COVID-19 has had on mental health. SASH and family housing or SASH for all, most of our housing partners have general occupancy housing or family housing and have been asking for years for a SASH type model to be brought to those low-income housing locations. We've tried to secure funding for a pilot, but we've been unsuccessful so far. Although it may involve different partners at the table, we believe we can still have a major impact on immunization rates, health screenings, ER visits, as well as addiction, hunger, and stability. Thank you all so much for letting us talk with you today about SASH and I think we're ready to open it up for questions. Super. Thank you very much. I'm going to open it up to the board first. Board members, questions or comments for Kim or Melissa? Yeah, first, thank you very much for the presentation and a lot of good work that's being done out there. Just a question. I don't think I heard... What is your total funding? Did you give us a number on what your total funding is? I know it stayed pretty stagnant, but... It's just over five million dollars. Okay. And when you combine everything together. Right, right, right. I mean, because it seems like when you obviously show like the reduction in ER visits and things like that, some of these cost benefits. So hopefully that will help you be able to get more panels and get more funding. But I'm sure it's hard to do that, but it's good to be able to see numbers when you're talking about this. But great. Thank you very much. Yeah, my first question was along the lines of Marines and just wondering that if across 350 of your participants you can document that you saved $760,000, do you have a kind of micro accounting as to which of those hospitals those folks might be associated with so that you can on a very tactical approach say, hey hospital, we're saving you this money. We've documented it. You can't challenge our data assuming it can't be challenged. And so maybe with emergency room visits and maybe with high blood pressure because you do know who your patient client base is that you can be into developed contracts that are pay for performance. Yeah, I would absolutely say that we can get right down to the town of where those people live. So that is definitely something that we could begin to explore. All right, so those 325 people that were in your emergency room, those are the same people in 2018 and 2019. Yes, and that's why we filtered for people that were current in both years that were with us for the whole time of both years so that we could do a year-by-year comparison. Well, it sounds like there might be an opportunity there. I mean, if you can show these hospitals that they're saving money in their budget there's got to be a way to leverage that a little bit. Another question I had was as you see, because you were Medicare-based, you probably don't have a lot of relationships of relationships with people that are pre-Medicare. I'm sorry, Medicare-based, pre-Medicare. And I'm just wondering if you have any insights into benefit packages in insurance plans that are not there now and you know that from being out there on the ground with folks that are transitioning to Medicare whether there are benefit plans in the insurance that they now have that would mean that you would be receiving people that are already kind of in your modality of treatment rather than having this kind of sharp break at say 65. So maybe suggestions like in the benchmark plan which I know is going to be going under a review for the large group and QHP populations are there things that you could advise those folks that they should look at in terms of rearrangement of benefits to help people transition into your programs? All great suggestions. I will say that we are currently talking with one of the local providers about their Medicare Advantage plan and whether we could offer SASH services under that. So not exactly what you're getting at but I understand your thinking and also our SASH for all would actually open that up for folks of all ages. And because when we first started out we were based out of congregate housing settings not everybody who lives in the congregate housing settings are 55 or older or 65 and older or 62 depending on which category you're looking at. And so we do have younger participants as well mostly of course disabled that we already are working with and working with the service needs that they have. Thank you. And I also just kind of if I could go back to your first question I'm sorry I should about the hospital piece about going out to the hospitals. I do think one of the dynamics that's at play right now is the fact that we're receiving the money through OneCare as part of their prepaid advanced shared savings. And so I do think that many hospitals are believing that they are pretty much funding SASH right now even though I know that when the all-pair model was negotiated and the blueprint SASH funding was kind of layered on to that that wasn't the intention initially but that is believed by some at this point. Is that believed or is that the reality. I would probably have to defer to probably you know back us to answer that question. But yeah again that my understanding through her was that that was not the intention but because the savings have not we haven't reaped the exact benchmarking that was set out in the original kind of preforma that that I think there is yes that I think they are paying because the savings isn't there that they thought they were going to have. Thank you. Okay other board members. I guess I would just chime in on that point. The piece of that that people miss is that the benchmark would be eight million dollars less but for the fact that that money is in there. So I know people look at it in different ways based on where they sit but the benchmark would actually be less if the SASH money and the blueprint money weren't in there. But thank you Kim and for coming in today and getting an update it's always good to hear about how the program is evolving and what's going on. I was a little bit curious about whether there are any lessons from Rhode Island that you're seeing that could translate to Vermont. Just I imagine there's potentially some lessons learned that could go back and forth between the two states or funding ideas or something like that. Yeah that was a great question and one I actually haven't thought a lot about. I would say Rhode Island is much smaller so I feel like they're learning from us. I think Minnesota is where the difference is because they are the organizations we're working with there are managed care organizations. So as Vermont is thinking more that direction from what I've been recently hearing that we may be able to learn more from Maryland also Baltimore Maryland but also from Minnesota currently and then Baltimore Maryland that we're working with. Thanks. Well thank you. Melissa and Kim it was great to hear from you and learn more about your program. I had the same question about Rhode Island so I'll skip that but I wondered if funding did expand how would you prioritize the needs across the state either programmatically or geographically? Where would you park those extra dollars? Where is the greatest need that's unmet as of now? Yeah and that's that is a struggle right because we have a lot of wants and so I think the first thing is the per panel fee we just got to get up a little bit and just just for some background that original budget for seventy thousand for panel was for nursing at thirty five dollars an hour and pretty much almost out of the gate of us getting funded you know our nursing contracts across the state are ranging anywhere from you know high forty dollars an hour to fifty five dollars an hour. So right there we have a huge gap in that kind of original budgeting. So we really do have to if we're not going to get an increase every year for the panels across the board we do have to give some funding to that because I worry we're going to reach a point where housing providers are going to say they can't they just can't do it any longer. They can't help supplement it. They can't find the extra sources that they've had to go out and secure. So that's one area. The second one I'd have to say is really we'd like 10 new panels and so that would probably be the second priority because we do have wait lists in area and we have areas that have just been waiting to you know to get a sash panel every year we try to add more affordable housing in the state and that those housing communities have not been able to offer sash and so that would probably be you know the next priority I would say and then followed by you know probably at this point it would be like the mental health expansion that we've just seen such remarkable results that we just believe and and honestly on the heels of COVID we just feel like it's now is the time and then I guess from that would be the sash for all you know and again that's that's mainly just because that's a newer initiative but we also see it could have huge you know huge huge savings and and I didn't say this I don't think during the presentation I have probably in previous presentations but you know based on what the evaluators told us we are the only program they had evaluated that actually showed a reduction in Medicare expenditures and they haven't seen that they're lucky if they see it break even let alone kind of bend the cost curve so we'd love to be able to do more. Just as a quick follow up geographically where are the wait lists the longest. Well deferred to Melissa on that. Yeah I can absolutely answer that so we as I think you might imagine just the populations right so Chittenden County has some wait lists Rutland has some wait lists but also there's places that are underserved right now like the middle of Orange County. We have services on both sides of Orange County but nothing in the middle so there's a Bellows Falls area Tonbridge area that's really just been clamoring for a panel for years and then also Brattleboro has had some wait lists lately as well. Great thank you. I always considered Bellows Falls to be Wyndham County. Okay yep you know what it's really interesting because there's that area where it's kind of like nobody is able to serve them and so who is the closest and I think for our purposes Orange was always the closest but yes I think you're right it is Wyndham County. Okay at this point we're going to open it up to the public for any comments or questions. Members of the public not seeing anyone so I want to thank you both for a great presentation and I know that the people in Washington are very familiar with the cost savings that you have achieved and they would like to see that replicated elsewhere across the country so keep up doing the good work. Thank you so very much and thank you all for your time. Thank you. At this point we're going to move to a discussion on fiscal year 21 hospital provider transfers and I'm going to turn it over to Russ McCracken, Patrick Rooney and Laurie Perry. Thank you Mr. Chair. Can you hear me? We can. All right let me know when you can see the presentation on the screen please. We can. All right super we'll get started. All right as the chair described we have a topic for consideration today a little bit of house cleaning regarding a couple of provider transfers so just a quick recap here of this process. At any point during the year a hospital may request changes to its approved budget. The board does expect to be reasonably informed of any of these changes. Any of those changes occurring prior to May 1 that being October 1 the beginning of the fiscal year through May 1 are expected to occur during the current fiscal year and any changes after that are expected to occur in the July 1 budget submission. And this includes changes resulting from provider transfers. For independent providers a letter of intent and documents to the Greenmount Care Board regarding a revised budget shall be filed within 30 days prior to the transfers and other reporting requirements. A notice to patients shall be sent and Greenmount Care Board does not approve these transfers. We track and acknowledge the resulting changes to the hospital budget and ensure that the patients receive the adequate notice. For budget adjustments the Greenmount Care Board staff will review within 15 days after receiving a completed request and make recommendations to the board. Regarding the provider transfers the board tracks existing health care dollars in and out of state hospitals these are not new dollars per se to the health care system but they do impact a hospital's budget. This policy does not require board approval of the provider transfer or acquisition. This goes for independent providers that move into a hospital in which the patients are to be given notice or hospital provider practices that separate from the hospital. This situation is a little bit more unique. It's a provider practice that has been billing under the tax ID number of the UVA Medical Center and that information is being shifted to Central Vermont Medical Center where the practice physically exists. So the timeframe here for this has been that we received an email the staff the Greenmount Care Board that is in February of 2021 with the provider transfers and appropriate schedules. We send a communication to Central Vermont and UVM to confirm that these transfers also affected the UVM Medical Center for documentation purposes and we received confirmation supporting schedules from UVMMC in April. During the duration we spoke as a team with our legal counsel as this as I said this is a little bit different as far as provider transfers considered because it's going inter-network that is the inter-UVM health network situation. And the reasons for this change were that at the end of fiscal year 20 they did transfer the three practices general surgery family family medicine and ear nose and throat. These are not reflected in the fiscal year 20 or 21 budgets in that these three practices exist in the UVM Medical Center's budget for those years. They do not exist in Central Vermont's budget for those years. These changes needed to occur prior to the end of fiscal year 20 and they did they occurred in the last week of fiscal year 20 ending on 9.30. And the reason for this was that they wanted to ensure continuation of being able to provide 340B drug benefits to the patients of those practices. Should they be part of that program. Any gap in that could have caused an interruption in the possibility for those benefits for patients who are parts of those practices. As stated before the providers located at Central Vermont already there's no change to the physical practice location. It exists there. It's just being has historically been billed under the tax ID of UVM Medical Center. And as the health network continues to consolidate some of the practices and business operations under that network these types of actions will will happen from time to time. Here is the financial breakdown for Central Vermont and UVM. Central Vermont will be gaining about 4.5 million in NPR and about 5.5 million in expenses and an operating loss of just over a million dollars. And UVM will be shedding the same amount of revenue and expenses and and also the operating loss that once existed with these three practices under UVM's budget finances. So our recommendation here is that we require UVM Central Vermont to reflect these changes in their FY 21 budgets when they submit it when they submit their FY 22 budgets so that when we're looking at a budget to budget perspective that this would be that change would be reflected in that so that neither organization is being misrepresented from a financial perspective based on the fact that these transfers have already occurred. And this approach treats the transfers as if they were changes that occurred prior to May 1 under the budget and amendments adjustment policy and there's a link here for anyone who wants to access that. We recommend this approach instead of asking the hospitals to request a formal amendment to their FY 21 budget because of the pandemic having skewed actual performances. Both hospitals are missing their revenue and operating expense targets in a pretty significant way. So they're coming in below what they had anticipated year to date. In addition to that the board has decided not to take enforcement action with respect to FY 21 budgets and in our view based on where we are in the budget cycle we're about five weeks away from submissions at this point. Most effective use of time and resources is to have a correct FY 21 budget baseline for fiscal year 22 budget submission. So that documentation should be updated prior to that FY 21 or FY 22 submission. So we open it up to board comments and discussions and we also have some motion language here for you to acknowledge these transfers and should there be any questions that I cannot answer Laurie Perry and Russ McCracken are both on the line. Turn it back over to you Mr. Chair. Thank you very much Patrick and it's my understanding that these practices it's this is really what I would call a mysterious paper Shuffle because they've been at Central Vermont they'll continue to be at Central Vermont. We're not adding any dollars to the system or subtracting any dollars to the system it's just the way that they're accounted for. And really the backstory was that there was some concern from some of these providers when they first wanted to do this a few years ago about the affiliation with the UVM teaching faculty. And so I think that this is something that totally makes sense to happen you know because you're going to be leaving federal dollars on the table with the 340B pricing. And again I think that what you're suggesting in your motion language makes an incredible amount of sense too because it's not like we're approving or disapproving is just how we're treating it in terms of how we're viewing the hospital budgets and you know this properly belongs at Central Vermont Medical Center. So with that I'll open it up to the the board for questions or comments. Yeah I just have one I mean it makes sense for the 22 budgets you know to be comparing the 21 and the 22 with it in the in the what would be the correct place. I guess for I know we're not doing enforcement for 21 but I would just suggest when they come in with 21 are you assuming then they don't make that change to the 21 budget and it's their original budget and then they'll just have a variance which they can explain or how are you thinking that the submission would come in there. I believe with what we've asked them to do is to make an alteration to those FY 21 budget numbers as if the practices were already there. Okay so when they come in for their 21 actuals they will they'll have a new budget if you will for 21. They'll be adjusted in that budget that they'll compare against. Correct. Okay so we have to change that in our systems and things like that as well which we can do but you'll have to change you know any of the reports that we see for 21 having the budget change. Correct. Because it's already loaded into our systems the other way. Laurie can you answer this please. Perhaps I have it wrong. I'm not sure I'm hearing Maureen correctly. Sure. Anytime that we've had these type of provider transfers and it's in the middle of the budget process like going into when we demonstrate these to you when they present their 22 we will show you a previous 21 budget these provider transfers so you get a new base for 21 to take their 22 growth against. Does that make sense. Yeah that makes sense for the 22. And then for 21 when we get their 21 stuff coming in are you going to do the same thing. We most likely will but also you're not doing enforcement on 21 anyways. No I know we're not doing enforcement but I still like to see what the changes are against a relative base but we can deal with that at the time it took us. Asking those type of questions when it comes in. Correct. Okay okay. Thanks. Other members of the board. I would just say this seems like a reasonable approach and I support the motion language. Same here I you know the way I'm hearing this is that basically there'd be a little retroactive adjustments in the 21 and 20 and the 20 21 21 budget to reflect in adaptive of what was really happening on the ground and it's an adjustment that needs to be made in order to move forward to 2022. I agree with what everyone said. Okay Robin would you like to make a motion and then I'll open it up for public comment. Sure I move that we acknowledge the provider transfers from UVM Medical Center to CVMC which were effective at the end of fiscal year 2020 and not reflected in those hospitals approved fiscal year 21 budget. Also that we instruct UVMMC and CVMC to include appropriate adjustments to their fiscal year 21 budgets to reflect the provider transfers when they submit their fiscal year 22 budgets in order to establish an adjusted fiscal year 21 baseline budget. Is there a second. Second. Okay thank you Tom. So at this point I'm going to open it up to the public for any public comment or discussion. Members of the public yes Dale. So I joined a little late and this question may have already been answered but what concerns me on transfers like this and what I'm struggling to understand is things like billing like I remember I got some bills from CVH and I called them up to pay it and they were like oh that's already been paid. It's that Medicaid paid late and I was like wait you billed me because Medicaid paid late. So does this change the billing for the consumer. If they've got a higher debt ratio does it change that whole policy does this change the staffing workforce in terms of who's available does CVH have the right to reduce staff they need to keep the staff as is. Does it affect transfers as far as recommendations. If you need a specialist does it change how do they still send you to Burlington or are they as a priority going to send you in-house which I'm not calling that bad. I'm just saying is it an adverse effect. I mean how does. Dale does understand that the patient will be unaffected and somebody can correct me if I'm getting this wrong but the the way it's been explained to me is that the patients will not be affected at all and this is merely being done to reflect the ability to access additional 340B prescription drug dollars and that in reality these have always been Central Vermont doctors. They were located there. They were not located at at the Burlington site and so it just makes sense from all perspectives to you know get this where they actually physically are and to access those additional 340B dollars and please anybody correct me if I've got any of that wrong. And I'll hear a correction so that must be the right answer so thank you for the clarification. Thank you for the question Dale very very important one because nobody wants the consumer to be affected by this. Is there any other public comment. Hearing none I'm going to shift the the motion back to the board. Is there any further discussion by the board. Hearing none all those in favor of the motion language as outlined in the slide in front of you on your screens. Please indicate by saying aye. Aye. Aye. Those opposed please say nay. Let the record show the motion carried unanimously. Thank you Patrick and team. Thank you Mr. Chair. At this point we're going to move to old business. Is there any old business to come before the board. Is there any new business to come before the board. Hearing none is there a motion to adjourn. So moved. Second. It's been moved by Maureen and seconded by Jess to adjourn. All those in favor of the motion signify by saying aye. Aye. Aye. Aye. Any opposed signify by saying nay. Thank you everyone and have a great rest of this incredibly beautiful day.