 So I'll call it to order the Green Mountain Care Board's hearing of August 23rd, 2023. I think there's one agenda item today, which is the UVM Health Network and its hospitals in Vermont's fiscal year 24 budgets. Before we get started, it's come to my attention that UVMs requested that Dr. Merman not participate in a review of its budgets. And I think given the concerns that have been raised, I should address that upfront. UVMs filed a motion seeking Dr. Merman's recusal because it believes he's conflicted. Dr. Merman's received an opinion from the Ethics Commission and has a written statement on file with the GMCB as required by the Code of Ethics. UVM believes there's other information that it thinks could change that analysis. And UVM's motion that we received yesterday indicates that it does not object to Dr. Merman's participation today in the Medical Center Health Network or Porter hearings. And that's the board to take up their accusal motion at a later date prior to deliberations. I think somebody's unmuted. If you're not speaking, could you please mute? Might be somebody in a car. Thank you. I think that is a reasonable way to approach the issue to have Dr. Merman participate in the Medical Center Health Network and Porter and take up the recusal motion at a later date. So we're going to proceed in that fashion today. Dr. Merman is recusing himself from participation in the CVMC budget and not participate in that part of the hearing. With that out of the way, Mr. McCracken, could you please swear? Oh, sorry. One other thing I should say is that there's a lot of material here. We may go quite a bit longer than scheduled. Those times are pretty approximate. So if you need to leave for any reason, just perhaps send Kristen Logenes an email and let us know. But I think we're going to be here probably a little bit longer, maybe even quite a bit longer, especially because we have a request for an executive session that we may take up. So with that, Mr. McCracken, if you could swear the witnesses and then Dr. Epen, you and your team can proceed with any opening remarks you may have. Good morning, everyone. And thank you, Chair Foster. I have the list of witnesses from the different UVM health network hospitals. It is a long list. So I'm not going to read through it, but for those identified on the list, if you could all raise your right hands. I will swear you all in at the same time. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth. So help you God. I do. I do. Great. Thanks very much. And I will turn it over to the UVM team for opening remarks. Great. Thank you. Sonny Epen, I'm going to just start with the opening remarks and then hand it over to Rick Vincent. First of all, thank you and good morning. Thank you in advance for what I trust will be a careful review of the proposed fiscal year 24 budgets for the UVM health networks Vermont hospital partners. This includes the University of Vermont Medical Center, Central Vermont Medical Center and Porter Hospital. We strongly believe these are responsible and reasonable budgets that will allow us to meet the needs of our patients and communities and continue to move us towards financial stability while limiting to the greatest extent possible. The financial impact on Vermonters. These budgets have been carefully reviewed and approved by our network board of trustees, which is made up of community volunteers. Our trustees take their oversight duties seriously and embody exactly what we would all hope for in our governance, compassion, awareness and a deep sense of responsibility. I'd like to thank our network trustees who are joining us today, including Ali Stigney, John Dwyer and Tom Galanca. I also want to start by acknowledging the very difficult task before all of us. Every person participating in this meeting shares the same goal to contain healthcare cost growth and improve healthcare system performance in Vermont, where in a national context, there has been no one else able to fully achieve these goals. Our entire health system is committed to working with you to address both cost containment and system improvement. The budgets we've submitted to you reflect that commitment. Compounding your difficult task of cost containment is the fact that healthcare costs are not evenly distributed in Vermont. But the burden of cost increases fall disproportionately on Vermonters who are commercially insured. Our net patient revenue requests represent the needs of our communities growing and aging population, as well as our networks focus on increasing patient access to care. Our commercial rates reflect the cost of providing these needed healthcare services. That means the commercial rate requests before you are solely what we need to cover cost inflation. As I mentioned earlier, the burden is mostly borne by commercial to ratepayers, as Medicare and Medicaid do not keep up with increases in cost inflation. An exception is critical access hospitals, which receive cost based funding from Medicare and therefore don't need to request the magnitude of commercial rate increases that the PPS hospitals need. This is a long standing structural problem that has real impact on Vermonters and the hospitals that serve them. And I hope we can continue to work together to address this. I've been in the job now for nine months. In that time, I've learned a lot about healthcare delivery in Vermont and Northern New York. It's been both humbling and inspiring. It's humbling because I see the critical role our organization plays in the lives of people in our region. As a provider of both acute complex academic medicine and safety net services. It's inspiring because I've met so many people across our system who are truly mission driven and dedicated to improving the health and lives of Vermonters and New Yorkers. The people of the UVM Health Network are dedicated to changing how healthcare is delivered, organized and paid for, because we all see the need for meaningful reform in these areas. I hope you realize that it's unique to have a healthcare system in a state government aligned on these fronts. As a newcomer, it feels like a real and exciting opportunity. And in fact, it's one of the reasons I took this job. Over the past year, we worked hard to focus on the things we can control in order to strengthen our workforce, increase revenue and find new efficiencies. This work has improved patient access to critical services like surgery and radiology. But serious and ongoing healthcare cost pressures are not unique to Vermont. We exist in a national healthcare economy where the costs of recruiting doctors and nurses amid a severe workforce shortage and the costs of new equipment and new drugs are very much outside of our control. I know last year's budget process was difficult for you as regulators and it was difficult for our health system. We faced unprecedented cost inflation and requested unprecedented commercial rate increases. Our cash position was severely depleted in FY22 due to the staggering cost of providing care and poor financial performance. We appreciated the board's willingness to recognize the circumstances hospitals were facing in FY22. I wish I could say this year was significantly better. Unfortunately, healthcare cost inflation hasn't entirely abated even as we've seen national news stories about general inflation returning to more quote unquote normal levels. Our expenses continue to rise for the remainder of FY22 and during FY23. We're currently about $90 million over budget for cost inflation for FY23. However, none of that $90 million is included in our FY24 request. We project additional cost inflation from 3.3% to 5.2% for FY24. I am happy to report in the past year, we've been able to reduce our reliance on temporary labor, which was the biggest driver behind last year's budget request. But we're still relying on far more temporary employees than what we would consider normal at a far higher cost than we pay for permanent employees. Since October, our full time traveler numbers are down by nearly 100 across our network and traveler expenses have declined by about $3 million per month. Additionally, the rate we pay for travelers has declined by 35% since the beginning of FY22. Our continued use of these travelers is primarily to maintain the critical access and care our communities need. But this is not sustainable without continuing support from you. Our dedicated people are also our largest cost. Over 60% of the network's expenses are salaries and benefits for employed staff, travelers and physicians. As we're experiencing both the regional and national workforce shortage, these labor costs are largely outside of our control while we focus on maintaining access to necessary services. The simple reality of operating a not-for-profit health system means we must take in enough revenue to cover the expenses of providing patient care. And just as importantly, we need to invest back into our people, equipment and facilities. We have no stockholders or investors. Every dollar that comes in supports our mission. Financial experts and lenders expect a financially healthy system to have a minimum of 2.5% margin. Our budget requests include margins of between 1.5% and 3% for our Vermont hospitals. FY24 is just one step forward of what we ultimately need to achieve in our network's operating margin to be a sustainable health system for Vermonters. The poor financial performance of the last few years has resulted in our need to remove or delay over $100 million in reinvestments across our network. Make no mistake, continuing to kick this can on these capital investments is having a mounting impact on access for patients. The budgets we've submitted for our three Vermont hospitals are designed to 1. Protect essential services. 2. Invest in innovations, service expansions and critical functions for our future sustainability. And 3. Minimize the cost impact on consumers. We recognize that this is a delicate balance. We can't ignore the need for investments in plants and equipment and important initiatives such as our Population Health Services Organization. These investments are essential to our future success in providing high quality, equitable, well coordinated and efficient care. As we begin today's meeting, I ask that all of you keep in mind that we are a not-for-profit rural health care system serving an area of more than a million people under very challenging conditions. Our patients need us more than ever before. We're seeing more people with more chronic and complex health care needs than we ever have, and we anticipate this need to grow more acute in the years ahead. We know we're not alone in these challenges we face. Across the U.S., more than 150 rural hospitals have closed since 2010, and many more are struggling today to provide essential but money-losing services such as mental health care and labor and delivery services. Here in Vermont, we're fortunate that we can have a transparent public conversation about how much health care costs should increase. But it's also important to have a public conversation about what our patients need, the challenges we face, and analyze the consequences of cost constraint. Are consumers seeing major access barriers? Are we deferring needed upgrades to facilities and equipment that our patients need? Are we driving people and our patients out of state to seek care? We look forward to a healthy conversation with you about how to best contain health care cost growth without compromising or harming the services our patients and communities depend on. Rick Vincent, our Chief Financial Officer of the UVM Health Network, will now share a few remarks. And then later, during the question and answer portion of today's hearing, Rick will help keep us organized and lead our network's response, and we'll call on as other colleagues as needed. Thank you very much. Thank you, Sunny. Good morning, everyone. Before today's review of our FY24 budgets gets underway, I'd like to thank Director Sarah Lindberg and her Green Mountain Care Board Hospital budget staff. Our network team has always very much appreciated Sarah's collaborative approach, always taking the time to meet with us, discuss issues, and work toward our common goal of having clear, understandable and actionable information. We hope the great work she has started in making the budget reviews a more data and metric driven process will be used by her successor as a base for continued improvement. Sarah will certainly be missed. We wish you the best of luck in your new role, Sarah. As discussed in our budget narrative, our FY23 year-to-date performance shows that we are slowly starting to recover from years of stark financial uncertainty brought on by the pandemic. Our FY24 budget helps us to continue to emerge from the pandemic's lasting impacts of extreme burnout of our nurses, physicians, and staff, a severe labor shortage, national hyperinflation, lack of capacity throughout our state for adequate, post-acute mental health and substance abuse treatment, access to care challenges, and the ever-growing need for healthcare services in our communities due to our aging and growing population. UVM Health Network continues to focus on our operational efficiency. A key evaluation for the UVM Medical Center, the largest partner in our network, is how we compare on a total cost basis to other academic medical centers in the country, such as the Association of American Medical Colleges Council on Teaching Hospitals and Health Systems Quarterly Survey. Over the last three years, the UVM Medical Center's expense for adjusted inpatient day has harbored around the 25th percentile, benchmarked against other teaching hospitals. Another evaluation of operational efficiencies, how the UVM Health Network compares on administrative shared services. In our response to the Green Mountain Care Ward staff on August 1st, we highlighted how we compare to Centelus benchmarks, which includes over 200 healthcare organizations throughout the country. Compared to that benchmark, the UVM Health Network is at the median for administrative shared service costs as a percentage of total costs. Being at the median shows great progress for our relatively young network, but we still have work to do to become more efficient. Through continued standardization of our systems, the use of robotic process automation, artificial intelligence, and other technologies, we will become more efficient. The budget review tool has attempted to get at operational efficiency performance through the administrative and general salaries to clinical salaries ratio. We highlighted in the August 17th letter sent to the board that there is an issue in that calculation as it relates to the UVM Health Network's administrative shared service costs and how they are accounted for in the cost report data. We hope that explanation and the adjusted calculation we provided, which puts the UVM Medical Center within the benchmark range was helpful in understanding that issue. The UVM Health Network has detailed our continued efforts to increase patient access, optimize our capacity, and strengthen our workforce, especially through professional development and advancement programs for current and new employees. Our FY24 budget as submitted will help us build financial sustainability into the future. As CFO, I'm extremely focused on the work within our networks control to stabilize our finances. I'm also deeply concerned about the financial impacts outside of our network, which are outside our ability to control. In last month's economic review and revenue forecast update prepared by Cabot, Rockler, and Associates LLC for the state of Vermont and legislative joint fiscal office. The report noted key reasons why it has been so difficult to hire permanent staff. The first is the record low unemployment both nationally and in Vermont. In June, the Vermont unemployment rate was 1.9%. It's hard for us to recruit and retain locally at that rate. Good news on that economic indicator which boosts tax revenues and reduces public program expenditures is bad news for us as an employer. Another factor making it harder for us to recruit regionally and nationally is Vermont's real estate value increases. Home price growth in Vermont is starting to recede from the highest rates we've ever seen, but prices remain far above normal pre-pandemic experience. We know that finding available housing is a major hurdle for people interested in joining our health network team. In the Burlington MSA, house price and growth is still 68% higher than prior to the peak. In late July, we shared with Director Limburg our credit rating agency's recent actions and commentaries regarding the UVM Health Network. As we have detailed in the last several budget submissions, our network's five-year financial framework uses rating agency A medians to establish financial metric targets, which is an objective representation of a financially stable health system. Over the last few years, the rating agencies had been clear that if the network did not start generating and operating even a margin of 7 to 9% and begin to replenish cash reserves, we would receive a rating downgrade. As we had alerted you, Fitch ratings downgraded us from A plus to A in June of this year. Credit ratings are an indicator of long-term sustainability and our network team takes this rating downgrade seriously. Despite our recent financial challenges, our rating agencies maintain high confidence in our organization and our long-term strategy. This past winter and spring, when board discussions of the upcoming hospital budget process and the FY24 hospital budget guidance began, there was a great deal of conversation about the two-year 8.6% NPR guidance for FY23 and FY24 combined. We clearly shared our opposition to the board's continued reliance on that approach. During those discussions and again later in the spring during the board's meeting to discuss VAZ's reconsideration request of the FY24 hospital budget guidance, the board reiterated that the continuation of the two-year NPR guidance was to create continuity over FY24 and FY23 and FY24 and that a hospital should submit the budgets they need for FY24. In the May 31st Green Mountain Care Board meeting, a quote from one board member, if a hospital's budget exceeds the NPR FPP growth guidance, the board will review the specifics and support for that NPR FPP growth provided by the hospital and its FY24 budget submission using the factors and criteria set out in this guidance. Hospitals listened and the FY24 budget submitted to the board on June 30th reflect the difficult work to build accurate budgets reflective of our community's needs and the access to care that Ramoners deserve. In the insurance rate review decisions and orders that were posted on the board's website on August 7th, the board wrote that insurers should assume the board will reduce hospitals requested commercial rates by 50%. We are not aware of any basis of fact or reasoning included in this broadly made assumption. We do not understand how the board could have already decided that they will have hospitals requested commercial rates before any hospitals had yet participated in the August budget hearings and before the board had deliberated on those budgets in September. We hope that assumption has not already been made and that we can count on your partnership in collaboration in this year's budget review process. Our FY24 budgets paint a realistic picture of what is needed to care for our patients today and into the future. We look forward to our continued work together to balance Vermont's healthcare cost growth and the solvency and sustainability of Vermont's hospital system. Thank you. All right. Thank you very much. I will figure out how to share my screen. So when we restrict this, so we'll just be focusing on UVM Medical Center initially. However, I suspect that some questions may be network-wide. So we'll be kind of trying to cover those along with the UVM MC results. So we see that for UVM MC, they are showing the highest MPR growth from fiscal year 22 to 24, as well as the highest operating expense growth at 15%. I think you spoke in your opening statements about some of the challenges in these operating expenses. And I'm just curious, what about your status as the Academic Medical Center? Do you think specifically is different for the operating expenses growth that you're facing compared to your other Vermont colleagues? Thank you, Sarah. So I'll get started and I'll probably pass to a few people, too, to just add probably Steve. So the one thing I think that makes the UVM Medical Center obviously unique compared to other partner organizations is that we take care of many more complex patients than we do at CBMC and Porter. We offer a much wider diversity of services. Those services that we offer, particularly the very high-level tertiary and quaternary care services are costly services. So they certainly will impact the cost growth more than what we would see at CBMC and at Porter. Steve, anything you want to add to that? Thank you, Rick. I would add that during the pandemic, when it was very difficult to do so, we opened multiple additional beds to care for Vermonters who needed us at great expense, mainly staff with travelers. And we still have many of those beds open because Vermonters need us. We also provide dialysis services across the state of Vermont. Our partner hospital, academic medical center in other states are not taking new dialysis patients right now at all. Adding to the great challenges, a couple of our dialysis clinics are almost 100% staff with travelers. But trying to reel those services in is impossible because it's keeping those people alive. Our budget increase has a lot to do with improving access to care. We've done tremendous work this year to improve access to radiology services. But a lot of that is by paying our people double time, overtime, Saturday clinics, and the same with the OR. We've made a major push this year to have our OR catch up on the backlogs. And we've done a lot of that by bringing in travelers to help us and by paying overtime and special pay. So our operating expenses are driven by increased access and utilization and caring for populations across the state. Thank you. Got it. And so I think when I look at your operating results over time, you mentioned it's a pretty historic ask. Can we see that, you know, we're not seeing a lot of change to margin or, you know, the cash reserves and I started on my notes in front of me. I think it's on page 27 of the narrative. It says that, you know, this is a small step towards kind of this recovery process. And I know that we're only talking about a fiscal year 24 budget today, but do you expect that these historic asks are likely to persist into future fiscal years? So we thought certainly this year that the ask was going to be lower than it is. Unfortunately, the continued use of and need for contract labor as Steve highlighted, we're doing it for the right reasons. We're doing it because we're trying to maintain access and trying to serve all the needs of Vermonters as the church here in Quaternary Center for our region. We support the Vermont healthcare system in a very unique way and for us to continue to provide that access definitely generated a much higher cost this year than what we were anticipating. As Sunny shared in his opening remarks, you know, even with the significant increase that we very much appreciated last year, you know, we still are 90 million dollars over our cost inflation estimates this year because we have maintained all that access that we feel that we need and that Vermonters need. Going into future years, I think two things. One, you know, we are starting to see inflation subside. We definitely are seeing that nationally for us as healthcare providers. What would the key there will be seeing a decline in that contract labor utilization, which we have started to see both in terms of full time equivalents and the rate that we pay for contract labor. We're seeing a fairly significant increase in, or at least we will see when new grads come off orientation here in the next couple of months, we should see a pretty big decline and maybe I'll ask Kerry to speak on that a little bit. So the anticipation I think is that costs inflation will start to subside and we were definitely working hard to impact that where we can so that rate increases don't need to be as large in future years. And two, I do think we still do have some government rate opportunities that could that could reduce those rate increases in the future. I think we talked about that a little bit during last year's hearing and some of the pursuits that we had in that space to keep commercial rates down. And I think we still have some opportunities there to impact that. But maybe Kerry, if you want to talk a little bit about the work that we've done to try to reduce our reliance on contract labor and some of the some of the positive signs that we see hopefully in the next couple of months. Certainly, good morning everyone. This is definitely the time of year that we see a bolus or an increase in registered nurses coming out of school and transitioning into practice. So the University of Vermont Medical Center, we have over 120 graduate nurses that are in the process of onboarding that will help the workforce challenges that we're facing with contingent labor. So it is a process and having those folks come on board are critical to sustaining the way we deliver care at University of Vermont Medical Center and all of the facilities in the state of Vermont and upstate New York. There's so there's the recruitment piece, which that's a part of we are working really closely with our academic partners to understand what what this year looks like next year and future in order to anticipate workforce needs and partner closely to ensure that that we are aligned related to the work we're doing and helping bring people into our workforce. In addition to that, we're working really closely with our own teams to understand where people that are employed in all of our facilities are interested in growth so that they can grow within the facility. So what that looks like is investment in individuals related to surgical texts and LPs and RNs and all of those things so we can support our own teams staying within our organization and growing to meet the workforce challenges. We have worked really closely with our teams to understand recruitment but we're working equally closely around retention because that's a critical piece. We want to bring people into the organization, but we will also want people to stay. So what that looks like to me is understanding the practice environments and looking at ways we can help support people find meaning and purpose in their work and satisfaction in their work. Some of the ways we're doing that is looking at programs like pathway to excellence, which outlines standards that are benchmarked and places across the country are utilizing. And we are working in that direction with all of our facilities and the network and that is going to take us time because we have strengths but we also have some gaps that we're working to close. That I think will help us with the retention piece and again that's going to take us time. So I feel like this year is a building year to help us move forward and we have targeted strategies to reduce travelers or contingent labor and we will continue to do that with our goals associated with recruitment and retention. Happy to answer any questions but hopefully I covered that. Yeah, thank you very much and that's probably a good segue into the labor piece. So we do see and I think there are more than that. So there's quite a few union negotiations that are likely to keep this trend kind of extending upward. If we use the 17 cost per ft and trend it forward. We see that you know you're north of that through fiscal year 22 and I suspect with some of this additional labor expense in the immediate horizon that that trend will continue so I have real two questions about this you've really hit about what you're trying to do to help improve recruitment and reduce these expenses. But I'm also curious about how you kind of factor that in when we think about the Vermont wide workforce. We know that the rates that UVM is paying and that you're kind enough to post in some cases can affect the market. So I'm just curious kind of how you think about how to balance that given the shortages across the whole delivery system. Thanks Sarah. So I'll get started and again I'll pitch to a couple of couple folks. So one I think just to make a point on the one of the items you raised that may be driving this up, Sarah, which is union negotiations. I think we want to be clear that actually that we are philosophy is to pay all our staff at an appropriate market rate. And we don't view union negotiations necessarily having an outsized impact on the rates that we pay. We try to be very consistent in that approach and that we're constantly looking for where our staff are compared to the market. And we we essentially treat that in our philosophy as we treat that equally, whether you're represented by a union or not. You know, we're constantly looking at that data in terms of where this is headed. We, you know, even what you're describing in terms of the impact that that we have on the on the greater Vermont wage base. We actually find in some of some of the roles there are other industries in Vermont that are actually pushing, pushing us. So I think it's happening in multiple directions depending on the on the roles. I think that we'll find as well that, you know, the benchmark data, particularly with the significant hyperinflation that we've seen that it's going to take a while before the benchmark data actually, you know, catches up with what's transpired over the last over the last year or two. So with that, I think all the presidents are probably able to to kind of round out our philosophy and where we the impact that we that we have on the on the wages of Vermont. So I'll start with maybe I'll start with Anna. Thanks, Rick. Good morning, everyone. So just to put a finer point on what Rick has already mentioned, we are committed to staying competitive in the market. And a reminder that our market isn't just the state of Vermont, it's also regional and in some cases national. And so we are committed to staying competitive on why because we really have to to maintain the services we're providing. As Rick has mentioned, we are using a lot of contract staff. I don't see that changing. I'm a nurse. We saw this nursing shortage for years before the pandemic and it certainly was accentuated with the pandemic with the great out migration of individuals from health care to add to what I've heard my colleagues say around workforce pipeline programs. I think our strategy to build those programs, which at CVMC we started in 2018, and we've graduated over 98 LNAs and almost as many LPNs RNs in that period of time is to really grow our talent locally. I think that's critical. But we need a partnership in that space, not just within health care but across the industry to Rick's point with our entry level position. Our market is not just health care. We lose people every day to other industries in the state of Vermont. The housing shortages are impacting our market as well as are the ability to have either daycare or elder care depending on what phase of the life continuum our employees are in. So a number of challenges in the workforce shortage space, and we're hoping to continue. Ms. Nunez? Yeah, I'm sorry. I'm sorry to interrupt. I just Dr. Merman's been recused from CVMC. So if you guys don't have an objection to him participating in this and hearing this, that's fine. But I just wanted to flag that that he, you know, this seems CVMC focused. I just wanted to put that out there. It's your choice. If you don't have an objection to it, fine. But I think my, my comments in this space are generic. There's some specificity to CVMC that Dr. Merman is well aware of. And so I'm comfortable continuing just sharing the comments related to market. Unless there are other objections. Okay. So again, just wanting to round that comment out by saying the market is driven by a number of factors and all of those we're working on to broaden the perspective. The programs we started at CVMC are now being embraced and across the UVM health network. So those programs are serving as launch points for the similar programs across the network again to address the pipeline issues workforce pipeline issues that we've experienced. Thanks. Thank you, Anna. Sorry, I actually lost track of the fact that we were doing this in order to so sorry that I called on a on on you, Anna, but if it's okay with the board, there are some some instances, I think that it wouldn't be helpful to get other person's perspectives on this as well. So, Rick, Rick, this is sunny. I just thought I just. Respond to Sarah's maybe question more globally. And I think you're right, Sarah. I think whenever there's a union. Involvement at a very global level. Wages and costs go up. Those are going to increase our health care costs. We just think it's the cost of doing business in Vermont. But that's the reality and I think that's what you were getting at. And we try to anticipate that because we. And I'll just echo what Steve and Rick said, which is that we. Try always to pay a very fair wage. That's a market wage. So we don't anticipate that those increases that come will be significant. Because we're already there, but you're right. Okay, anything else you want to comment on for this topic before I scoot along. Steve, anything you want to add. Thank you, Rick. I'd like to make a couple of comments. So UVM medical center is in the midst of negotiating our 1st contract with our support staff right now. We're hoping to have that contract done by October. And we will restart a new contract negotiation with our nurses in January of 24. So we do have 2 big upcoming contracts. I will tell you that it's in the best interest of the medical center and our employees to have fair, strong contracts. It helps us with recruiting. It helps drive down traveler numbers and it's predictable. So I think the major difference between negotiating with the union and keeping everyone at market is the union people we negotiate for typically 3 years. And we get them to market in the start of the contract and then give them predictable increases over the next couple of years to help manage what our costs would be out in the out years 2526 and so on. For our employees are not in the unions. We adjust in real time, but our philosophy is the same to pay everyone at market. So I really see it as a difference of predictability, but fair strong contracts are good for our staff. They're good for the hospital. And so they're good for our patients. And so we will continue to work hard with our unions who are our employees to have good strong contracts. Even when it's difficult at parts and negotiations at the end, it's good for all. And the last thing I'll say, Sarah, is that the cost of everything is going up right now. And we hear from our employees all the time that the bagel shop down the road is paying more than some of our food services staff. And so we have to have a wage that is competitive to have enough people here to do the work that we need. So we're not using expensive travelers for that work. Thank you. Thank you. And when I move here, just kind of again, look, you forgot what screen I'm operating on. Pardon me. When we look at the changes, I'm a nerd, I call it the covariance, but how utilization adjusted discharges are changing as compared to operating expenses and net payer revenue. We see that the operating expenses from 21 to 22 really shot up, but utilization was more in line with kind of a typical pre pandemic craziness amount. So I think you've talked to, you know, why that trajectory is pointing that way. I just want to give you an opportunity if you want to flag anything else about that, that growth and where you're thinking of it for 24 and beyond. Yeah, I think I think Sarah we hit on that fairly comprehensively both in what Steve share and the fact that as as the as the tertiary and quaternary and safety net hospital for the for the region. We've maintained a significant amount of access for both services for transfers, and even in Steve can probably talk a little bit about transfers as well that we haven't always been able to meet the needs there even with all the increased costs that we've incurred. So the that trajectory is is certainly due to us trying to fulfill our mission of being there for for for monitors. Steve, I don't know if you want to say anything else. I think you get on these fairly fairly well earlier. Sarah, when we presented our budget update in December of 22. We told you that we were declining about 5 patients a day for transfer. And since that time through a lot of work on access and improving accessibility because that's been a major focus of us over the year 23. I have the data and in July of 23, we declined 68 patients total compared to. 159 in December. So about a little over 2 per day and most of those patients we may decline on Thursday night, but take them Saturday morning. They're not permanently declined. So we made a lot of done a lot of work to improve access. We still have great challenges with getting people discharged in a timely fashion every single day we have between 30 and 50 people here who are ready for discharge. So that drives up the cost of care, but we're not being reimbursed for that care. But we have made it done a lot of work on that. Thank you. And then Burlington HSA and the University of Vermont is going to look very different in these indicators your tertiary care facility. So we see, you know, quite a few discharges coming from outside your HSA. We also see, you know, one of the highest proportion of commercial patients in the Burlington HSA and we see that a heavy proportion of those dollars are staying within the HSA. I know that you've raised some concerns about the completeness of the all pair claims database in reflecting this accurately. And I was just curious about the populations that we're missing, which are going to be out of state patients and those who have self funded insurance, you know, what you think might be different about what who we're missing. That would change some of what we see without them. You're asking that question, sir, in terms of the context of how this compares to other hospitals or. So I'm only going to see Vermont residents. And I'm missing a fair portion of the self funded market and I'm not seeing the folks that are coming to you from out of state. I never saw people without insurance or, you know, like federal employees, military. When I look at vcures pre and post go back, which is when we lost the self funded market it looked like the PMPM of the population left went down, and that the utilization rate went down substantially so I totally by we're missing a bunch of you know what what other records are going to show. So I'm just wondering how you think any vcures results might be different if we had a more complete sample of the claims like what is it about the out of state patients and or those with self funded insurance that you think might be different or that we might be missing in that data set. So at least one thing I think that we've that we've seen is that the out of state data data would show a higher acuity of patients if they're coming here from out of state that's. And you're looking at the patients that essentially are around the UVM Medical Center again the UVM Medical Center is unique in that it's both the community hospital for the area and it's the tertiary and quaternary care referral center for the region and so the out of state data. And that's one thing I think that you would see is a higher acuity if that was included in terms of the self insured business probably might. We might actually have some experts here on the on the call that can that can chime in on this but I don't anticipate that that would have a significantly I don't think it would paint a significantly different picture than what you're seeing you're seeing here. I don't know if there's anybody else that wants to wants to add anything. Rick this is Kelly I can just add if that's okay with you. Absolutely. Sarah I think you hit on the out of state and what Rick just said the tertiary. We do serve, you know, out of state, New Hampshire and New York Medicaid, along with other medicaid. And that would certainly influence the patient the picture here. And again, that could be, you know, we have had mass Medicaid for, you know, various reasons of requiring tertiary care here so it really depends on people who have migrated into this state and the coverage they've maintained, either traveling, or again our close partner so I do think the out of state would create a different picture. Okay, thank you. So we talked about this ratio and you have a robust response about kind of what you think. Sal. This is Tom Walsh. Sorry to speak out of out of turn for a moment but I wanted to just ask you a couple questions about this tool. If I could, the data that it's displaying is the data that we said we were going to use during our guidance is that am I understanding that correctly. Yeah, everything in here was in the guidance. Yep. Yeah. Yeah. And there's no analysis that's going on here. Right. There's no T tests or a Nova regression or algorithms being used to analyze any of these data. This is a display. Correct. Also, yeah. So we could have done box. This is box pot box plots with whiskers. We could have done bar charts. We could have done tables. It's just a means of displaying the data that we said we were going to use. So correct. Okay, thanks. So when we look at the academic medical center, compared to the list of associated medical colleges we can also further filter that so we're just looking at rural facilities that were included in it. That subset. We also made sure to add all of the comparators that UVM identified. I believe there were 12 other hospitals that were in the unique position of being both a community health facility and an tertiary court, you know, advanced academic medical center. I'm just curious, you know, why you think that's such a rare situation or, you know, how, how you approach that when you don't have a whole lot of people to compare yourselves to, like, how you kind of approach that when you're trying to, you know, see how good a job you're doing on stuff. Yeah, it's difficult and we, the way that we, the way that we use the data as we look at, you know, obviously multiple sources to try to triangulate around how we're doing in certain areas. So we shared with you this intelligence data, for example, in terms of administrative shared services. CMI, you know, that we use visit data to essentially try to give us a sense of where we're at. We've had external evaluations as well. So not relying just on kind of static benchmark data that's out there but actually have somebody, you know, have an organization come in and tell us, you know, is our CMI appropriate for just as an example is our CMI appropriate for, you know, the community of the patients that we have. And so we triangulate using multiple pieces of data. The CMI is one that we know. We included a little bit of detail in this and our response that we know that we've struggled in this, in this area for some time. We're always going to look, the UVM Medical Center is always going to look lower than a, than a pure academic medical center that you would find, you know, in Boston and New York that has outlets for their, for their non acute patients. They have outlets for, because they don't also serve as the community hospital for their, for their region. So CMI is always going to look lower for the UVM Medical Center because of the unique role that they play. But we've, through benchmark data through engagements, we know that we're, we're, we're, we're below where we should be in truly representing the acuity of our, of our patients is just again just as one example. We've tried to, to, to improve in that area to truly reflect the acuity of our patients through education, through process improvements through many different factors. But the key, the key thing that will change for us is this system actually we just finished the two week implementation last week, which is iodine, which is going to be a significant game changer for us, which when we started down this path pre pandemic to improve in this area, you know, we, we had seen that most of the most, most of the organizations that had had higher CMI, particularly academic medical centers had some type of data mining system that they were using to kind of reduce the, the reliance on a, on a human being combing through reams and reams of EMR data to truly document the acuity of the patient. So that's again, just as one example, we don't lie on one sole piece of data for it, you know, to determine how are we doing in this in areas, you know, rating agencies, for example, we use those that tell us how we're doing financially. So we use multiple sources to try to, to try to highlight the improvement opportunities that we have. So you must want to say something. Yeah, just a couple of things Sarah, thank you. This clearly our CMI's are not a real representation of the complexity of our patients. That became obvious to me as I walked around. University of Vermont Medical Center and I saw the coding. We've, we've actually brought in some consultants that I've used when I was in Boston. They've taken a preliminary look. And we're going to really truly implement this moving forward. So they really expect the CMI to go up. As we more accurately document. And capture the complexity of our patients. So the question is how much will it go up? I don't know. But we're going to find out over the next year. So I think we as an organization have been reticent to put dollars into capturing the coding better. But it is important. It doesn't change care. It just better captures our complexity and, and our reimbursement. So it's important. The other thing is having having worked in. Academic medical centers in Boston again. That were situated right in the heart of the city. Yet we're not the community hospitals in those areas. The University of Vermont Medical Center plays a really unique role. And doing both of those. So we see the reflection of that as well. Rick, can I have one last thing? So thank you, Rick and Sonny. What I would add, Sarah, is that we participate in the vision database. Which basically is all the academic medical centers across the country and their quality and safety database. And there are other peer academic medical centers that are similar to us. There's no two that are exactly the same. And so for issues that we track, such as. I'll just give a quality when we've been working on how many patients are transferred to the academic medical center and then die within 24 hours. Because you could make a case that maybe those people shouldn't have come. All rural academic medical centers that are in our group have a high rate of that because we're typically surrounded by small hospitals without a lot of resources. And the patients who are very sick would like to get a consult by neurosurgery or the cardiologist or something like that. So those patients come here in evaluation and then oftentimes are determined that we can't do anything else. We're trying to figure out ways through telemedicine to our transfer center to help keep those people local. So they don't have to go undergo that transfer. We're working with our partners across the United States on issues like that on issues like case mix index on issues like how to make sure that we can be both the local community hospital in the academic medical center. I will say as a practicing physician for 30 years. I always loved the fact that we were both our community hospital in the academic medical center. It makes us very special. And I think it's one of the very unique things about UVM medical center. Thank you. Sure. Can I just go back to Tom's point? Yeah, sure. Because I might I might have been confused. And this is like an internal question. And if I shouldn't be asking it, you should just tell me to be quiet Rick or somebody else. When did we actually get the guidance. That we're seeing today. I was adopted in March of 2023. And so we got the guidance in March of 2023. Yep. Yeah, the data before. Yeah, that this actual tool, I believe was put out on was it August sometime in early August, right? Sarah in terms of the actual data that was that that was behind the guidance that was created in in March. This the summary display here. Yep. That's that. Thank you, Sonny and good morning. But that is my point. This is a display. We could have shown just a table. We could have done pie charts or bar charts. This is a box plot with whiskers, but it's the same. So there's no change in what we asked for in guidance. It's just the way that Sarah being Sarah figured out a cool way to show the data. But there's no new analysis that's going on. And Rick, if I could jump in member Walsh, we strongly disagree with that characterization. The data that sits behind this tool was presented to us for the first time on August 1, and we don't believe it conforms to the guidance that was adopted in conformity with the statute and with the rules back in March. We did not intend to spend valuable time during the budget hearings debating this issue, but having been raised, we do feel it's necessary to put on the record, our view of this tool. I understand the point you're trying to make. This is simply displaying the facilities we said we were going to display. It isn't, but I'm not sure again that it's valuable for us to have that debate here. Fair enough. Okay. And so in exhibit nine, I believe it is you list a CMI of 1.8. I presume that is for the full patient panel, whereas this would be just Medicare. Do I have that correct? I believe that's correct, Sarah. I don't have the numbers in front of me. Okay. I guess my question being, do you translate the commercial severity into a Medicare MSDRG to get that CMI or because I know that not everyone pays that way commercially? Yeah, we definitely do calculate an overall CMI for all of our patients. So, yes, we do a calculation to get to that CMI for all patient groups. Okay. Thank you. And then as you already discussed, there was a substantial change in your cash position between the fiscal year 21 and 22. And I'm just, if you could speak to kind of how you evaluate the use of cash resources when times are lean like this, what goes into that kind of decision making process for you? So the biggest impact there has been in our capital spend. So this really started at the beginning of the pandemic where the capital approval and request process was completely centralized. So historically, the way that we've managed capital is we've created allocations for routine capital that each partner organization would have, and they would make their determination with some guidance from leadership on how they would prioritize the needs. But as long as they stayed within their allocation for that given year, each partner was allowed to spend within that pool. When the pandemic started, we had to centralize that process so that every capital request, no matter the size, had to be reviewed centrally to ensure that we could truly afford to proceed with that capital purchase. So what it's done, and all of that was in reaction to try to conserve our cash and try not to have it drop below where it already was. What that's done is we focused on really the break fix items. So if something was getting old where it was on the verge of potentially failing or safety needs, those types of things, that has been the focus of ours for the last few years to try to keep this cash balance from going down any further. Steve spoke to that a little bit in his remarks. And it's also, you see the impact of the dynamic of that backlog of capital that we built up over the last few years when you look at our financial framework, even though we, if our budget is approved and if all our other assumptions hold true, I mean, we're able to generate an operating EBIT of margin close to 7%. You can see that in the first couple of years, so 25, 24, 25 cash really doesn't grow by an amount that you would expect it to grow if you're generating that kind of margin because again, we've got to address this backlog of capital that has been built up over the last few last few years. Okay. And so the next exhibit has to do with cost coverage. So for EVMMC, we see, you know, after these are adjusted with Vermont All-Pay Relative Weights, we see, you know, some relatively higher coverage of the Medicare allowable costs for outpatient versus inpatient services. See some noisiness around the Medicare reimbursement. And we would expect, I think, with the new Soul Community Hospital designation that that outpatient line would get a little closer, go north a little bit with that 7% bump on that. And then again, this decline on the cost coverage from Medicaid is on that downward trajectory. You did spend time in your narrative commending them for the rate increases they were able to realize for this year. So we appreciate you're reflecting that in your budget. So, you know, as you've said, you don't have a whole lot of comparators, but we do have somebody next door. We have Dartmouth has a higher relative payment and a higher relative cost than you for the commercial population. So that's in my judgment probably due to the limitations of our data set. We're getting the people that travel to Dartmouth for the acute care and we're missing the people that are coming from New York to get that acute care. So we would say that, you know, that's probably part of what makes that comparison tricky. However, I think in this point is made quite clearly that that Medicare payment on a per case basis is much higher at Dartmouth because they have the higher wage adjustment historically and some other differences in their Medicare reimbursement. We do see that your, you know, relative cost coverage is lower. We do have some suspicions that the inclusive population based payment might be making that look a little more dramatic than it likely is. So that that it's in there, but I don't think it's all in there. And then again for Medicaid, we actually see a higher reimbursement at Dartmouth per discharge again that's probably measuring acuity versus anything else. However, on the outpatient side, we see that your costs are lower than Dartmouth substantially in that your payments are a little bit higher. I'm seeing a little bit more apples to apples again with that soul community hospital bump. I would expect this payment to get closer to the cost. And then we see, again, similar values between you and Dartmouth for the Medicaid population. And just to click over to the RAND data on this topic, you know, I did add a. I'm sorry. I'm sorry. It's time again. If we could look at the Medicare again for a second. I guess the wage adjustment is different for New Hampshire because of its proximity to Boston, but probably the biggest difference is the difference in teaching payments as a component. That's based on the size of the medical school and Dartmouth medical school and teaching component at their hospital is just much larger. So they receive a bigger payment from Medicare for that. Just want to be clear about that. Okay. Is it possible to look at the actual cases? The differences in the kinds of cases that go. Yeah, we have a lot more detail that we we have it for grouped by you know DRG and by APC for certain services. If that's helpful, we can look at that. We did look at it back in October of 21 was the 1st time we did this analysis. Were you able to see differences in the kinds of cases? Dealer juice off the top of my head. I wouldn't trust my memory, but I'm happy to kind of share the complete data set. Yeah, I mean, I think that goes back to. When Dartmouth can provide the care. That they can see where there's value for their providers. In reimbursement. So it's not unusual for other hospitals like the Brigham, for example. To have more physicians. And more services. Available for the cases that they can make more money. If you don't have to provide for the whole community. Then you can take you can pick and choose where you're going to have availability. It's a difference between what University of Vermont Medical Center has to do and taking care of everyone. And specialty hospitals or consult hospitals. That can tailor what they are going to have available. I'm not implying that Dartmouth is deliberately doing that. It's just the nature of when you're not having to cover everyone, what you're able to do. So I think it's really important that when we make comparisons. That we really have to look at the specifics. Yeah. Thank you, Sonya. I think that's a, it's a point well taken. And the point I was trying to make is was simpler. That the Dartmouth medical school. Is larger. They're more students. They're more residents. And the adjustment that Medicare makes for teaching facilities, the additional money paid. Per discharge. For teaching is higher. The larger the school. So because Dartmouth medical school and the resident has a greater number of residents. Greater number of students. It's payment from Medicare. Will be larger. So it's not just the wage component that's been talked about. But there's the teaching component and that that's where that comes from. Fair, true. Sorry. Absolutely right. Yep. Great. So the Rand study has, you know, more global, you know, national coverage from their sample. And we did add the teaching hospital filter as, and so when we do that, we see that, you know, University of Vermont is at the median from 2018 to 2020. Dartmouth is kind of between the 25th and 50th percentile, but very close. However, an outpatient, we see that, you know, Dartmouth is in a similar range close to the 25th percentile and UVM is above the 75th percentile. So I just had a couple of questions. One is, you know, we've heard that the Green Mountain Care Board has been like substantially limiting the amount of commercial rate that the hospital feels like it should get. But I would expect if that were true that you'd be lower on this distribution, like have a lower relative reimbursement. So I just was curious if you, you know what, just curious what you'd say about that. Yeah. So this in getting into this data, Sarah, to be honest, I'm a little bit kind of over my seas here. So I, and I don't know if we've got the experts that have really dug into this to understand the data a little bit more closely. And even if, you know, even if commercial rates are lower in Vermont, we, you know, we don't know. It's hard to tell exactly, you know, what the, what that data tells. So I don't know if we actually have anybody on the, we have somebody on our team that really kind of dug into this data. Let me just see if there's somebody on the. Actually, you might have to get back to you on that one, Sarah. Sorry. Okay. And then as part of the findings in rate review, at least for 21 to 22, it looked like the Vermont hospitals got twice the rate of the non Vermont hospitals. So I would expect that you would probably be higher in this distribution if you were getting higher rates than these other peers. And it just got me to think like, I know how I see this as a regulator, but from a hospital's perspective, where's the like right place to be on this sort of distribution, like for relative commercial reimbursement. Again, the, it all depends on where Medicare and Medicaid rates are. So I think you just showed that the, that the rates for for the academic for Dartmouth on the prior slide, you know, there's differences there as well. So the ratio of commercial rates to government pair rates factors into this as well. And as a regulator, I think, you know, what you need to look at is is the is the commercial rate essentially justified based on the the pair mix that we have here in Vermont. So I think for us, as, as, as we've done in the last several budget hearings, we've been very clear on what drives the commercial rate. I think the transparency around that is unlike anything. I think that you would see in any other organization. We clearly show the cost inflation that we are projecting for the for the coming year. We show the expected rate increase that that we'll get from Medicare and Medicaid. And the difference is the commercial rate increase that we need to cover that, that inflation. So these benchmark data, that's one piece of the puzzle, but we share in, in, in very clear excruciating detail how that commercial rate is, is generated and hopefully, you know, that helps the the board and making its decision on whether or not it's an appropriate rate or not. Okay, that was all that I had to your foster can turn to board questions. Yeah, thank you very much. While we just take a quick 4 minute break and then we'll start with the board questions. And before we do that, I just wanted to flag. Just for the record that member homes wasn't able to be here today. But she will watch the, the tape and my anticipate will be participating in deliberations. She might be able to join later, but if not, she will watch the tape and participate in deliberations. I think. And so we'll take a break till 920 and then we'll have board questions. Thank you. It's 920 and we can resume with board questions. Are there any board members of questions for UVM? I'll go ahead and kick us off. That's all right with you chair foster. Please. Okay, so thank you and hi everyone. Nice to see you this morning. I'm just to give you a bit of a roadmap. I'm going to start with some follow up questions to the discussion. So far this morning switch to my questions from the materials. And then I have some questions that board member homes sent along that I will ask on her behalf. So, in terms of the discussion so far this morning related to. UVM moving into recreating some of CVMC successful programs for growing their own. I wonder if you could speak to that a little bit more. Quite frankly, it's always been. Something that I've wondered about in terms of how the smaller hospitals seem to be quite successful with these programs in terms of traveler reduction. Obviously, you may have some contracted staff that are. More technical, but certainly. I would think that your existing staff, you would have some that would like to move into more technical roles. So, could you speak to why that's been slow to get started and how long you would expect it to be. Really up and running. So I'll get started and I, and I'll, I'll pitch to Steve and maybe even carry to speak to that, Robin. So I think there, there are some pretty significant programs that the UVM Medical Center has actually implemented in the last several years to try to grow our own and create career ladders for for staff. They've also funded and helped support organizations outside of the UVM Medical Center to keep them afloat so that they could continue to provide the resources we need. The respiratory tech program is an example of that that, you know, without our support, you know, that that pipeline of folks would have would have dried up for us. So I know Steve, if you want to get started and then maybe carry can talk a little bit about what's happening on the on the nursing side. Robin, I would tell you just historically, prior to the pandemic, the academic medical center didn't have huge challenges, filling roles that there were some hot spots, but in general, we had a good pool of applicants for most positions. And the local colleges were actually helping us with many jobs. We had, for example, Champlain College was giving us respiratory or x-ray tax. And through the pandemic, we've seen that our pipeline dry up somewhat. And so we do have many programs going on. So, for example, you just, we just announced last week, our respiratory therapy program, which is in partnership with Vermont. Colleges where we're helping, we're doing a pay to work program where people go to school for two years, continue on with a full time job at the medical center or in the network. And then at the end of the program, they commit to working within the UV health network for three years. We've been running an MRI apprentice program for some time at the medical center where we take medical assistance and train them to be MRI techs. We have a lab partnership with SUNY, New York, where we've launched a two year medical technologist degree, which is not available in Vermont to help train med techs, which we desperately need. For nursing, we have many programs. For inpatient nursing, we have the senior practicum where UVM students who commit in their fourth year to working at the medical center, we help cover their fourth year tuition. We have an LNA to LPN to RN program, and we have a number of other outreach programs to high school students to bring them on. So, while we probably haven't had the same challenges of the smaller hospitals for as long, we've learned from them, we've built quickly, and I do believe that the pipelines that we've built will serve us well. And I do think you'll see us do many more over the next couple of years through everything in our power to have a stable committed workforce that's here and can get good jobs here. And then once we get them over a long career can do multiple different jobs, work up the career ladder. I'm sorry, one I wanted to mention is we have a good OR tech program, which is a real big need for us. And so we have an OR tech program to also train them here at the medical center and the OR techs are training here going out to CVMC and other hospitals in the network. And I think if it's all right, I would add Stephen Rick have highlighted a number of things. The only thing I would add is the strategic focus on workforce development and partnership with the colleges in Vermont. And a recent example of that is VTC and Norwich partnering to look at how we can support pipeline across a trajectory of years with our own employees and all of the Vermont facilities to bring on our own team members and grow them in place. And so that takes a concerted effort and a coordinated manner to do that and to plot out over subsequent years, not only how we grow our own employees into LPNs registered nurses individuals that have bachelor's degrees that want to go to an accelerated RN program there's a number of ways to help support our own workforce. In addition to that, the colleges are really struggling with faculty related to these programs and so we're looking at ways to partner with them to support the practical learning pieces within our own institutions to support the growth of our workforce. Thank you we certainly have in the past heard the challenges around the faculty component. So thank you for that. And I know you mentioned earlier that you were expecting about I think it was 120 new grads. Overall, do you have kind of a ballpark estimate of how how many staff, these programs that you've implemented or in the process of implementing might touch. Don't have an exact number Robin but we can follow up with that on all those on all those will take a note and we'll be back to. That's fine. Yeah, I don't need an exact number I'm just trying to get an order of magnitude. So I can have a sense of how it compares with current workforce and travelers that's why I'm asking the question. Also, you had mentioned working on retention and some of the programs that you have in place for that. Would it be possible for us to get a sense of your retention rates and obviously you may not have that, but that could be another follow up if that would be best. Absolutely, I think we can do that and follow up. Okay, great. All right. So I wanted to turn now to the phso. And thank you for answering some of my more detailed questions that were asked in writing around the phso and its connection with the blueprint and how that staffing works. I do have some additional follow up questions. In your answer to the quest staff analysis questions that was submitted on August 1st. And this is on page 11, you indicated that part of what the phso would be working on would be delegated arrangements with commercial payers to further avoid duplication. And could you speak a little bit to what those arrangements are and which payers you may be collaborating with? Jessica, if you're able to answer that. Yeah, I can answer that. So the thought there is that we would be able to do such things, not that we have discussions underway. And that part of the organizing of the work in that way is to think about how we could continue to transition to more value based payments and work within the phso. Got it. Great. And do you have any thoughts on, on sort of which commercial space you might move into 1st? Should you be successful in negotiating that with a commercial payer? I think we remain open to all transitions to continue value based payments, but we don't have a particular order of operations in terms of which payers we can tend to seek first in that Kelly, unless you have any. Added detail there. I think your spot on Jessica. Thank you. Also, in that same part of the narrative. You've, you indicate, and this is towards the end of page 11. Certainly while one care makes up a significant portion of your networks attributed lives, you have other value based contracts that require industry standard performance analytics. And could you speak a little bit about those contracts? If that is something which requires confidentiality, if you can just note that and I could include that as a rationale for an executive session. So I can speak broadly to it and then if you have more specific questions, I think we can, we can think about how to best answer those. And in terms of arrangements that we are currently in, we have a number of Medicare advantage arrangements and those include value based components. And then, of course, we have our own internal population. So our own self-insured population. And that's another population for us to think about as we approach value based care. Great. I'm sorry. Go ahead, Rick. Just checking to see if Kelly wants to add anything there and if it's something we can share if we have to wait for a second obsession. Yeah, there's a variety, but there's some other smaller programs in addition to MA and so I prefer to discuss that in executive session. Happy to do so. Okay, let me just make myself a note. Because by the time we get there, I don't want to have forgotten. Okay. Thank you. Also related to the PHS. So I just wanted to talk a little bit and get a little bit better understanding of the graphic that you included on page 12. It looks to. So this graphic tries to show care management approach before and after the PHS. So I believe I was a little confused about the governance and eligibility components being being included as one of the functions that was centralized because I would, for example, with the blueprint have said that the governance for the blueprint was at the state level with the blueprint executive team. So could you just speak a little bit more qualitatively about how that transition, like what changes have resulted from that transition? Specifically what changes in terms of the administration of blueprint funds or overall in terms of the way that that case management is delivered. Certainly, I think both actually, I do have some follow up questions on blueprint specifically. So in terms of case management, so that's the governance referred to on this slide and everything referred to in the now section is referred to internal to the network now. So prior to that prior to this, you had individual components that were separate and by bringing it all together within the PHS. So we have we're able to standardize the work across the network and the system and provide best practice sharing and collaboration for case management and also think about care management systematically. So that's what's referred to in terms of governance there. And then in terms of the administration of the blueprint funds, similarly, again, talking about internal but also thinking about our responsibility within the system to the HSAs and to the distribution of funds. And so we're rather than thinking about that in component parts, we're able to think about that together within the PHS. Okay, great. So, one of the questions that I also had is in the metrics that you provided related to care coordination expense as a percentage of total expense that was listed in the comparators as 0.72%. So, do you do you have any sense of what's typical with other hospitals in terms of this type of care management structure. So, for example, is the PHS so structure typical, or is it different from what is typical in the industry. If you know. I can speak from my own experience in another health care system in the greater Boston area. And so I would say in terms of the cost, we were definitely within benchmark for our knowledge of what's knowledge nationally. We can look more specifically and give a more specific answer if needed in terms of the way case management is delivered in population health services and value based services. More and more programs are looking like ours or have already built structures like ours where you're thinking about centralizing the systematic structure and then providing case management services across the organization versus each individual organization trying to do that separately. And part of the reason why we do that is because what we want to do is align the incentives, align the contracts and align the payments so that we're all we're delivering it in a consistent manner across the system in conjunction with partnerships with payers a variety of payers. And that I would say that that's consistent for other population health management programs as well, not just case management. Okay, thank you. In terms of the structure specifically around the blueprint. Could you speak a little bit to how the staffing works. And we can keep it to UVMMC for now. And I can ask about the other hospitals later. I hear you saying there's some economies of scale to central administration. I'm wondering about individual case management FTEs that are assigned to the Burlington HSA and how those where those FTEs are located and how they interact with the community. All care management FTEs, including those that are funded by the blueprint are located throughout the practices. So some of that is direct embedded. Some of that is virtually embedded, but their, their case management teams that are provided to our practices and to our providers. And so while their employment structures may be more centralized, the actual work that they do is embedded in the practices and that's to provide consistency for the practices and for the providers because case management services also support providers as well. And the work that they're doing. So that's their, their, their situated across the network appropriately given the size and scope of each practice. Got it. And then the follow up related to specifically to the Burlington service area in the follow up questions that you submitted recently. I think it was Tuesday. Or maybe Monday you indicated that for the blueprint HSA, the UVM practices I think you said were about 37% of the HSA and that there were 25 community practices, independent practices that were also interacted with and could you just provide me with a little more detail about how that works. Like how, whether the funds flow are going directly to those practices in the case of the practices in Chittenden or in the Burlington HSA. The funds flow and the people. For the practices that are outside of our system where we use the appropriate distribution methodology and those funds flow directly to those practices. Okay, so they, for example, might be hiring their own case manager or embed whoever they feel like their practice needs. Exactly. Okay. Yeah. So the work that we're doing is for the network only for network resources only. Yeah, in, in, I believe that's just in Burlington. Right. So in Barry and Porter, there was some discussion in the follow up questions about shared practices, which we can talk about when we get to those hospitals. Just one second. Right. So turning briefly to the ACO. So you indicated in your follow up that you intend to that UVM intends to participate in the one in one care. Is that for all of all three programs? Yes. Yes. Okay. Thank you. And then shifting to pharmacy. Can you speak to how your trends in 340, 340 b rebates, how they've changed over time fiscal year 21, 22, 23, and whether you expect a growth in 24. So let me see if we've got somebody who can answer that specifically. I think we have West on the. Call we swear and then sorry we did swear and then West. Are you able to answer that? You may be on mute. Actually, he looks like he's not on Robin. So we can, we can follow up on that item. So from 20 to 22 the rebates you're looking for the trends. Yes, please. Okay. Okay. Shifting to utilization. So in your discussion of utilization in the narrative. You specifically mentioned. Or sprints and also some access initiatives around radiology to increase access, which is great to hear. I think we all know there's there has been some struggles with access issues. In Vermont generally, but particularly at UVM. I'm wondering if you have other access initiatives that you haven't highlighted either in your narrative or this morning that you could speak to and or your plans for access initiatives. Moving forward for fiscal year 24. Thank you Robin for that question. I'm sure he's on here. Brad, would you like to speak to that? Yeah, sure. Good morning. So I would highlight and I believe this came back in answers. Maybe in some of the other questions are electronic console initiative. So this is the ability. For a provider to ask a question to a specialist. So those numbers continue to expand. That's a key initiative in fiscal year 24 that we're looking to assertively expand. And then also some key investments in provider recruitment. And really, you know, what this comes down to is really some staff. And some better systems to make it more efficient specifically around sourcing. So being much, much more proactive about sourcing these requirements rather being passive. And in terms of the E consult, I know in your narrative, you did speak a little bit to how that impacts revenue for both the referring or the consulting providers and the specialist. Can you just go into that in a little more detail because I want to make sure I really understand how that translates into dollars. I'll take that one as well, Brad. I'm not sure I'm the ultimate expert on the revenue side of that. I don't know, Rick, if there's someone else on the team on the call. So you're looking for the impact on the revenue from both the specialist and the primary care perspective, Robin. Yeah, yeah, because certainly you can see how that would increase access to specialty care. I just don't understand how that then translates into utilization and MPR. Yeah, so the way that the way to think about it is one, it definitely on the specialist side, it creates more appointment slots. If there are issues that are being taken care of in the moment with the primary care provider, so it creates access availability there from the primary care perspective. I'm not sure there's really a revenue impact necessarily, but certainly they're getting through their visit in a complete way. They're not having to wait for the consult or the guidance to come back from the specialist. So from a revenue perspective, it would really be purely on the specialist side that it increases the access for them to see more patients. So Rick, if I could add just a couple of quick points. So Robin, we don't bill for the consults, but we have some good data that shows that 30% of the consults don't require a specially visit afterwards. And so that opens up 30% of visits for patients who do need to see the specialist. That's the big opportunity here. So the specialists like it because the people that are coming to see them really need to see them and can see them more quickly. That's the real benefit here. And we really think that over this year, it's going to really improve access for many of our key specialists that are hard to get into because they'll be 30% new spaces the way I think about it. Okay, got it. Thank you. I think the buy-in-large when you look at that, it's really about how do we get greater access for our patients to get the specialty care that they need. And then hopefully the secondary benefit is what Steve is talking about. And depending on the specialty, it can translate to more direct revenue. Okay, thank you. In your discussion, so the other question I had is around the building of the shared services organization. How do the New York hospitals contribute to those expenses? And what's the general New York Vermont split there? The way that we do our shared service costs is we combine all the shared services into one pot, if you will. So right now we don't have a network employer. So the employers that we have are the UVM Medical Center, CVMC Porter and the New York hospitals. But we aggregate all the costs for our shared services. So we aggregate all the IT costs, HR, marketing, revenue cycle, all gets aggregated. And we come up with a total cost for all of shared services. Once we have that aggregated costs for everyone, we allocated out to all the hospitals based on their proportion of net patient revenue. So the New York hospitals get their allocation based on how much net patient revenue they make up of the network total. There's a little bit more detail behind that in that we then have to essentially credit anybody that contributed at expenses to the pot of money. But very, very basic, that's how we do it. We combine it and then we allocate it based on that patient revenue. Okay. And is that actual NPR like from the prior year? Is that projected NPR for the current year? We use the budgeted NPR for the coming year. Okay. Thanks. Okay. On page 28 of the narrative, there's a discussion related to known increases for Medicare and Medicaid that are included in the budgets. The Medicare projected increase in inpatient rate projects an increase in inpatient and a decrease in outpatient. Can you just speak to that in a little more detail? So the sorry, so the inpatient rate increase. Actually, I might call on our that's one of our team members here just to make sure that I've got this correct. Mark, are you able to answer that question on what specifically is driving the inpatient and outpatient rate? I only have the blended rates over it for Medicare. So we'll have to get the split of the mix back split out by in out and pro that we used. Thank you. That's, it's fine to follow up if that's the easiest course. So let me just tell you a couple other questions related to this page. We're, I'm also curious about the relative waiting that gets you to the average rate increases on page 17 of the narrative and how an increase in Medicaid from New York is factored in. I think those are all of the questions on those two pages that and you can follow up. So which which chart specifically on page 17? I guess the page 17. So it's the average rate increases. So I think that would be in the bottom half of the page. So you're looking what's for what the, what the assumption is behind those rate increases and then how New York Medicaid factors into that? Yes. Okay. So, so for Medicaid, that one I can, we can speak to specifically right now. So those increases that you see there, the 0.7, the 1.9 and the 2.2. So those are the primary care rate increases that the legislature approved earlier this year. The reason why those percentages are different is really has to do with the proportion of the services in those organizations that are made up by primary care. So for Porter, you know, there, there's not a lot of additional services beyond primary care. They have, you know, they have some surgery, some radiology. Since they since their services are made up by such a large amount for primary care that that percentage increases higher for them versus when you look at the medical center, there's many more services. So the impact of that primary care rate increases much is much smaller. Got it. So for example, we believe that there's a seven and a half increase in Medicaid from New York. So that's not factored into your Medicaid percentages. Presumably that could impact UVM given the number of transfer patients you have from New York. Is that a fair assessment or assumption? Yeah, we'll have to take a look at that. The vast majority of that increase obviously benefits our New York hospitals. And there is, there is a small portion of that. Yes, that would flow across to Vermont. Okay. Yeah, so if you could follow up on that would be great. And so this next question is a question from doctor from doctor home. So I will do my best to ask it. What role does increasing productivity and clinics have in increasing access. So you've shared with the board your visits and clinical fte's per month. In her analysis, she didn't see measurable progress increasing throughput for the past year. The number of visits per clinician seemed low. So, could you speak to how these sort of your plans with these numbers and can you explain some of the lower numbers for example. Average for this year pulmonary 3 patients seen per per provider per day ortho spine 5 seen per provider per day. Pete's cardio for Pete's endo 3 infectious disease for per provider per day. Etc. So I'll turn to Brad and I think Jen gagged and can also help to answer that question for you, Robin. Yeah, absolutely. So, in general, the more productive our providers are, the more access there are, and that's not to imply based on the demand that we are keeping up with the access demand. I am. Robin, I'm sorry, may have to reread it. I am confused by the per day piece. Because I thought we submitted visits per month. Well, that would actually be worse to be frank, because what she that numbers that just pulled out were average. Over the course of the year, 3 pulmonary patients seen per provider, she said per day, but if that's per month, that would obviously be fewer. So, perhaps what would make sense is to go back to that exhibit that you submitted, we can we can perhaps Sarah can help me. I'm going to write this up as a follow up question and you can provide. Robin, can I jump in for a second? Please, Dave. Well, I was looking at some of this data as well. So, I think what I did was took like the month of July 2023 and that switch and then divided by 20 clinical days. And I estimated about 240 clinical days per per year. So if it's about 20, 20 work days per month times 12 months was 40 work days per year. So that's where you get to these per days, because I think that's the kind of an almost a more intuitive way to look at these these data. So, you know, we have, when you look at that for, say, Tilly cardiology 1200 patients per year, five patients per day, or in July 86 patients, which is 4.3 patients per day per clinical FTE is the way that that data was sent. Thank you, Dr. Mervin. That makes sense. So I think the difference there is we provided data on what we refer to as our full clinical FTE. And if you do the math that way, there's an assumption that this is really the ambulatory clinic FTE clinical FTE. So most of these providers have clinical effort on the inpatient floors, clinical effort with call. So that you couldn't really do the math, I don't think in that way, because the clinical efforts much more than just being an ambulatory clinic. Just as a follow up then for that to talk about that now, then would you be able to adjust this for ambulatory clinical FTE? Because say like endocrinology, eight patients per clinical FTE per day is what I see in 2022. You know, my understanding is that the endocrinology group does not have a significant burden outside of the clinic, but maybe I'm mistaken on that. But it would be really helpful to see these lists per clinical FTE per month per day per year. We can divide it out, make it whatever looks easiest to read, but then also and then benchmarks for that if you have like visit benchmarks for what would be an expected per clinical FTE per day productivity. Yeah, no, I totally appreciate where the question is going. It makes a lot of sense. My direct answer is I don't know how much work that would take. We can take that in follow up. And for example, maybe an obvious example like with spine, we have surgeons in the OR, that's part of their clinical FTE. So happy to follow up with who's appropriate and look at an example or two. Brad, what I would add is that, and I'm not close to the meta group salary system as much now as I have been at other times, but every physician here is benchmark to get across a productivity target. So I'm confident through Sullivan-Cotter or something we can share back good data that shows the productivity of our providers and the providers here are all academic physicians. So they have a teaching mission. Many of them have a research mission and many of them have clinical both in the clinic and in the hospital as well as call, but I'm confident we have that data to share back. The benchmark. And I do think David and Robin, I think those are really good questions and Brad and Jason, I think we need to figure out a good way to deliver this so that we can compare it. So I think it's a good question. We probably haven't done the work yet. We got to come back and do it. And so it's probably not 240 days a year. It's probably 225 days a year, because there's vacations, right? So we should probably have a standardized way to be able to show you what an FTE is and what a clinical FTE is in the ambulatory space. So I think we have to take that on as work, whether it's for this budget or for the next budget. It seems important for Ross internally and for you. So I hear that. Thanks. Thanks for the opportunity for the interjection, Robin. Thank you for bailing me out, Dave. So on page 35 of the narrative, you cite one of your major strategic projects next year as related to Fannie Allen. Could you speak a little bit more to what that plan is, what you think the expected cost of it is? And if you were to be granted the CUN for the ambulatory surgical center, would you still purchase Fannie Allen and does that make sense? Yeah, so our lease is running out on Fannie Allen. So we have to do something if we want to keep that facility. And we feel like it's a very strategic location for us. There's just not a lot of land left in Chittenden County. There's not a lot of property to develop. And obviously, as you've seen, we didn't hit on it too much in this budget narrative. But in prior budget narratives, we shared the population projections and the aging of our population here in this market area that is going to demand a lot more facilities and a lot more resources. To take care of the patients for years to come. So we have to, we have to nail down opportunities for land where we can and facilities where we can and we view Fannie Allen as a key to that that we would certainly need that campus. Even if the outpatient surgery center, CUN is approved. Steve, anything you want to add? What I would add Robin is that we desperately need the outpatient surgery center and the Fannie Allen campus. The Fannie Allen campus serves acute rehab. When we had to close acute rehab, we did not find a good suitable location in Chittenden County to move that. So rehab is open there now. We do a lot of imaging there physical therapy there. We have an urgent care there that we think is ideally located for Chittenden County. And when we get the outpatient surgery center, see one approved and we're able to move outpatient surgery there will repurpose those to improve access. Well, we're not exactly sure what we'll put there, but something. There's also a medical office building there that's important for our patients. And there's other space there that could be developed. Last I'll mention is parking. We have a desperately short number of parking spaces for our staff and that parking lot is 1 of our key locations. So the Fannie is part of our future even after we get the OSC approved. Thanks. So turning now to your balance sheet on your balance sheet. There's a jump in current assets from a budget at 87 million to this year to 198 million. Can you provide more detail? So that I believe is our planned. Borrowing, but Mark, can you can you validate that? I'm here. I was just clicking through some files. I would have to see the exact line, but that would be the material item. And if that's related to anything is probably what related to the potential borrowing. What related to the new OSC in that line? Thanks. On the PNL. It looks like in March, there isn't it was estimated that UVMMC would realize 60 million in revenue from the sale of investments. You've budgeted 17 million. Do you have updated estimates for gains? From sale of investments for fiscal year 23. We do have more months of actual data that we can we can follow up on that Robin, unless you have the numbers right there in front of you, Mark. No, Rick, that's a part of our balance sheet. You know, Robin, that that we work together with our portfolio managers and they make moves along the year that based upon current trends. So we'll just have to get back to you to see if the trend is any different than what we projected. Okay. Thank you. And if you could also get back to us with an updated projection on net operating income, which in the budget submission was budgeted at 39 million, that would be great. And then just one last question, which is, where do you book your donations? We didn't notice community foundation revenue or general contributions revenue on the PNL. So any donations that are so first of all, they have to be used. So if there's a if the money has actually been used for supporting staff. You know, purchasing some supplies where you see that comma, come into the PNL is the expenses incurred. And then in the other revenue section, there's a net, there's a net assets released income line. So whenever we use those donated funds, endowment funds, specific purpose funds. That's when we recognize we recognize the revenue on the PNL when we've recognized the expense. Thank you very much. That's, I think that's it for me other than for executive session related to those contracts. So I'll turn it back to you chair foster. Actually, chair foster, if you don't mind, we do have Wes on the line. Now he was having West Big Mill and he was having some technical difficulties. So he can at least answer one of the. The questions you had about the, the 340 b rebates trending from 20 to 22. So. Wes, are you there? I'm here. Can you hear me? Can I ask Mr Vincent? Was he sworn in? Oh, I'm sorry. Same question. Yes, he was on the, he was on the list that we sent to you. It's Wesley McMillan VP of clinical pharmacy. Yes, but was he here for that portion? Do you know? Oh, I was. Thank you. You're welcome. So, thank you, Robin. The 340 b program within UVMC has definitely grown organically over the last couple of fiscal years and going back further than that. And largely driven by patient increasing patient volumes, both in our outpatient setting. And within our retail footprint. So, the 340 b program is, is dedicated to outpatient medication procurement for for patients who qualify for the program. So, over the last couple of fiscal years, it's it's grown very nicely based on our patient care volumes increasing. What's going to happen with within physical year 24 is that our pharmaceutical manufacturer. Colleagues, if you will, have restricted access to 340 b discounts across across our contract pharmacy arrangements. And that impacts UVM medical center. CVMC and important medical center on the on the Vermont side of the shop as well as our upstate New York partnerships as well. The value of the program within the contract pharmacy arrangements is in the tens of millions and expected that that number will be significantly impacted with these manufacturer actions. We're doing our best as a network to mitigate the financial impact of that so that the true financial impact and added expense is really unknown. We're working towards mitigating those financial impacts, but something that we'll have to work through in this coming fiscal year. Thank you. And you can certainly provide this as follow up if that makes sense, but it would be helpful to actually see the dollars and the trends over time, which may be buried in the materials and I missed it, but it would be helpful to see it all in one place. Thank you. If you could follow up with that, that would be great. Great. Great. That's it for me. All right. Thank you. I have a couple of questions relating to. The August 17th letter that was sent regarding the benchmarking tools that we used. A case mix index is referenced in that letter and that measures patient acuity. Is that right? Correct. Yep. And what does it look at to measure that? So he looks at, sorry, just trying to get to my notes here, Chair Foster. Is it diagnoses, instruments, severity, those kinds of things? Correct. Yep. Chair Foster, it's what's documented in the chart around the patient's acuity. So when the patient presents and the physician writes the note, writes what their past medical history is, what their current symptoms are, what testing has been done, that adds up to a case mix index. So if the chart is incomplete in any way or you don't capture some key piece of information that will make the case mix index look artificially low. And that then impacts your DRG billing? It does. And what impact does that have on the different payers? Does it only impact Medicare or is it commercial insurers, Medicaid? It's primarily Medicare, but the acuity of the patients do, for some small portions of the other payers, it does impact payment there as well. Right. And then the data point, Director Lindberg had the adjusted cost per discharge is the cost for a single discharge at your hospital, but it's then adjusted for how complex those patients are based on that CMI. Correct. And the tool that we have, I think the data that Director Lindberg had was UVM's cost per discharge was 14,000 and maybe around like the 75th percentile or so. But your view is that data is misleading or inaccurate? Yes, due to the case mix index. So as I shared earlier, the case mix index. So when you look at that top right hand chart that Director Lindberg has up right now, the UVM Medical Center data point is the 2.05 percent. So we know that we're not appropriately documenting and coding the acuity of our patients. That's where we spoke about the iodine system that we just finished the implementation on. So with an appropriate and accurate accounting for the acuity of our patients, that will change any type of CMI adjusted cost calculation. So the chart down on the bottom right hand corner there, all expenses remained where they were, no changes, a change in CMI would drive down that average cost per Medicare discharge. And Chair Foster, what iodine actually does is it reminds providers of things they might have missed. So it says we're looking at the chart and we found you didn't actually document maybe the person's potassium or something like that. It helps the provider to appropriately document all the important elements. Provider have these alerts while they're billing and then the system prompts them to make adjustments. It's not while they're billing. It goes back and looks at the notes in real time and captures places for the provider to add important information to the chart. I'll give you a really simple example. A provider may have asked for a potassium level. And that potassium level could have come back high. And they have made even comments to say that this patient has a high potassium level. But they never wrote the words hyperkalemia, which means high potassium. You have to have those words in the chart to be able to bill for hyperkalemia. So what iodine would do is say, gosh, I see that there's some data that says this patient has high potassium. You've mentioned the words high potassium, but you've never documented hyperkalemia. Does this patient fit the need for hyperkalemia? So this comes back to the doctor after the bit, not when they're billing. It comes back to the doctor later. So what's great about iodine is it does it in real time. So there's a couple of things. One is you can capture comorbidities even before the patient gets there. So you can know that these patients have a history of ABCDE. So the patient's going to come in to see Steve. It's already on his chart that this patient has a history of these things. So you're queued into that. Number two is while you're there as the hospitalist, you can see the things that are happening. And you can get reminders. And then there is a part that looks back on it. And at 24 to 48 hours, depending on how efficient you are. And then there's a part that looks way back. And then says, Steve, you have a tendency not to code congestive heart failure. When these criteria are met, will you actually document that? So there's an educational process to that as well. Yeah. I've seen this some EMR systems themselves actually have this technology. I don't know if Epic does, but your letter that this was sent to the board says that UVM is known quote known for some time through external assessments and comparisons to benchmarks. That we're not accurately capturing the QD of our patients. Can you advise for how long UVMs known that? I would say that this goes back to pre pandemic. So 2019, 18, 19. We've known that we've had an opportunity to increase the the accuracy of our coding and documentation. And this doesn't all only impact CMI, but it also impacts quality metrics. So when we look at the vision database and looking at how we compare mortality rates, for example, readmission rates, that acuity of the patient factors into those to those numbers as well. So that's, that's really when we started to use traditional methods to try to improve the accuracy of our coding and documentation that. That really hasn't resulted in the impacts that we've been looking for. The letter I just want to add to that place. I would say that while all hospitals are continuously working to improve their documentation so it's not, you know, not a foreign thing for it to be at the medical center. I will say that during a latter part of fiscal year 22 and fiscal year 23, it has been a focused effort while it has been a manual process, a focused effort to look at service lines and what is the typical case mix index. And we have been focusing and educating on that and we have seen some financial improvements in that documentation and iodine itself is kind of the next level of improvement to automate and make it a simpler system for our providers to provide that additional information via query. The letter references some external assessments and comparisons to benchmarks. Can you flesh that out what those were and when they were done and how many of them were done? We'll have to get the detail behind that. We know we had 3M did an assessment, but we can get you some more detail on exactly how many of those were done. Do you have a sense of the timing of when those were performed? Not off the top of my head. Well, we can we can get back to you. Just directionally was that something sort of undertaken like this summer or years past or some sort of mix? It wasn't this summer. So more goes back more than more than the summer when those assessments were done. And do those assessments you had a projection in the letter? Did those assessments play into the projection that you submitted to the board? That's that's our estimate on where we think our CMI will land when when we are accurately documenting and coding the acuity of our patients. And is that assessment based in part on what the assessments or the benchmarking that your letter references showed? Correct. Would you provide the board the benchmarks and assessments? We can. Yes. On the projection, so I get the point that like, you know, this data, you think makes UVM look less favorable than it should. And if the board used this 2.3 range, it would it would change that. Can you walk me through how that projection was performed? In terms of the calculation. Yeah. So if Sarah wants to pull that, if you don't mind Sarah pulling that back up on the screen that chart that you had up a little earlier. Which chart? I'm sorry. I got. Sorry, the calculation that shows what happens when the CMI changes. There it is. So this is the calculation that that we included in the letter that shows what happens when the CMI increases for for this calculation. Right. Sorry, I was focused on the calculation that was performed to conclude the revised CMI should be 2.3. Yes, we can provide some additional detail behind that that calculation as well. When, when was that projection performed? When we received the the actual the 1st time we looked at the. The budget tool, which was on August 1st, we started going through all the different components of the budget tool and we started looking at the. At the areas where either we were within benchmark or we were outside of benchmark, and this was 1 that was was flagged. So we dug deeper into the. Into the data and that's when we started to look at at this specific metric. Can you or I'll walk me through how the projection was calculated. We can provide that detail for you. Later this week. Okay. Yeah, if there's work papers or math behind that. It would be great if you can send that over to us if you're not prepared today to speak to it. That would be helpful. When do you anticipate UVM CMI increasing? Like is it going to be, you know, you said you've had 2 weeks of this new program. Will we see it reflected in this year's performance or will it be sort of a 3, 4 year thing to get up to that 2.3 level? If we could increase the CMI number for their 23 or 24 budget. It won't all happen this year. It likely will be a year or two before we get the full. Impact of this will be analyzing the. The new workflows that that have been put in place in the system itself to look for opportunities Sunday. I don't know you implemented a similar system. I don't know if you have a sense on how long it took for you started to see the real impacts of of the system. Yeah, it's it's it's trickier than you might imagine. It takes a real cultural change. Because what has to happen is that. There needs to be a relationship between the nurses. Who are using the software tool. And seeing the opportunities. That relationship between the nurses and the doctors. So that they're talking to the doctors. Calling the doctors. Without harassing them because they're already overtaxed. And the last thing they want to hear is like they're not documenting properly. And so the doctors have to. Kind of go through a training process. To be able to appreciate what's coming in at them so. So it has that's the work that has to happen behind the scenes. And we have to be delicate and careful about it. Because doctor and nurse practitioners are feeling like they're being pushed so hard already. And so that's the walk that we're doing. First there's a lot of education. You take that on slowly. Start forming relationships. And then you start going in and saying, oh, you're going to get these automated messages. If you have any questions, come back and talk to me about it. But here's what we're going to target and usually take it on piece by piece. And build. And then people hopefully start to learn that so they don't need to get those reminders that. When you check a high potassium that you can write hyperkalemia. Etc. Etc. That makes sense. So that's why it takes some time to build up. And change the culture to be able to get us there. Have you performed a sort of risk assessment of the likelihood that your projections will bear out? We have not. No. And, you know, this was one of the factors that I am considering for all hospitals and sort of my thinking of the budget requests is how expensive are they. And it could impact how I think about UVM's budget request. And that gives me a concern that there's this number. In this letter. That's a projection that may bear out in two or three years, but it might not. And so I struggle with. Should I rely on it to decide that for monitors should pay more money in the commercial rate. And what happens if the projections don't bear out. What's your. I think you have to take the. Go ahead. So, I mean, I think that if we do better. On the way that we build Medicare. And that we get reimbursed. That would be a positive in the long run and would decrease. How much we would need to get our from our commercial payers. So, I'm I'm a little asked me that question again, Owen. Are you saying. If we don't reach this. We'll need even a higher commercial increase. No. Close. What I was saying is I might rely on this number. To determine that your rate request is appropriate. To some degree, because you're not as expensive as you look according to this number. And so it would incline me to maybe give you more money on your request. But if your request doesn't pull through. Then I've given a rate increase that's higher than I should have. And that means for monitors have to pay more. And so I'm concerned about relying on a projection. To do that. Well, I would like to add that Rick or Judy. Yeah, I would like to add that, of course, projections are always estimates and. Just like when you're doing budgets, they're estimates on what you know at the current time. And what I can say that I do know is that. The medical center has exceeded its budgeted case mix index. For fiscal year 23, because we have focused on that area as an area of improvement. Where we think that we need to really dig in is how we're training our new providers that come on every July. And as we focus in those areas and we make those improvements. It won't necessarily be in year one, but we do see the pathway to get to the 2.3. And your question about, are you over providing in terms of a rated increase? I would say no, there is a pathway to get there that will improve in terms of our cost. However, factoring what we have put into the budget, I think it's an appropriate rate request. I do feel confident that we are committed to educating our providers to ensure that the medical records completely capture all of the. Great work that is being done to care for our patients. So we've already started that process in a manual way. We're adding on a electronic version of that. I do think that adoption will come and we are monitoring those even as we speak now. One last comment to foster for as long as I've been in leadership, we've been wanting to add a tool to help providers remind them to do better. And one time after another, there's been an issue things like a pandemic, things like epic upgrades have and things like having financial issues have made it difficult to add the tool. We have finally made the commitment to add the tool. We've been educating our providers. We've done rollouts. The teams have done a very good job. They've made it easy for the providers to provide additional important information. And so I think our charts will be accurate, more accurate based on this and what you're saying is, are your charts accurate? This will improve the accuracy of our charts, the accuracy of what's in there. So I am confident the number will increase. Exactly when we get to 2.3, it's always a goal, right? We'll keep stretching, but we know other academic medical centers have done similar programs and gotten the results that we're projecting. Yeah, you should hold this accountable to it. Yeah, I mean, you know, I think that that's a fair point. And, you know, there's personal accountability for whoever responsible for these projections. And I would hope that, you know, it's really dangerous for us to give a big rate increases with the affordability challenges we have. And if we do it based on a representation and a calculation that the medical center has made or the network, there should be accountability for somebody if it's wrong, somebody that did it. Like somebody should be responsible for these things because asking us to give large rate increases is really hard on Vermonters. So I'll just put a plug in for personal accountability because it's really hard for us to give that money. Have it turn out to be wrong and tell Vermonters, sorry, we made a mistake. So I just think that's critical. Yeah, so, oh, and I guess here, I feel like we're we're stretching ourselves to get to this number, which we haven't done in past years. And we're, this is allowing us to lower our ask for our commercial rates, right? So I think it's great that you're holding this accountable. We want to reach this number. If we exceed this number, we'd be happy to come back and show you that and show you the impact of what that would have on future commercial rate increases as well. So I think this is what you want us to be doing. Because it would have been easy for us to just sit back and say, yeah, we'll continue to get the same CMI's that we've been getting. And what we're doing is doing just the opposite. We're challenging ourselves to be more accurate, to be better about the way we're documenting in order to collect the dollars that we believe we should get from Medicare. And that will decrease our ask to our commercial insurance. And is that that's because the cost shift thing people talk about the Medicare pays too little. So if you're actually billing Medicare properly, they'll be paying more. Therefore, you don't have to put so much on commercial. Is that what you mean? Yeah, that's exactly it. You've seen that our commercial rates are calculated based on what the Medicaid and Medicare rates are. Right. So if we can get more out of that. In Vermont, the Medicaid, Medicaid, Medicare rates are fixed ultimately and then the commercial rates make up the difference of what our costs are. Right. How much money would this be? If you went, you're budgeted for your CMI at 1.88. If you went up to 2.3, how much money are we talking? It looks like you're. Well, I just I'll leave it there. Yeah, it's in the neighborhood of around $20 million if we were able to get to that to that number. Chair Foster, I'd just like to add 1 point to this discussion. Jason Sanders just our earlier discussion. We talked about CMI is also a mix issue of the patients we care for in particular the patients we admit. So part of the projection will always have the day-to-day decision of that community care we provide as well as the tertiary, primary care and the more community care we provide is a delusional factor in the overall CMI. Thank you. Okay. So, if you've been under billing Medicare because of this issue and it's predominantly a Medicare. Issue and you shift Medicare shortfalls to commercial. Does that mean that Vermonters have been paying for that shortfall and billing? I wouldn't say that because obviously you've seen our financial results the last several years and the way that that we focused on the commercial rate increase is based on cost inflation. We certainly, if we do better in this area, there's opportunity to continue to have that impact the commercial rate. This is an area that we will continue to work on and hopefully we'll in the future. Certainly this year with our efforts with the iodine implementation will impact the finances and commercial rates in the future. What if it's going to impact it in the future? Didn't impact it in the past? I think there are many different components in the past that impacted our finances and our commercial rates that you can't attribute solely to the CMI increase that we haven't been able to capture. And those factors are different in the prospectively? No, they're not different going forward. We still need to evaluate all the different trends that we see, whether it's a cost trend or a volume trend. And we put together our budgets based on what we project those to be and CMI will be one of those variables that we include like we have in the past. Oh, and I'll answer your question. If there's something that we find that was being done inefficiently and we can do better about it, you're right. If we had done it more efficiently in the past years, it would have shown a benefit to all Vermonters. So everything that we're doing to try to get more efficient. Our PHSO, our services like HR where we try to use the economies of scale. If we could have done it better last year, it would have saved Vermonters money. If we could have done it better 10 years ago, it would have saved Vermonters money. You're absolutely right. So we should be continually trying to do this, which is what we're trying to do. So this is one example. That is what that is what we all want. What you want is what we want. So what Vermonters deserve. I agree with that. And this goes to the accountability piece. So on some level, there's been some portion of $20 million a year because of the documentation issue that's been pushed to Vermont commercial insurers by your budgeting structure. And I feel like that's difficult as a regulator to tell Vermonters. I speak with a lot of them to get their upset about the rates. And so I have to tell them UVM had an issue. Look, look, we all have issues. This care board has issues. I've got issues. We all have to push it back the other way. I think a really good regulator. Sheriff Foster, I'll just add until Dr. even makes it back. We've been working on case mix index. Sorry, I lost you as my computer died. But can you hear me now? That's a quicker quick recovery. Yeah, well, I've got it on the phone, but I was going to say that really good regulators would have caught that our CMI is low. And it would have been a really good external sort of reference to say, hey, are you sure about your CMI compared to the other academic institutions? It seems to be low. I don't think our job here is to try to put blame on different people. I think that is like, how do we work together to get to that right? If I can, if I can enter up for a second, it sounds like you just did. No, I mean, no more so than you did. I would just say that I would just say that it's us working together to be able to identify these kinds of issues. Yeah. I mean, I think that's sort of a common refrain. Like I've heard it in many different walks that, you know, it's the regulator's job to find the issue. And I think there's some truth to that. We all, we would love to find that, but I think it's very hard to do. Maybe we do have some culpability for not finding this issue. Maybe. But it's your, it's your billing. It's your, it's your billing. So I kind of feel like we can debate this, but Chair Foster, I've been in leadership at the medical center in one role or another since 2006. And every year I've been in leadership, we've worked on improving case mix index. It's a constant project for clinicians to do a better job of charting. The positions mostly want to do it for quality, not for billing. And so physicians sometimes don't realize that writing hyperkalemia matters because they just want to have a chart that shows what's going on. But every single year we've done work to try and improve our case mix index, mostly to drive improved quality. And recently there's been tools that you can purchase that help make it easier for clinicians. We haven't been able to buy those for certain years or implement them because of other huge challenges. The case mix index is critically important because we want to capture the quality and safety of the care we deliver. We want the charts to be accurate for that. And billing is a side part of that, but I can guarantee you we've been very focused on doing our best. And we've done a major project at the medical center this year and we've put case mix index improvement of $9 million into our 24 budget, which we're accountable to. Thank you. I appreciate that. And I get it. No one's perfect. We're not the medical centers. Not we get it. David, Dr. Claus might want to share a comment or two. If you don't mind, Chair. Hi, I'm prepared to move on. I, you know, I've got a fair amount of questions. So if you want Ms. Dr. Claus to send something later, that's fine. But I think we should move on. Mr. Buster, could I have a quick moment to call back in with my backup recorder? Just take a brief second. Yeah. Why don't we just take a two minute break? We'll come back at 1040 if that's sufficient. Thank you. Thanks. Okay, I think we can resume. I want to shift to the discussion in that letter. Really pharmaceutical expenses. The retail pharmacy expenses budget at $170 million or 49% growth over 22 actuals. That strikes me as large and as curious what impact that had on your budget request. So the pharmaceutical expense, and I'm just going to, and I'm Sarah again, if you don't mind pulling up that chart that we included in the. In the letter, just so we're speaking to the actual numbers there that would be, that would be great. So our pharmaceutical expense is made up of two components. One is the expense related to the pharmaceuticals that we provide during patient encounters. So the patient on an inpatient floor receives pharmaceutical or an outpatient clinic or one of our physician offices. There's one component of our pharmacy expense that is tied to that activity. And then another component of our pharmacy expense is retail pharmacy expense, which is, which is covered by revenue that is not patient related revenue. It's retail related revenue. In terms of our budget requests, the piece that is tied specifically to our rate needs. So from the rate needs from Medicare, Medicaid and commercial is only the component that is tied to physician to patient encounter. The patient that is on an inpatient floor or an outpatient clinic, those pharmaceutical expenses are tied to the rate need. Okay. And the retail pharmacy that expense, does that have any impact on your NPR request or your commercial rate request? It does not. So the retail pharmacy revenue actually does flows in a different revenue line. So it's not part of NPR and does not impact the required rate increase. Okay. So is there any relevance to that number, the $170 million expense increase for this budget? So for retail pharmacy, no, there's no relevance to that in terms of the rate increase needed. There's no relevance. Okay. And then the part of pharmaceutical expense that is part of NPR. I think it's in the budget at $120 million. Is that $120 million of expense that is net of revenue that may be associated with it? No, that's the true expense related to the pharmaceuticals. The revenue that we estimate and again for the pharmaceutical expense revenue that or the pharmaceutical revenue that we generate through patient encounters. We can't get to an exact number because the reimbursement for many of those services is either on a DRG or it's paid in some other episode type of reimbursement where you get one payment for the pharmaceutical, the stay and anything else tied to that encounter. We can't come up with an exact estimate, but based on using our aggregate collection rates, we estimate that revenue to be about $248 million. Sorry, just to make sure I'm clear. It's 120 million expense and the revenue related to specifically the pharmaceutical component of the expenses to 48 or for all of the services associated with those pharmaceutical expenses. No, just the pharmaceutical component. So the 120 million expense is that having any impact on your commercial rate request? Just the cost inflation on that expense. So the way that we calculate the required rate increases, we aggregate the cost inflation on all our expenses, salaries, pharmaceuticals, supplies. So only the cost inflation component of the expenses what factors into the needed rate request. And how much money is that on this 120 million? That we'll have to get back to you on exactly what that number is unless we might have a chart here that has broken that out. Rick, it's 4.6 million. Thank you, Mark. Thank you. So, I might understand this, but if you're, if the 120 million is all covered by the associated revenue, why are you adding expense to the budget relating to this? So we're adding cost inflation to the to the budget for that expense base. Because of the revenue covering the cost of the expense, this is the dynamics that we have within a health care organization. You have some services that we provide that generate margins, some that lose money, pharmaceutical. Revenue obviously is one that makes money that goes to subsidize other parts of the health care system that lose money. So what we look at for rate increase is what do we need to cover cost inflation? That's one dynamic that we don't have the ability to absorb through other through other means. And that's how we that's how we determine the we look at cost inflation for the entire the entire amount of our expense base that needs to be covered by the the appropriate amount of rate inflation to offset that increase. And how much did the revenue associated with this expense go up as compared to last year? So you said it's 120 million. So it's 108 to 120. But only 4.6 of that is cost inflation. Did the revenue side of this go up as well? Or was that flat? I would assume that the revenue piece went up as well, but we can get back to you on that. And so even though that expense line might actually be making money and theoretically it could be making even more money than last year or 22 actuals. It's included as an expense that should drive higher rate because some other place in your hospital had losses that weren't covered. Again, no, the only thing that factors into our rate need and to be clear, it's not just commercial. What we need for rate increases for Medicare Medicaid and commercial is only the cost inflation component of our expense base. Right. Shifting the utilization speak a bit about the aging population and the people moving into Chittenden County. Did you normalize the increased population shift to Chittenden County based on the demographics of those folks? We did. Again, just to use as an example of the impact that utilization has. So in the budget narrative that we submitted, we did include a chart in there that shows the differences in age bands and how they utilize healthcare services. So we looked at those that are under 45, those that are between 45 and 64. Actually, if you scroll down a little bit to show the differences in how healthcare utilization changes as you age. So we have, again, just to show the impact of the growing population and the aging population, we showed both numbers. We showed the impact of just the population change, which is the first chart you see there and then normalizing that change for the differences in the age bands. Have you had utilization estimates in your prior budgets? I know you have. And my question is whether or not those projections have borne out. How accurate have you been in the past in connection with estimating utilization for your budgets? So for the last few years, it's been a little bit more difficult to do. Certainly this year's budget was much easier to do as things are stabilizing back to more normal predictability. 21, coming out of the pandemic, 21, 22, that utilization was obviously more difficult to predict, but because of the large decrease in volume in 20, going back to pre-pandemic levels, when the historical trends were a little bit more stable, I would say we were very accurate in coming up with those estimates. My feeling is that our FY24 budget were back to that place based on FY23. In FY22, we now have a lot better sense on where volumes are headed for the coming year. I hear a lot about the housing challenges people are having. Does your estimates on population growth, do those things consider whether or not there's even enough housing for that kind of population increase? No, we have not factored in an adjustment factor for what impact housing may have on that continued population growth. I want to shift to admin expenses. I think you discussed this a little bit with Member Lunge. The letter says that it took away that our calculation we had is misleading in your view because it includes all of the health network shared service salaries that run through UVM. You spoke earlier about there's an apportionment for different hospitals based on their NPR. If the medical center is 65% of your NPR as a network, that means 65% of the admin expenses in the shared services is attributed to the medical center. When you say that all the shared services run through UVM, does that mean all of them are just UVM medical centers apportionment? Yeah, so there's two different calculations that are happening here and two different calculations that we're talking about. In terms of how we allocate shared services across the network, that we allocate proportionally based on net patient revenue. In the budget tool, the data source that they're looking at there is not our financial statements. So it doesn't factor in the allocation that we've made for shared services based on that patient revenue. What it's looking at is purely cost report data for any of those adjustments have been made. So that's what we clarified in the response that we sent back that once those adjustments are made and you have a true accounting, if you will, which is what our financial statements look like in the way that we allocate. Once you've accounted for that to take out the impact that we don't do in those cost reports or at least not in the data source that was used for that metric, that's the issue. So there's two different data sources. One for the budget tool, it's cost report data that hasn't yet been adjusted for the allocation that we make for shared services versus what we're actually doing on our financial statements and the budgets that you're reviewing today. Okay, so just to make sure I understand it, the calculation we have in our budget tool is all UVM health network shared services. The adjustment that you made in your letter takes it. So it's just the apportionment of the network shared services that should be attributed to UVM medical center based on NPR. Correct. It's except for the first part of your statement. It's not all network shared services, but because the UVM health network cost report has the vast majority of health network shared services in it. What our calculation is doing is taking that component and bringing it down to the to the 65% if you will net patient revenue component that the UVM medical center is actually paying for shared services. And the cost report, you said it's not all of the health networks shared. What parts are not in those cost reports. So there is a piece of shared services that again when we aggregate them all together there's a there's a there's a piece at CVMC there's a piece at that quarter. To give you an example so an HR department, the vast majority of the HR personnel and costs are at the UVM medical center, meaning they are the employer of record. There is, you know, two or three people at CVMC there is, you know, a few people at Porter where they're the employer of record, which factors into the into the into the cost report, but the vast majority of the network shared services and ends up on the UVM medical centers cost report because they have they have the bulk of those those employees. And is that kind of home office if you will issue. Is that in any of your peer group cost reports as well as that problem you need to UVM or do others have that issue. So you definitely see it so everybody has a little bit different setup. Some networks actually have a separate corporate entity for their network shared services. So I think when you look at that tool and you look at some of those that are on the lower end of the separate network entity where they have no shared service costs running through their individual hospital costs reports. If you look at Dartmouth, for example, that's even further beyond the UVM medical center, which is the if you scroll if you highlight. So if you look at Dartmouth, for example, at 38% I guarantee you the same phenomenon is happening there the bulk of their shared services is running through they don't have a separate corporate entity for network shared services. So the bulk of their their shared service costs are running through the Dartmouth hospital cost report. I have to assume they're doing the same thing where the actual costs however are being allocated based on some debt patient revenue or other metric to their partner hospitals. And these that are lower Emory or Beth Israel or some of these lower ones are they do they have that issue. So again I would I would suspect that they have a separate corporate entity for network shared services so they have an Emory, a separate tax ID number separate corporate structure for their shared services that their shared service costs are not running through their hospital cost report. Does it make sense someone because I was confused by this as well initially. I think it makes sense to me. Okay, I just want to make sure. So the other questions that contracted labor salaries. So you're basically saying that, you know, our proportion looks misleading because we actually pay more for physician services, but it's just not in our cost report because we contracted out. How much money is that for UVM. Which which number are you looking for chair, chair Foster the budget for 24 budget or the. I'm sorry relating to this budget tool. So what is that 21 or 22 data. You know what when we first speed here while we have that as a follow up and you know we're trying to make sure it's apples to apples and so do you know whether or not the comparison group hospitals have misrepresented clinical labor costs because of this contracted labor services issue. There could be some of that happening what the other the other the other component potentially creating mismatch in the comparison is just how much contract labor systems are using their there's wide barrier variability across the country. So, for example, in more populated areas like or areas that haven't had to use as many contract labor resources in Texas, Louisiana, Mississippi, the South, their utilization of contract labor is much lower than in rural areas like ours. So, there could be some some issues in terms of the cost report, but more likely what's creating that variation there is just the utilization of contract labor across the across the country. Right. I want to shift topics to affordability, which is part of our mission and our review of this. When you set your commercial rate. Is there any process in which you consider how much for monitors can afford to pay. And I get that you try to keep it as lean and mean and as efficient as possible. I get that. But is there an adjustment made or review or analysis of what for monitors can afford. Even if it's not consistent with your efforts to get it as low as possible. We have in our budget which drives that number. We're looking at what can we do to to decrease that number. When we put together our budgets we we look on first pass on what other adjustments can we make to those cost inflation assumptions when so the rate that you see today is not the first rate that you would have saw. You would have seen had we just submitted the budget on first pass. We went back through all of our adjustments trying to make the number as low as possible. Looking at what we were planning for salary increases. Talking to our supply chain leaders to say is there something that we can do about this cost inflation. Is there a way to offset it. Looking at at lower cost alternatives that might have different inflation assumptions that tie to them. So we do go through that process from when we first generate a rolled up budget to what you see today. We're definitely thinking about affordability and trying to make that trying to make that rate increase as low as possible. We're also at the same time trying to produce trying to pursue other non commercial rate increases. There are those opportunities still exists out there to try to try to make the care that we're providing more affordable. We still think that there's that there's a good chance that we can make those happen in future years. They just we couldn't get them across the across the finish line for this for this particular budget. Steve, I don't know if you want to add anything to that. Chair Foster, I'll start with health care is expensive and health care to tertiary academic medical center. Things that we do are amazing. And I'm proud of them, but they cost a lot of money. Our jobs who are very best to have them cost the least possible. They possibly can for Vermonters. That's by providing high quality care, safe care, minimizing complications and then comparing ourselves. We know from the Medicare benchmark data that we're in the bottom 25th percentile for costs for that the care we deliver is it is expensive. We work every single day to make sure we deliver the most keeping it as low cost as we can. But labor costs are 61% of our budget. They're going up health care is a people business. We need to pay our people well to provide high quality care. The equipment we're using is expensive and we have a lot of other pressures right now that are making it even more expensive access right now. We're paying people extra to catch up. We're keeping that extra operating room open by paying overtime and special pay. We're paying people on Saturdays to do mammograms, CT scans, MRIs to keep up to get caught back up. But I do want you to know that everything that we do we benchmark ourselves, but we acknowledge health care is expensive and it's on all of us to work to keep it as low cost as we can while providing good access, safe, high quality care. The other thing that I would add, Chair Foster, just in terms of the affordability question and decision point that we made before we submitted this budget. I think we highlighted earlier on, I think Sonny had this in his comments at the beginning that we've incurred $90 million more cost inflation than what we put in our FY23 and 22 budgets. That means that the commercial rate increase, the Medicare rate increase and the Medicaid rate increase did not cover that cost inflation. When we put together the budget, there was discussion both in terms of that cost inflation that wasn't covered. Do we add an additional piece to our required rate increase to make up for the fact that we didn't, we undershot exactly how much our cost inflation was going to be this past year. We also had a discussion about the fact that we are significantly depleted from a cash reserve perspective, which means that we're falling behind in terms of capital investments. And so we had a discussion, do we add more to the rate increase to account for the fact that we have a significant amount of cost inflation that wasn't covered by rates. And that we need more resources to take care of our models and we decided not to do that. And it was all due to the affordability question. What we've submitted in the budget is truly what we need to start to make some progress here on our finances and meeting the needs of our. Partially due to the volume of questions, but so if I interrupt you, that's why. Just yes or no, does the network look at how much money Vermonters have to pay for increased health insurance costs when it does its budgetary process. I'm not aware of a data source if you would, if you will, that would tell us that in terms of what's available to pay what Vermonters are available to pay. I mean, we know that there still is some subsidies that are going to continue in terms of the exchange programs. We, you know, we keep tabs on that to see if that changes. But in terms of a number that you can point to in terms of what, you know, what is available out there for Vermonters to pay. We're just not aware of any index or data source that's out there. Understood. And do you agree that the affordability of health care is. One important and to that the care board should be considering it in, in light of your budget requests. They certainly should be taking it into consideration in the budget requests, but in addition, one of the other. Needs that the Green Mountain care board needs to needs to needs to look after is the access to appropriate quality health care for Vermonters. That balance between financial sustainability access to care and affordability. All has to be taken into consideration in terms of what you're looking at from from our budget request. Yeah, agreed. So some of the public comment we received that happened with the vase requests. It's happening with the budget process is that non hospitals like primary care independent practices, mental health, physical therapy, long term care. They're saying that their rates that they're getting from insurance companies are really, really small, if not non existent as compared to UVMs and other hospitals. If we credit that assertion. And I guess I'm getting out is, should we consider that. The system and what the system's getting in a rate when we determine your rate. I don't know if I can, if I can answer that that question. Are you are you asking it in terms of is there other unregulated entities that you should be taken into consideration and the rates that they're receiving in terms of our request or. Yeah, so you talked about access, but what I'm told and the board is frequently hearing is that there's access issues because you know the independent primary care practice down the street can't afford to raise nursing salaries and they can't afford to. Pay extra to have a nurse work on the weekends and that's harming access. And so you discussed your access challenges and the need for rate to do that to pay. You know, to care for your community appropriate point. My question is, should the care board be considering all the other providers in the system. And considering your rate request. So, I, I'm not sure how to quite answer that question, but I will say that certainly you can see very clearly that our decisions in terms of access have negatively impacted. Our financials so the, the, whether it's a private practice physician group, a nursing home that's not, you know, that's not connected to our network. Any of those. Those providers if they don't have enough resources, they do restrict access and it has a very direct impact on on our organizations, but I don't know how to answer the question in terms of how. You take a look at an unregulated entity and factor that into to these deliberations here on our on our budget. Yeah, and that's what I'm struggling with. They say if we give you 13.5%, they're going to get left out and have a very difficult time getting rate. In fact, historically, they don't get rate if we give large increases to the hospitals. That's what they say. And so they can't provide the access to their community. And my question is, should I be cognizant of that and considering that and how much rate I give to the hospital because I get that the rate will be good for the hospitals access. And my concern is it's not good for the rest of the systems access. Yeah, sorry, I can't, I can't give you anything. Is that actually true. We're frequently told that, and it looks like from the data we've seen that the hospital rate increases are historically significantly larger than non hospitals. But I just wonder if if they got a larger increase, if that would change their access or not. And do you have regulatory control over what they get or don't get. And is that like sort of out of scope of what we should be talking about. I'm not having a hard time to kind of figure that out. That's my question to you if you think that's appropriate. Clearly the top half of those with how our ability to provide access goes. And so, I think there are going to be Vermonters that can afford to pay for and get care with private practitioners, etc. But I don't think that's what we're looking at. We're looking at, can we provide access to everybody. And when we lay out what I see is our request. We're trying to do that. And so, I don't, I don't know what to do with the private practitioner or the private group that is taking care of a subset of patient patients, but it's hard for me to, it's hard for us to opine on that. That's a different, it seems like a different group. Okay. It is a different group, but I take it your position is that the care board shouldn't should be reviewing your budget and only your budget and your financial need and not the impact that they might have on the rest of the Vermont healthcare system is trying to provide care as well. No, that's not what I said, I said that if we have knowledge about what that direct impact is and we should be really careful about that about how they make decisions when they when we don't know. It becomes really difficult for both of us from our end and from your end to be able to say, if we did this, this would what would happen to a private practice group that we don't really have vision into. I'll try and finish up here. Your budget request for fiscal year 23 the budgeted margin. How much was that was it 1.7 2% something like that. Mark, do you have a hang on Rick, I'm pulling it up right now. Had it had in the narrative from last year, page 15 as 1.7. Um, actually the budget. That's in the budget system. I have 2%. Okay, 2% or 39.3 million. And year to date, where is the University of Vermont Medical Center on margin. Let me get that right now. I have that too. The budget tool has it at 3%. Year to day actual through July and I'm just making sure that I'm looking at the right hospital. The actual is 2.1% or 35.1 million through July. Just want to keep the is it network and University of Vermont Medical Center. Just want to make sure that we're doing each of those correctly. Right. Actually, I am only referring to University of Vermont Medical Center right now. So, thank you. And you said there was $90 million of cost inflation in fiscal year 23. That wasn't budgeted for 22 and 23. 22 and 23. Okay. And so not withstanding that $90 million cost inflation. You're still at about what you had budgeted for your fiscal year 23. Margin is that right? Correct. So you're able to absorb that 90 million, whatever part of it is in 23. Without having to see your margin compress. Yeah, we have a fair amount of still 1 time dollars in the in the FY 23 results. So we've received some FEMA dollars. We've received some catch up payments for GME, IGT arrangements. So there are some some some numbers in there that won't continue into FY 24. But without those, obviously the cost inflation overruns would have would have produced a much different results so far in FY 23. Okay, care board made its 23 decision. It considered those in determining that the rate could be lower than the 19.9% requested, right? Did we we look at that point in time we were looking at and we still are produce pursuing hospital directed payments as as a as a as an opportunity for our network to reduce the future commercial rates. We talked about that. They haven't materialized, but it's still something that we're that we're pursuing. Okay. So, I want to bring up a topic that was addressed in your intro. I think, you know, Dr. even you said working with us the care board and the medical center together on cost containment. So you said something about the increase last year was very much appreciated. And it sounds like that increase, which was hard to do, you know, to prove that kind of level. But after the board did it seems like the amount of money the care board gave in its rate increase decision was not wrong. It seems appropriate. You had this 90 million unexpected cost. You had the GME money and the Medicare reimbursement change. You had the FEMA money and you have the margin you had anticipated. But, you know, after we make budget decisions that aren't consistent with what you submit, there's generally some fairly caustic language. And it's inconsistent with you saying you're trying to work together with us and saying that you appreciated it. So, you know, the media the day of the decision, which I think called the care board's decision, at least implied that it was wrong or not based on anything. And Dr. Leffler, you sent a message to UVM employees where you said quote, the care board approved a smaller amount of 14.77 how they arrived at this numbers unclear. And so strongly believe that this type of dartboard decision making doesn't help our patients, our community or healthcare across the state of Vermont. I wasn't involved in that decision, but looking at the data now it looks to me like that decision improved affordability for Vermonters and UVM still hit its margin. Are we going to see this kind of rhetoric. If the care board doesn't provide the kind of rate request you're seeking this year. So I won't speak to the rhetoric that was produced last year, Chair Foster, but I can tell you what we're looking for through this process is whatever the decision is that it truly is based on data and facts. I feel like we've provided all the data and excruciating detail to help you all make for the board to make their decision. We did talk about the impacts that we could see in terms of rate relief, which did factor in into the into the lower rate. Certainly we did not know at the time that we could pursue FEMA dollars. Obviously, we knew that it was still a possibility, but we had to significantly scramble to find ways to offset the fact that the commercial rate came down. And the rationale behind it was was a little bit harder to understand. What we're looking for this year is is the decision that's made. If it's made based on the data that you see and that that you you're basing it on the the facts that we've presented the facts that you have available to your to the board. And that we'll have to take a look and see exactly what impact that has. I think we're going to talk about that in executive session, but I, I share with you that the budget that we have submitted we without knowing, you know, what other dollars may be available next year. This is what we what we need. And I think you can see in our financial metrics, we're still going to be struggling financially next year. And I think one of the questions that we've made for for the impact this will have on our cash reserves to reinvest in the organization. We're not. We're not making a huge leap in just one year. This is going to take time to to rebuild. And so that that's what I wouldn't. That's what I would share with you. I'm going to go back to your foster since you called me out. I'd like to be able to respond. The budget that we submitted for our 23 budget took hundreds of hours to put together. And when we brought the budget to the Greenmount care board, it was our very best estimate of what we thought it was going to cost to provide high quality care for monitors for fiscal 23. There were things that we were unsure of when we submitted the budget that were very grateful did come to pass even dollars and other things. What you're talking about the email I sent was an internal email to staff and my specific comment was as we presented our budget. The hearing there were people in the meeting back and forth in real time on the public session determining kind of a middle ground like well I want to cut it by this much we should cut it by that much let's meet in the middle. That felt to me not fact based compared to the work we put in after the budget was approved and the other dollars came in. We've worked unbelievably hard at the medical center this year every all 8000 people here to turn us around. We lost $24 million in fiscal 22 and we have a positive margin this year. That took intense hard work. We do want to say that we are grateful for the dollars that came in last year in the budget that we got. It was a specific comment around the budget that we built and how it felt like in front of the public. There was a back and forth about what the rate was going to be and how you met in the middle. I understand that I think that's a fair fair observation as you know we don't have an option to discuss this with board members outside of public view. But you know I've negotiated a number of things and it seems like it's kind of typical for people to have different views and to kind of coalesce around a particular area kind of accommodating people's different views. And I imagine that happens with your budget. Mr. Vincent said there's a number iterations and you went back and forth. Right. I mean your number when you give it to us. It's not some sacrosanct thing you said it's your best guess. So did you have back and forth when you came up with your budget and then kind of all came to an agreement. Yes. I think you're right. But I do think when you look back on the first thing about the 90 million if you remember the 90 million isn't just UVMMC is it's also split between UVMMC and and CVMC. But when we're trying to make a budget when we get whatever dollars are given to us there are things that you're not noticing that are happening behind the scenes that we're not doing in order to get to that point. Yeah. Right. And that's what's really hard. That that I wish I mean so the way that our our repairs happen behind the scenes is based on the dollars that are coming in. And so are we going to fix that elevator proactively or are we going to wait till it breaks. Do we have enough. We know it's going to break sometime this year. Do we want to wait or do we want to proactively do it. We want to go ahead and buy epic for home health and hospice because that would make the ease of care for our patients moving from our hospitals into home health and back so that our the documentation can go flow seamlessly like the rest of the system. Can we afford to do that or not. So there's a lot of decisions that are happening that are truly for patient care that don't happen when we don't have the dollars. That's the hard part of being able to kind of visually see what's going on. So when you when you say you know you didn't get what we didn't get what we asked for it becomes really tough because when we make decisions that impact patient care. It makes it a lot harder to recruit patient recruit doctors when we have a decreased amount of dollars that are coming in. It's a lot harder to reward doctors for the work that they're doing when we know we can't have enough. That has an impact on the future years. All of those things that we're putting into play very transparently. I mean there I mean you see where all the dollars are flowing. That's the challenge that we have. So you know you can give us whatever you know we ask you for what we really think is a reasonable adjustment for what we need which has already gone through a bunch of compromises. Lots of people arguing that it should be more. Some people arguing that it should be less just like what you're seeing. And we're thinking about all of those factors when we put it into place. But there's no doubt that if there are changes to what we've asked for that we make changes in what we can do. It's pretty straightforward. It isn't and it's transparent because everyone can see what we're doing. Totally totally right. I think that's exactly a great point. I think it's true. If we don't give you as much money you're going to have to make hard decisions and that's what we're trying to balance is what are the consequences to that. And what are the consequences of giving the increases that are requested. So Dr. Eppen I think you're spot on. It makes hard decisions. You could do more if you got more. But you I appreciate your opening remarks about understanding what we're trying to do. Just a couple quick ones here and I apologize for my care board members. We can go late if we need to. But on this point of you obtaining more money to help with access to care isn't. Do you think that the high cost of care is a significant barrier to health care. Yes. If care costs less we could do more. And so is that a situation that we should be considering in connection with this budget that the high cost of care can be a significant barrier to health care. If you could control the cost of care. So if you could control the biggest part of our cost of care which is our people. If you could reduce the cost of nurses. If you could reduce the cost of doctors that would really help us. If you just simply give us less money in that fixed environment that doesn't help us. Right. But what I'm getting is the health care advocate talks sometimes about how we're losing access because people can't afford health care. And you know that's something is that something I should be balancing in our budget decisions that the cost of health care is impacting people's access. You want money to improve access. But is there a downside to that of blocking access because of the financial decision. I think that's the balance. That's the delicate balance that we're walking unless we can figure out a different way. I mean we can we can talk about this. This might be out of scope. But talk about is there a different way that our system can pay for health care. Can we use the Vermont provider tax in a different way so that it supports people that are having trouble paying for their insurance. Can we use the wealthy folks who don't collect an income but have lots of money. Can we tax their wealth in a way that would help support the rest of Vermonters who can't afford it. There's lots of different ways to do it. I don't think reducing how much you're paying us is necessarily the way to do it. That's the balance. You can't have all of it. Care costs this much. Lots of it is out of our control. If you reduce how much we get. We reduce how much we can do. We're trying to be as efficient as possible. We want to be as efficient as possible when we deliver care. I don't doubt that for a second. I'll just add that right now we have significant backlogs. People are right now seeking care and paying for it and affording it. And so to this point what we see right now in Vermont is there are access challenges. We've heard about them before. We came in front of the Green Mountain Care Board in the past around access challenges and we're doing every single thing in our power to improve access while keeping it as affordable as possible. Some people are accessing plenty of care. So I want to read you a couple quotes just to set the framework of what I'm seeing here in 2018. Your former CEO said that quote the high cost continues to be a significant barrier to health care. This situation is unacceptable. He also said I see many patients who went without treatment because they simply cannot afford care that has to change. And it's those points and the fact that that's five years ago and health care in Vermont has gone up significantly if it was unacceptable back then. And there are patients avoiding treatment. I think that's something that we should be thinking about and maybe in your future budgets. We can ask for it in our guidance but it seems like there is an act if there's an access problem back then that was unacceptable because of cost there is today to. And I'm just flagging that as something that we have a responsibility as regulators to consider. There are many people waiting to get into your hospitals for sure. But there are some people who are not because I can't pay for it. Yeah I think I think I get part for me to speak for what John was saying but I think when we talk about it when I talk about it on a large scale. I would say the same thing. It's a national problem though not a local problem when we talk about that that we have an issue with the way that health care is being delivered in America. We're doing an in a phenomenal job in Vermont compared to most places. And so I think I think you got to keep it in context of where we are. And I think you're right. I think there are we know that there are people that don't get the care that they want or deserve because they can't afford it. But we have an amazing system that delivers care to everyone and we're committed to doing that equitably. The people that often leave our system because they can't get access to doing it are the people that have a lot of money. They can go elsewhere to get care. They can pay for it with private practitioners that only take certain insurances etc. We don't do that. Our job is to be a different model of what we're trying to do. So when you reduce when we have executive compensation I understand that the justification is that their benchmark and this is the amount of money that's needed. Yes or no. Will you provide the board those benchmarks. I'm trying to remember. I think this is something that we can share I believe in executive session model look to look to Eric and Sonny to validate that. And as with any data regarding competitively sensitive decisions like how much to pay versus doctors executives. We can provide you with information regarding what is taken account in making those decisions to a degree and to that degree. We can talk about it in executive session. Would you provide the benchmarks that were used to set the executive salaries confidentially to us. We can talk about that in executive session and I can talk about it with your legal team to ensure that that would be possible. So I don't think whether or not you'll provide the documents is confidential information. So I think you can answer if you'll provide us the documents. We'll talk about it in executive session and with your counsel. Okay. Well it's your burden to justify your budget and I think looking at the benchmarks would assist us in validating that. We understand our burden and we understand the criteria by which the board is required to judge our budgets. In terms of executive compensation. When you have the incentive compensation. Do you have any reviewer consideration of UVM's ability to control operating expenses. I'm getting as the factors that are looked at in terms of setting executive compensation. And maybe this is a question for the chair of the board. But do you consider UVM's ability to control its operating expenses in determining whether or not there should be incentive comp awarded. So I guess I guess I could probably comment. I don't know if Allie wants to comment or she was waiting for executive session to comment. But yeah, but I won't go ahead. Yeah, I was going to say. Oh, and that certainly a biggest part of whether or not executive bonuses get paid is based on whether or not you hit your financial margin. So if you say that it would be virtually impossible for us to hit our financial margins unless we are operating as efficiently as possible. And so in the past number of years and this will be another year. We will not be able to make a margin. And so the biggest part and sometimes the only part of the bonuses have not been paid and they will not be paid again this year. So does that answer your question. Yes, is the answer. Well, kind of because you can you can hit your margin if you have extremely high rate increases. I'm talking about operating expenses. Is there like a review of operating. So some of the things we're trying to achieve as a state is affordability right and access. And we have we're paying as a system you know what I consider significant sums of money to executives and healthcare systems at UVM in particular. And we want to ensure we have this stable of thoroughbred talent right that we're paying for. And is it being properly incentivized to achieve what the state wants. Is there any opportunity to ensure that this team of leadership is incentivized in the way that's consistent with what we want as a state which is lowering costs, improving access delaying weight or improving wait times are those things is there an opportunity there to align the state goals with how the incentive cop is awarded. So we have a complex compensation committee that looks at this our voluntary board and I think again I'm not sure if Ali is going to comment now or later on about the process of what they go through. I can tell you it's having gone through it once now and seen it it is rigorous. They really hold the executives accountable and they're about the patient's experience and their accessibility. The costs costs are funny you can you know you have to be careful about what you're going after when you go after costs you could decrease costs. Right that's why margin is a good number there, but there are many, many of these. So some of the things that we talk about are we have tangible measures of the employee experience that we're looking at for this year and and that's done by a Gallup survey that's put out and every executive every hospital partner. President has a goal that is to improve their employee experience because we know that's going to connect to the way we have access. So for each employee experience, similarly, every hospital partner, including me has the same thing our hospital patient experience has to be improved by a tangible measure as measured by press gaining the margin is a part of that as well. And then every one of the shared services has a benchmark that they have to reach to be able to do it so for HR it could be our turnover rate is our turnover rate getting better. It's going to be improved faster whatever those every one of the executives in those areas has a very tangible specific piece. I don't know Eric again if I'm happy to at the end of our. Let me let me let me interrupt the whole thing with you. Yeah, I'm happy to show the whole thing with you if that's okay. Yeah, yeah, just if you can if you're willing to send it to us. That's great. And I'll just put in a plug that ensuring that alignment is beneficial and we can we can move on. I'd heard and read somewhere that UVM executives had taken pay cuts or for gone bonuses or some variety of that during COVID. And I was wondering, you know, I get everyone's mission driven and talented and you know you have a high market value I get that. But given the affordability challenges we're having. Is that an appropriate thing to happen here this year or next year to lower some of these executive costs and I know that's not going to solve the problem. I know that doesn't solve affordability but for people paying it. It is hard for them to see these 2,000,000 900, you know those kinds of salaries are very high in Vermont. And I wonder if that's something you don't have to answer it. I'll just put it out there that perhaps that's something that could be considered due to the affordability challenge I lodged you for doing it during COVID. And I'll just put a plug in that perhaps that's something that should be visited I know I'm not trying to take away your money at all I get it you worked hard your top notch people. But there's a lot of top notch people working really hard to pay this and it's hard for them to see that kind of number and so I'll just leave it at that. The only other quick thing is there was a digger article back in 2017 discussing several private flights that UVM Medical Center had chartered to investigate the acquisitions of the New York hospitals. Can you tell me when the last time UVM any UVM entity the health ventures, the captive anytime a UVM entity last chartered a private flight. Well, I can certainly say that it hasn't happened since I've been here that I'm aware of and certainly I have not been on one. I don't know if anyone else is aware. I just encourage anyone to speak freely if they're aware of it. I'm not aware of any sense 17 definitely not since 19 since I've been president. Great. And is I'm asking these because of the financial challenges people are having, but is his first class travel permitted for anyone who's traveling is being paid by any UVM entity. I can say that I think we have very strict guidelines on it. I think for international travel for business. I think we are allowed business class, but I'm not sure if I see some HR person. We can give you the I'm happy to share those regulations with you on that we have across the network around our travel travel guidelines. It's they're open and transparent and everyone knows about them. Great. Yeah, if you can send them and again, I'll put in a plug that just for people paying these rates, some austerity measures and enforcement of that would be, I think a good optics and helpful for people and not just good optics. I think it's the right thing to do, given where we are as a health care system. I know you guys recognize that. So, so thank you. I have nothing else. Thank you all very much for answering my questions. I apologize for taking so long. Hey, great. Dave Marmin. I don't know if anybody needs to take a few minute break. It's been a while since the last one. I'm okay going on. Rick, do you need anybody? Okay, I just want to pick up a few things with chair Foster left off with regarding executive compensation bonuses. Dr up and you mentioned there is a margin target that had a large component. It sounds like you're actually making a margin in FY 23 as of now and projected to make one. Is that with that not count? No, it was it was a correct me again if I'm wrong. I wasn't here when it was done, but you have to make the margin that was actually there for the network to hit that target for everyone and we will not make it this year. We will not hit that target. It was, it's not a, if you hit 20% of it, you get 20% of it. You had to hit the margin actually. It's a binary threshold. Okay. Yeah. So just a few, I had some a bunch of questions that I had sort of wanted to ask you, but then there's a few things that came up, which I don't want to like go too extensively into but just a few things a follow up question from from chair Foster regarding the FY 23 actuals. When, when during the year, does the, does the rate increase related to the board's order come into effect? So the vast majority of the, the rate increase comes into effect in January, most of our most of our commercial contracts are January. Some of the, some of the Medicare rate increases come into effect on in October. So a small portion happens there, but the bulk of the rate increases happen on January 1st. Okay. And if, if you were to, and when was the FEMA and GME money, when did that come in? We'll have to get back to you on the exact months, but it was so the GME money was definitely in June. That's when the retroactive payment was made for last fiscal year. The FEMA dollars, I believe we're in the February, March time frame somewhere in there. Okay. Because looking at January on and I actually don't have it up in front of me right now. March and each month. Do you know what the margin would be? If you just include. Yeah, but there's no doubt that January was the, was the turning point. So the, the rates taking in coming into effect in January, plus. All of the, the additional work that we've done to improve access. Reduce costs. One of the things that we highlighted in our, in our narrative is that we. We were significantly under budget on administrative shared service costs so far this year, somewhere in the 20. Million dollar range. So all of those impacts really started to take place and started to happen in the January time frame. The, the actual margin without the FEMA dollars. Dr. Merman will have to, we'll have to, we'll have to get back to you. So Dr. Merman, one thing to take into account is that many of our costs go up October 1st. So new contracts for employees. The, the union wage changes cost of living increases. All kick in October 1st. This year as well. And so you don't cover those costs until the commercial rate kicks in in January. Same with, with 23 budget. Our expenses went up significantly in October 1st of 23. And then when the commercial rate kicked in in January, that helped overcome those cost increases for labor and other issues. Okay. And that's a cycle that occurs annually. Yes. But it, it would seem to be more predictive of, of where your revenue would lie. At least, I mean, maybe, maybe margin because of those increased costs would be challenging, but at least revenue to look at once the rate increased kicked in in January. So from January to now. We build our rate increase based on 9 months of the new rate. That's how we do it. We build it into the budget. Yes, we built it in in kind of a pathway of when we thought dollars were going to come in. Dr. Merman in addition, you were asking about FEMA dollars and certain things that have been one time or initiatives we have taken on so it's not just been the rate. We also impacted our wage index by taking the rural wage index. We apply for self community hospitals. So we have been looking for ways to augment and supplement the, the rate increase. So it's a number of factors in addition to the FEMA as well. We've worked very hard on applying for every opportunity for funding that we could. Yeah, actually, that brings up a point that Rick, Dr. Mr. Benson, sorry, had mentioned earlier on that I wanted to follow up on. Sorry. You had said there was other opportunities to potentially improve governmental reimbursements. What are some of those opportunities. The biggest one is hospital directed payments, which I think we discussed a little bit with the board last last year during the budget process. What that is is for academic medical summers, similar to the GME program to reflect the fact that academic medical centers take care of much more acute patients. They typically serve as the safety net hospital for their, their region. Medicare recognize or Medicaid, if you will, federal Medicaid, if you will recognize as the fact that that academic medical centers require additional resources and the math behind those funds is it takes the hospital very, very kind of high level. There's a lot more detail behind this, but just very, very high level takes the Medicaid revenue that you generate on your hospital billings and brings them up to the commercial rates. So it reflects the fact that you need more resources to take care of the patients that you're taking care of and also the fact that you're you're training future providers that will help the health care industry to meet the access needs. But you need a, just like the GME program, you need a, you need a partner in doing that, which we obviously have a very good partner with UVM to pursue these types of opportunities. So we're still pursuing it, but it hasn't yet, we haven't yet crossed the finish line with that, with that pursuit. I guess this is a little bit of a segue from a prior comments, which I just wanted to ask if any of you were able to partake in the series of board meetings we had in the spring on cost shifting. I did not participate. I don't know if anybody else on the call was there. I listened in on one of them. David, I was on the Medicare rate. I think was it in Montana or Wyoming. I can't remember that guy. I did listen to his. I was wondering if you had any reflections. Her presentation was a little bit less specific, I think, on trying to understand the impacts that go to the elements of cost shifting or revenue shifting. But I was wondering if you had any reflections on that and how you approach cost shifting and what you learned from that presentation. Yeah, I can't speak specific. Yeah, I was going to say, I gotta go back and review my notes. I wasn't expecting it, but you know, David, I think just broadly, sorry, didn't mean to cut you off Rick and I'll let you answer it just broadly. I think it's really different when you're an organization where the goal is, I want to try to provide equitable high quality care to everyone that walks in the door. And that if we see a need, regardless of whether it gets reimbursed that we want to then provide that care, it's really different when you take, when you have that kind of a situation and that kind of a commitment. Versus, you know, you could have a an academic medical center that picks and choose chooses what they want to do and and can deliberately make decisions about not covering certain things and it's subtle. And I'm just going to give you the example right is that if you don't have psychiatrists. You can't provide mental health care. And so you can, you can, and you know this, you're in the emergency room, you got to take everyone that comes in. But there's no place to put them. And so people realize and learn where they can go and where they can't go to do that when you're in a system that looks at those kinds of things. We're in a system that our goal is how do we take care of everyone? How do we take care of the needs of our community? And so we look at it really differently. We look at we look at it. We do look at what makes money and what brings dollars in only for the purpose that we can then take those dollars and put it into areas that we know we can't make money yet we have to provide the service. And so it's a really different way to look at how to deliver care. And so when I think when I was listening to the woman from that was talking about Montana, I think you have to look at it in the context of all the other hospitals and what were they doing? Did they shift the kinds of providers that they had because of what they were going to deliver or not? When you saw I saw that I think if I remember right there were like some hospitals that had higher costs, but but didn't really provide information about what they were doing and what they weren't doing with the kinds of care they were providing. So it was it was interesting. But yeah, I don't want to I don't want to comment down that road. Sorry, Rick. I didn't want to interrupt you. I think what I would say, Dr. Merman is so again, so I apologize I didn't participate in that in that session, but I think this is where we've been incredibly transparent with the cost shift the last many years. We've included in our materials and exhibit for each hospital clearly showing the cost inflation that that we're projecting for this current year. From there we show very clearly the Medicare and Medicaid rate increases that we're projecting and then what the required commercial rate needs to be to cover that cost inflation. That I think that level of transparency. I'm not sure you would find another regulatory processes, if you will, like, like, like we have here in Vermont that we're very, very clear and we show the exact figures and the exact cost, cost shift every year when we submit our our budgets. So I would say I would encourage you to listen to the, especially the other two presentations other hers was quite interesting regarding cost shifting. And they do comment a lot on sort of the concept of cost shifting, which some people say the cost shift doesn't exist. I don't think that's accurate. I think that what they're trying to say is that the cost shift is more of a relationship to market power than it is a necessity that I think an example was used once when there was a cardiac that Medicare doesn't cover the increased costs of the cardiac stents. We shift that cost to commercial payers. And then these speakers would argue that the that that's because of market power and that hospitals that don't have market power and all the hospitals I've ever worked at I've been very fortunate in this seat everybody comes through the door and takes care of them and if they can't have been fortunate to work in a place where I can transfer them to a hospital who who's more than willing to take them regardless of their ability to pay. But that these hospitals, some hospitals don't have the market power and thus can't negotiate for high rates now we have a different system here in Vermont. And so therefore they are lower costs their costs are closer to the Medicare allowable costs, but their quality remains the same. And so I think it actually really speaks to what you guys did last year you didn't get as much money through the rate as you want to do scrambled to find money you worked really hard to reduce costs and in the end, you've made a 2% margin and done quite well improving access to care decreasing reliance on travelers all the great work that you've done. So it's, I think it's a really interesting concept that would really encourage you to listen through those sessions and try to figure out how to think about how to integrate those into your budgetary process and your philosophy as you approach it. Yeah, I think just just a really good point. Yeah, go ahead, Rick. Maybe just to make one comment. I think part of that is what is what Sunny shared is those organizations may very well be deciding to not hire that psychiatrist to not keep beds open because they don't have the capacity in the post acute system to to to manage the flow of patients. So I think the decisions that organizations are making to get to those to get to the financial targets that they need if they haven't. If they haven't been able to truly cover the costs that they're incurring, I think it's important to under understand because I think we've been very clear that we haven't made those we haven't made those choices. And again, we've been very transparent with what with what that that cost shift means for means for us. Sorry, Sunny. Yeah, and I was just going to add just to what Rick was saying before you respond to them is that so first of all the Medicare cost reports I'd have to really understand like the consistency of how those are reported just like we just like we heard about the cost reports right if you don't understand what goes into it is a part of a system is it a standalone. Is it a largely Medicare driven hospital. That that'd be a really important thing. The other parties on like things like provider tax, where does the Medicare dollars go in that particular state are they using it comparable to how we're using it to provider taxes go right back into taking housing and food food insecurity, etc. Those are important. But the other part to remind me I would just not buy the stent if I couldn't afford it right if I thought that was the best that but I can't afford it because I'm going to go broke I'll use the second tier stent to do that. And so it's like those kinds of decisions that are challenging. And if here's the really big important part though, if it's you and me and we know that Dartmouth has a better stent because either the clot rate is lower, or the longevity is higher, but we're using it here. The people that can afford it will go over and get that. And what we're trying to do is we don't care who your insurer is we don't care if you can pay out of pocket or not we're going to give you the same highest quality stent possible. That's what we want to do. And those are the subtleties that you won't catch in the in the differences right that we have to be really careful about. I would really encourage you to watch these and read the body picture on this. I would say that the argument that we made by those folks would be that the stent price goes up Medicare doesn't cover that increased cost of the stent. So now you have a lower margin operation. So the way you manage your lower margin operation could be to increase your volume. And you have lower margin per patient and then you actually increase access and do more. It's just an option as opposed to just passing the cost directly on to the commercial insurer. It doesn't work like that. It doesn't work like that. We try to do as much volume as we can when we have the need. And so it doesn't work like the the only way you can drive that is either you have to take the lower margin and we do less of what we don't have a margin on. Just tell me just imagine if you're the cardiologist and we tell you listen. We're going to use this new stent. It's great. But you're going to have to do twice as many in the same amount of time. That's how we're going to make up for your for your margin for your dollars. Just imagine if you're the doc or whoever you are in that provider. It's a scenario that doesn't work in reality. Unless you're going to compensate people differently for for those kinds of things. And we've worked really hard on equity on the as you know on the compensation side as well. Right. That's really really important to us. Yeah. I wouldn't want the interventional cardiologist to hunt me down and say you know Dr. Merman just suggested I do twice as many cats for week for the same conversation. It clearly requires up staffing and that resource too. But I would encourage you to listen through it and look at it. There's a pretty extensive body literature especially over the last five or six years that really calls into question the necessity and it's more more related to market effects. There's one thing I want to talk through Sarah. Is there a way you can put up page 38 of the narrative. One moment please. Yeah it's the. Since the analysis of page 37 38 of the submission discussing this sort of complicated financial and quality impacts of the inability to transfer patients to post acute care other appropriate care settings. I mean this is you know we've asked all hospitals to submit information on this. This is something that you know as a clinician I've known about for a long period of time is this is a huge challenge for health care organizations to manage or struggle to manage the impacts of transferring patients out of the hospital who need post acute care. So I just wanted to make sure I understand the this analysis clearly. So it looks to me that what you guys did here and I'm just going to you know for specific concerns I'm going to only look at the UVMC and discuss the UVMC component of this but what we have here in the first column is the actual average length of stay which I assume you use a similar statistical method to the vision of taking you know sort of a more more complicated geometric mean or what not but this is the average average length of stay of patients admitted to UVM and the vision is a matched group. It sounds like they're matched by demographics they're matched by DRG groups so meaning their diagnosis related groups from other organizations throughout the country. I would assume peer peer peer patients elsewhere. Is that right. And so and so Vizient looks at these this peer group and says OK well we would expect UVM and see that your your patients would have the same length of stay. And so the next column is your actual daily census and then and then you come up with an expected daily sentence by it by adjusting for that different length of stay. And then the difference between those two numbers multiplied by the number of days per year. I get I get slightly different than that but it was close enough that I assume that's where that calculation come gives you a 27000 roughly uncompensated annual patient days. And then I don't know if I quite understand the adjustment for the non DRG payment. But that's OK for this. We adjust it and we get the adjusted uncompensated annual days and then you have a you have a measurement of your direct cost per day of 22 22 and then you end up with $52 million in uncompensated care and this quantifies the burden that UVM MC is seeing on this big challenge of of it's not just post acute care. It's you know as we've heard from other hospitals it's it's patients who don't actually even have significant medical need. So that skilled nursing facility and qualified for skilled nursing facilities. People are talking about paying for hotel rooms apartments other things. But this is the complex reality of what we're seeing is the real big challenge here. And that costs about $52 million in 2022. Does that seem fairly accurate. It does. And just to maybe explain a couple of the numbers there Dr. Merman that may not have made sense. So the 15 the 15 percent adjustment for non DRG payment. What we're doing there is saying essentially some of those days that exceed the expected length of stay will we're likely still getting payment on meeting that care is compensated. So that's why we're adjusting the numbers down. And that expected length of stay is again this analysis is not perfect. You know we had to we had to put something together that attempts to get at this. But the expected length of stay is the closest thing that we have to what the DRG length of stay would be meaning once you extend beyond that 5.2 you're essentially not getting paid for that for that care. So hopefully that helps to tie together a couple of those a couple of those variables. OK. I think I appreciate that. I think I understand that. All right. And then so for the sake of the argument I think you just standardized the average cost per day as the same over the three years more for ease of calculation. There's probably some adjustment to that cost. But for the ease of this calculation and to sort of illustrate a point I think that that was that was equal for those days. And then it appears that in 2023 was that was it was a harder year even then 2022 with $60 million of almost $60 million of uncoped care off of this model. But the budget for 2024 looks optimistic that you're hoping to save 10 million dollars essentially here in uncompensated care or which I think is essentially due to a reduction in the actual length of stay. Is that where that's coming from. So exactly. Yeah. So Dr. Merman we've done a huge huge project at the medical center a throughput project and we've worked with case management the physicians we have patient placement rounds both the medical center across the network. To move people out to more appropriate locations. We've had some positive results over the last quarter of this year through great work by the providers and teams here and we project that to continue into 24. What's what's working. I would say it's better communication between providers case management the floor setting a discharge date on the day they show up and then daily patient placement rounds where the issues are being addressed in real time so it doesn't get to that Friday afternoon when you realize the person doesn't have the wheelchair at home or the one lasting they need to go. So I would really say it's better communication and real focus we put major focus into this this spring as we need it for access. We need those beds that are being taken up by people who don't need to be at the academic medical center for someone else who does. Yep. And is this this I believe is ECG which I thought was a nice name being in the medical field of a consulting company. But is this the ECG work that you were referenced in the submission. It's both local and ECG work. Yes. We've done a lot of work as well. We use their help as well. OK. And then and then so and just to sort of discuss this in a little bit more detail. So when patients are having a higher length of stay it leads to other you know maybe not downstream upstream issues to get patients into the hospital. And so so I would assume that higher lengths of stay for inpatient admissions have an impact on Dr. Leffler your and my specialty of emergency medicine longer ED length of stay. Is that is that something you guys have experienced. Without question. So when I commented earlier about having five patients per day that we declined in December. Those are people that were probably stuck in an ED across the state of Vermont. Now we're down to two. That really is the throughput work that's having a bed available for those people from across Vermont to come and get the tertiary care they need. OK. And so are there. So are there other factors that you look at in this data other than the inability to transfer patients to these settings that are leading to increased lengths of stay compared to the comparison group. Dr. Dr. Remember if I if I may Dave Klaus the Network Chief Medical Officer. So yes I mean an initial analysis showed that that a significant portion of our gap between actual length of stay and expected length of stay was related to poor capacity inadequate capacity in our post acute settings. However there was also a significant area for opportunity for improvement in our operations. Dr. Leffler has spoken about the value and the the positive impact that we're already seeing with initiation of patient progression rounds. In addition to that there were major operational changes taken about on the inpatient floors at UVMMC and to some extent at other institutions in terms of going to a concept of unit based care where essentially all the professionals were concentrated geographically in one unit to enhance their ability to function as a cohesive team. And so with those together we are seeing slow but significant improvements in improvement in our in our actual average length of stay. OK. So are that are the patients in the both both the actual and the the rest did you want to say something. I'm very sorry to interrupt. Dr. Klaus you weren't on the witness list and I don't believe I swore you in initially. So I hate to take the time to do this. If you're we're going to keep the discussion with you as a witness I would like to have you under oath. Absolutely. I guess I did it without knowing I wasn't on the list before but I'm happy to. Well if you if you were sworn in before then and you took those before that is fine with me if you just weren't on the list. OK. OK. So you're you're under oath. Thank you so much. Thank you. Thanks for us. OK. So so I guess the question I have is in are all patients in the actual and expected length of stay are they discharged to skilled nursing facilities or other post acute care settings. So I'm sorry. So this this encompasses patients regardless of their regardless of their destination after inpatient care. OK. So this is this is all all admitted patients. So this is all that compared to peer groups. So OK. So they're patients in this in this data set that could have a you know have a two day length of stay. And go home. That is correct. The vision data will actually decrease or will eliminate a certain percentage. The 1% of what they call outliers the 1% in each D.R.G. That has the highest length of stay. But aside from that yes all all comers and someone who is discharged the same day of admission is assigned a length of stay of one day. OK. So so this data actually doesn't just represent. Like as you said you're working at you found other operational improvements and efficiencies through this process that are not related to. Skill nursing facility discharges. So this data actually represents UVM's length of stay over the expected length of stay for all patients. And it could a lot of that like the state could be due to things other than the inability to discharge to an acute care setting post acute care setting. So it's so it's right. It's total on compensated care. But we do know we've done a lot of study here that are observed or expected for routine cases that are going home is better than average. We do better on like that's under one observed to expected. And our complex patients that have two or three comorbidities that need nursing on placement are way over observed to expected. So the people that are getting you know their their gallbladder out Dr. Merman and they're supposed to go home in three days or oftentimes going home in two. We have good data on that. OK. But OK. Dr. Merman add to that because I've dug in by service line et cetera on where we have the actual average length of stay higher than expected. And the way the system calculates is if we've had a patient that's been here for 200 days let's say and they get discharged it goes into that calculation for average length of stay. So I want to make sure that we understand that even though the number is higher we've actually made significant improvement in being able to place some of our longer term patients. And that uncompensated care will go up when we discharge that patient because that is when the actual billing will drop through. OK. I guess I was just trying to understand this chart and I guess to me it sounds not exactly what I'm looking for in that it's not defining who are the patients that are hard. Who are these. I think you used the term in here. Hard to discharge patients or patients that need post acute care or other settings compared to a peer group patients right. We're not taking a subset of patients that are hard to discharge and comparing them against that other subset of patients that are discharged. We're taking all patients and comparing them to all patients and in that we have a pretty heterogeneous group of patients. So so when I look at this fifty two million dollars of uncomped care you know a lot of things could be driving that other than just the inability to discharge a patient to sub acute rehab. It is total patients. It is total uncompensated care. And I think as Dr. Leffler and Dr. Klaus pointed out the largest piece of that is the inability to discharge patients. But if you're looking for another breakdown. I don't I don't believe we were asked to provide that in the in the narrative but we're happy to try to try to do that for you. Indicate the estimated annual expenditures associated with providing care that cannot be reimbursed through the inability to transfer patients to post acute care or other appropriate care settings. So that would be helpful to get a little bit more clarity that answer that specific question because I think that what we're looking at is the one one way one could look at this and I'm not saying this is exactly right. But you could look at the cost of the increased length of stay throughout the EVM medical center and attribute all that cost to difficulty just charging patients and I don't think you can say that with this data. I would love to read you a public comment that we received earlier this year that kind of relates to some of your. Some of what you spoke about Dr. Leffler regarding the ability to take patients from other hospitals and some of what you were talking about Dr. Klaus about the internal operational efficiencies. So I experienced this came in in February experienced what seems to be a heart attack on Monday night and which the coply ER on Tuesday after determining that my symptoms of chest pressure needed to get checked out. In the ER coply I was accepted in you in the UVM system 24 to 48 hours to get in almost 48 hours later I was transferred to UVM to a palatial room in Miller. It is now Saturday. I wasn't able to get my heart catheterization procedure yesterday to do to other urgent cases that came in and now I'm not sure if it will happen this weekend or not. I'm so frustrated that I got delayed by going to coply. One doc said I would have been taken care of had I gone straight to UVM and now I'm so frustrated that I've had to fast for a second day while I wait for the elusive cath lab to determine if they will open today. This has cost me at least two extra days in the hospital and a generally healthy person so I don't so I didn't realize how screwed the system is in business you seem to make all your interactions with customers to be easy and get them what they need. I'm so frustrated that no one knows when things will happen when things will happen being stable now and I'm at the bottom of the pile. This is very frustrating. I would suggest if you can't do cath procedures at a local hospital then don't penalize patients coming in via the system and definitely open the cath lab on the weekend if they get backlogged. I don't anyways I don't want to get a nice experience at the hospital. I want to get diagnosed and go home. To me this actually speaks to both of what you're speaking about there the impact on other hospitals having to board patients that need to be transferred. But also that there's opportunity to decrease like this day by improving access to procedures. So Dr. Merman first off February was right after December when we were delaying a lot of people. That's unfortunate. I just hate that the first thing I look at every single day on the census is how many people we couldn't accept last night. First thing I look at every day because it bothers me. It's part of our mission to accept those patients. Then to keep the cath lab open on weekends year and year doctor and you're aware that we have to have the cath lab ready on the weekends for emergent cases. So we have to call on a team. So every Saturday and Sunday the cardiologist who's on call has to make the determination if they took a stable patient to the cath lab and then the ER has someone who's highly acute or gets transferred here. That's a real problem. We don't have three teams on on Saturdays. So we try and manage that out which unfortunately this person is right and everything they said that means they unfortunately have to wait in our system. We are working on that. But right now we have one team on call for emergency cases. If there's a second one we do urgently call the second one but we don't typically have the cath lab running all day Saturday or Sunday with the routine cases to keep the availability open for the emergent ones. I appreciate you keeping a close eye on this. It's very impactful for the system and if there's any opportunity to look at surge planning in these time periods where there's a high demand. I just want to make a comment. We could pay a full time second team to be on and do the routine cases but that would drive up costs a lot. We have to pay special pay on weekends. We have to have an extra cardiologist. It's kind of what the whole thing we're talking about here today with cost and access. There's a balance to this point. We've said we're going to make people wait over the weekends. We could present a program to the Green Mountain care board that would have a second team on and do all those other cases. But that would drive up the expense. So I think that's the balance that all of us are working on today. That's a valid point. I think that I guess I wonder in that situation and maybe this is a great discussion to have on another time as if there could be a surge plan to get through backlog and not. Live in backlog. Which I think is your experience through the suburb January February time frame. We've done that for many things. We are doing more cardiac cases during the week but we haven't done on weekends but it's fair fair point. But I would really appreciate if you could come up with a little bit closer to what you think is a realistic amount of money for what it's costing UVMC to take care of patients who are awaiting. You know who have long stays associated with difficulty of accessing post-acute care. I think a lot of these actually my questions have been addressed. But you're faster. A few questions have come up through through conversations. Not today. And we discussed today about UVMC is unique position of being the state's only academic medical center. So what are what are some examples just from a standpoint of examples are additional costs that are associated with being an academic medical center. So the first you already start Steve and please go ahead. So the first is definitely the the breadth of the services that we that we offer. So being an academic medical center and the tertiary and quaternary referral center for a region means that you're offering very expensive and highly specialized services. So that's certainly one of the one of the impacts that that we see from a cost perspective. The other is that we we take all commerce. So the acuity of the patients that we see because we are that that referral center means that that we're taking care of much sicker patients than what you typically see in other hospital settings. Those are the those are the two biggest from my perspective. Steve and Judy if you want to add that be great. Yeah. So the first thing I would say is that if you look at all the transfers we take over a year we lose millions of dollars just on transfers. Other hospitals who find people that are complex and hard to take care of transfer the tune to us. It's actually our mission to take care of them. There are small subpopulations of patients who come that we actually earn a margin on but but many we lose money on. We lose significant money on dialysis and in the state of Vermont subspecialty care because you need an even number of doctors. You can't have one point six pediatric oncologists. We round up and try and cover that and we still have access challenges with that. So by providing the full breadth of tertiary care for patients in our region but also our learners. There's a lot of cost carrying cost to all those things and having all those services available in real time for people here. I think that was actually I wasn't expecting you to answer what it was a tertiary care center but more of an academic medical center. So what I would say it's a similar answer for we provide many services here to make sure we can attract and train our learners for the future of health care. And so having the robots here having things like that. That's what our learners need for the future. So they're ready to provide care when they are having capacity here to teach people the full spectrum of health care they're going to need to learn is expensive to do. There are services we do low numbers of patients on with high quality but are expensive for the infrastructure for that. And I would just say if you if you've ever had a medical student with you. It slows you down. Right. I mean so when we schedule medical students my history of scheduling medical students with a primary care physician is you cut their load in a third to a half so that you can have the medical student. Learning residents not that great an extent they start slow so that you when you start you have to put more effort in hopefully by the time they finish they're actually enhancing your ability to deliver care. But overall there's a cost associated with that right. So those are I think those are the very tangible costs and I think Steve gave you the more sort of here's what we need to deliver in order to be a good academic medical center. But there's just a very specific tangible cost like you're not as productive working with a learner as you are working by yourself. I could set my table a lot faster than working with my three year old right. And I actually think that relates all the way back to where we started this morning. It feels like a long time ago around the productivity of our academic physicians in clinic. I think this academic mission part of our work pertains to that. And that's why academic clinical targets are lower often. But it also also just add one thing quickly are some of our costs are infrastructure costs I.T. for example some of the systems we need to do research and clinical trials are higher costs than nonacademic medical centers. So do and there's governmental and other grant revenue to cost to cover some of the costs of the academic trying to differentiate academic from tertiary functions are there. Yes any any type of grants that that are taking place any type of research activity. Almost all of that is certainly covered by an external source. But there is there is infrastructure costs that that again that are born by the an academic medical center that wouldn't be completely covered. The other component we were talking about residency programs earlier today. You know the residency program at the medical center. Obviously the number of residents outstrips the reimbursement that we get for for that that that complement of residents and I think many you know many academic medical centers have have done that one because again we're training the future generation of providers. So there's definitely there's definitely infrastructure components to an academic medical center that make them that make them unique. Are there are there academic functions that are not covered by grant revenue. Governmental pay its payers. And what is the cost of that. I can't even you can't even separate that. Yeah not really I mean it's such. It's hard I mean if you just look at the salaries just simply look at the salaries and look at the reimbursement you won't hit the number. So just start with that that what you get from Medicare and you compare it to the salaries that we pay you won't hit the number and then on top of that add on the the sort of administrative load that you have to provide the teaching opportunities that you have to provide. There's probably somebody that's done that David probably exists. I mean the ACG me probably has something and we could probably dig that up if that if that's important there but but in overall if you think about the benefit that we as an as a state in a region get from being an academic medical center being able to be on the cutting edge on on much more forward thinking on where we want to go because of that. The opportunity to recruit folks and you know bring them here get them excited about the organization and the and the area and then keep them here we've been incredibly successful with the recruiting part of that. I think all of that I mean you sort of have to balance that for the you know the organization and the state of the value of having an academic medical center on the academic part of it so I think it's a complex math problem that I think there are probably people on both sides of that argument. I think that I guess the reason why I'm asking is it kind of speaks to your earlier comments doctor up and about the regulator's role in understanding the granularity of an operation that came up with CMI. And that you know with really high skyrocketing insurance rates and the impact that's making on Vermonters and small businesses and individuals is at what point do we need to think about accountability for the costs of the academic training system. System compared to the benefits of the academic training system for the state of Vermont and for the people who are now paying those rising costs. And I think it's it's not a it's not a there's not a clear answer. It's not a CMI. It's not a numerical value. But but and maybe we need to think about as a state of where the more appropriate funding sources and maybe that's tax revenue versus high commercial insurance rates for a state where as as as Mr. Vincent mentioned he doesn't have specific measures of Vermont's ability for moderate ability to pay for insurance. But our median income is 20 20 points below the mean. I mean it's we have very low median incomes as a state. So for and for a lot of people in Vermont who live in Bennington or Brattleboro or White River Junction or St. J. you know that UVM is not really an available resource for them anyway. So it's a bigger societal question to me that it raises than a specific question in this budget. Yeah. Dr. Herman just a comment over the past couple of years we've accepted many many more transfers from Southern Vermont because partners around us are full all the time. So we're bringing many more people up here and we know that about a third of the residents that we graduate stay in Vermont and I would argue strongly they do go to Brattleboro and Bennington and Manchester and Rutland and do help fill those sites. So in a real shortage of health care providers having an academic medical center which is training nurses doctors nurse practitioners to populate the health care system in Vermont. That's a huge benefit. I totally agree with that. I just I think the complexity is how do you quantify that and we could go on for hours and I think that I'd love to hear your thoughts doctors. Well, I quickly this is building a doctor left point as we've looked the past few years. We've seen that more than four out of 10 doctors across the state of Vermont, either trained at the Larner College of Medicine or completed residency at the medical center. Across primary care and special needs. Yeah. I have one more line of questioning that I it's thinking about asking about which is essentially you've, it's been discussed several times if the board does not approve your full budget request and the assessment of services going to be performed to figure out, you know, where reductions are going to need to be made. Last year it says if you're forced to make reductions we'll look at service lines that are low volume or do not cover their costs. So in 2023 did you do an assessment of which services would need to be cut. And what did you find. So, go ahead. I think we're going to talk about I think that's the conversation for the executive session David is like, rather than talk about that here. So we have we have done a reasonable not, I wouldn't say thorough, but we've done a look at what we would need to do. So I think that's the part that we're saving for later. But I can tell you in general that every year after we get our rates, we compare rates to what we budgeted. We figure out what in the shortfall is if there is one and how we're going to adjust the budget the budget is a plan for the following year. And in 2023, after the rates came in lower, there were some other dollars that were coming that we were unsure of when the budget we didn't even know about them when the budget was submitted. We were unsure of them at the day of the hearing, and then many of those dollars did come in, which allowed us to provide the services and expand access over 23 through a lot of hard work. And whatever rate comes in this year, however it comes in, we'll build on to the plan that we have to modify what we do to manage that. Thank you for that. So when you're, I think I'll try to ask questions and if in and around this area that if you feel need to go into executive session please let me know but when when you are evaluating a service for a potential reduction. Why is it that some services don't cover their costs. Pretty much all comes down to the reimbursement rate on that service. There's some services that we that we provide where the reimbursement that psychiatry, for example, is is a service that isn't that isn't reimbursed at a high enough rate to cover to cover the costs. What we just talked about the transfers or the uncompensated care, which I hear you will shrink the box in terms of what we're actually looking at. But that's another example of a lever where we don't have, we're not getting enough revenue to cover the cost of the care that we're providing for a large portion of our inpatient staff. So, okay, so, so, so there's also volume data. Yep. There's also volume right there's certain services that if you had enough volume of that service that you could then there's an accounting scale that's associated with it so when you look at the example that you used about. If you had enough cat volume, then you could sustainably open up a second cat room running all day long, because you know that there's going to be enough volume to be able to get compensated for that. But if you want to keep it open just for that urgent need, then then you won't have it and there are some places we have to do that. So if you run an OB service, you've got to be available 24 seven regardless of the volume and the cost the fixed cost of that is really high. If you have enough volume. That's fine you can do it if you don't right there's both of those there's the reimbursement piece. There's the volume piece as well. And with regards to reimbursement piece I just want to pick up on the reimbursement piece for a minute. You're negotiating with commercial insurance but the so at the end of the you get the green mount care board gives the budget order you negotiate with the commercial insurance. Say like last year is this a like an across the board even even increase to reimbursements or do you have abilities to negotiate specific service line increases up for some maybe less up for others. So if you run across the board and actually we can have Kelly Lang give you a little bit more detail exactly how that's done but even within the individual service lines we have to we're keeping an eye on where we need to stay within bounds. So it's not that you can increase a particular service line beyond what the typical market rate is but we don't do it across the board we do look at service by service to allocate that that rate increase. So Kelly you don't want to add anymore. Also, you know we're just service by service and we inpatient outpatient professionals so again the different buckets of care based on how the payers reimburse payers having different methodologies. So, is there ever a concerted effort to take the essential services of a safety net hospital and negotiate higher reimbursement rates for those comparative to other reimbursement increases. Contracting and sorry. Eric was going to beat me today I think this is part of executive session conversation. Yeah. But at a high end David I mean when you think about also that when you open up a particular service it's not just your commercial payers that are using that service so there's Medicare and Medicaid that are a majority of that. And the payment system and the vagaries that are associated with what gets reimbursed well and what aren't are largely out of our control. All right, does that make sense so like, like you can, you can go for that all you want. But the reality is is that lots of that is preset and unfortunate in America and the way that we've, we've chosen to pay for some things and not chosen to pay for others. I, I think I'd like to talk more with you all in executive session about the details of this. I think for now, I'm going to, I'm going to pass off to to whoever's next. Unfortunately, I don't think Professor Holmes has been able to join us today. So, I think only Tom Walsh is left. Thank you so much. Yeah, so Dr. Merman, I'll, I'll call a lunch break now just so Cassidy and everyone can have a break. Why don't we pinch it to 45 minutes instead of the full hour and then we're obviously going to go over. There's going to be healthcare advocate questions and some other things. So everything will get pushed back a bit. And I appreciate everyone understanding that it's a really important decisions and UVM should have the opportunity to address all the board member issues. So thanks for your patience. We'll probably go to maybe six o'clock tonight or something like that. So could be longer could be.