 Okay, then I'm going to call today's meeting to order. The first item on the agenda will be the executive director's report. And while Susan's giving that executive director's report, if everybody could just finish going through the minutes from the 13th, that would be helpful. So executive director Barrett. Okay, I will try to speak slowly so folks can read. So, you know, I just have a few announcements first as I mentioned last week. Tonight we are going to be hosting our primary care advisory group that is obviously going to be virtual and the column number is on our website under a press release and Abigail is that number listed on right on the top of right under the press release, I believe it is right under for today's date for the column for the PCAG. We just want to make sure folks have the press release. Perfect. Please reach out if members from the public are interested and have a hard time finding that number but it is very clear on our press release. I also just want to say that we did receive some public comment regarding the hospital budget guidance. We did post that as well with our materials for today's meeting, and it's likely we will be extending that public comment period that will be part of Patrick's presentation today. So, please look at our website to provide any other to find out where to submit additional public comments after today's meeting if necessary. And for next week's meeting, I think we'll have more clarity after today's meeting, but it's probably likely we'll continue this discussion on hospital budgets. So, stay tuned for an updated schedule on our website. And that is all I have to report out, Mr. Chair. Thank you, Susan. Is there a motion on the minutes of Wednesday, May 13? It's been moved and seconded to approve the minutes of Wednesday, May 13 without any additions, deletions or corrections. Is there any further discussion? If not, all those in favor signify by saying aye. Aye. Any opposed? Okay, thank you. So at this time I'm going to call the last four digits of the phone numbers that do not have the names attached to on the participants list so that Abigail can keep an accurate record of who was at the meeting. So I'm going to start with 5001. It's Julia. So I'll have to help the advocate. Thank you, Julia. 8913. This is Lori G and Turco GI and T you are CEO. Thank you, Lori. 8703. Mike Del Treco. Thank you, Mike. 10505. Jennifer Collis, UVM Medical Center. Thank you, Jennifer. 6376. Mort Wasserman. Thank you, Mort. 7438. Ham Davis. Thank you, Ham. 0043. Thank you, Becky. 2636. Howard Weiss, Tisman, Vermont Public Radio. Thank you, Howard. 8878. Jennifer Transport Medical Center. Thank you, Jen. 5058. Hi, Susan Krakowski MVP. Thank you, Susan. 5835. That's Abigail. Oh, sorry, Abigail. You think I'd recognize that by now? Okay. 1042. Welcome, Robin. 8823. Stephanie Burrell from NMC. Hi, Stephanie. Okay, 7000. Dan Bennett from Gifford. Hey, Dan. 7520. Bob Hersey from NVRH. Hi, Bob. Good afternoon. Yeah. It goes by fast when the sun's shining out there. It does. 1970. 828. 1970. This is Janine. I'm recording 144. 3212. Hi, it's Kathy Mahoney from the advisory committee. Thank you, Kathy. 2079. Nick Sherman. Lee and I'm public affairs. Welcome, Nick. 2079. That's me, Nick. 3452. It's Rebecca Cobans. It's across the ship. Okay, I think that I have everybody else's name. Is there anybody whose number I did not call? Yes, this is Don Budby. 8887. North Western Medical Center. Thank you, Don. Anyone else? This is Susan Aronoff from the DD Council. You're in the system, Susan, so your name does come up fortunately. Okay, I didn't hear it. Thank you. Yeah. Okay, great. So thank you, everyone. And the purpose of this afternoon's meeting is to discuss hospital budget guidance for 2021. And before I get started, if anyone has any loud cats like Robin or any other distracting noises, if you could put yourself on mute, that would be good. If during the presentation, if there are distractions from something other than the presenter, then what I will do is I will mute the whole conversation. So the presenter will have to unmute themselves so that they can keep coming through. But we just want to be able to have a clear audio of whatever is being talked about or presented this afternoon. So this is, has been an ongoing discussion on what is the proper guidance to give for hospital budgets for the 2021 year, given the way the world was turned upside down by COVID-19. And we've made some progress. And at the last meeting, we talked about a number of items, including what the proper guidance is, what the proper enforcement would be, what the guidance for a change of charge might look like. And just to tee it up before I turn it over to Patrick, as you recall, we did not settle on any clear path on what enforcement could be. What I had proposed as a change to the guidance that had been circulated was that we took the total budget allowance for 20 and then added 3.5% onto that. And then, so for example, if a hospital made an even $100 million in NPR, that's what they were given for their approved budget in 20 years. We would tack 3.5% onto that. And their enforcement would be based only if they went above $203,500,000. And we did not have any conclusion to that discussion. And I'm just saying that those are the type of decisions that we will have to lock down at some point. It could be today, but it could be in the future. And we are not going to have a final vote on the budget guidance today so that hospitals and others will have a chance for public comment before we do. So if you remember, at last week's meeting, we charged the hospital finance team to work with a couple of board members to come up with some possible options for what the guidance might be for changing charge. And again, just to throw out an example that I had thrown out in the past, and again, this is just one board member, so it means absolutely nothing. But for an example, I had suggested that after listening to board member lunch talk about a two-part rate that I thought it was a brilliant idea and that I was suggesting that we have one part of the change in charge that's more clearly linked to what the historic change in charge has been. And I asked the team to come up with what the five-year CAGR has been for the change in charge for the last five years. And that's come out to about 2.8%. So I'm thinking that, at least in my mind, I'd like to see a base change in charge around 3%. But again, that's just a suggestion and no decisions have been made. But in addition to that, a second component that would be temporary and that would be based upon the drop in commercial revenue that the hospitals saw because of COVID and give them an opportunity to get back on firm financial footing. And for those that say, well, what are you trying to do as far as rates? I would say that we're not trying to have a whipsaw in the rates that people would pay through insurance because keep in mind what we're talking about. Whenever you talk about the expenditures of a system, it's not just price, it's also utilization. And what COVID did was drop that utilization down considerably. So in order to get the hospitals back on financial footing, what we're really considering is giving them a chance to meet that pent-up demand over a period of time, which would be tempered not only by a hospital's ability to meet pent-up demand because of their staffing resources and their physical plant resources, but also to deal with the fact that some people might be afraid and may not be willing to come out quickly to meet any of that pent-up demand. So all of that is just a long way of saying that we've got a lot of decisions to make on the guidance, but I see the change in charge as being a very significant discussion and I see the enforcement as being a significant discussion. And I just also want to acknowledge the fact that the board received a letter from Vaas this morning asking that the budget process be delayed even further and possibly consider not having a budget process for 21. So that has to be one of the options that's out there, and I would say that we have to consider all options and then come to what we think is best for the state of Vermont as far as consumers and also as far as making our hospitals financially healthy because consumers don't benefit if they don't have a healthy healthcare system. So with that, Patrick, a very long introduction, but I'm turning it over to you. Thank you, Kevin. It dovetails well into our conversation. And now you can share your screen. Thank you. I'm going to make sure I get this into reading view for everyone today as I did not do that last week. So it's probably a little hard for people to see. Okay. Can everyone see my screen and hear me? So I cannot see your screen yet. Does anybody see your screen yet? I think it's loading. I don't see it yet either. It's coming. Okay. I got it now, Patrick. Okay, good. Thank you. Thank you. If for any reason I break up on the regular while I'm talking, please let me know and I will phone in. We had some construction here last week, and I think it possible interference with my presentation. So if that occurs again, please stop me and I will call in and remove my discussion from our internet bandwidth and move it over to the telephone line. So thank you very much. Are you prepared to share her screen with the slides if that occurs? I think she is now. Perfect. Thank you. All right. Thank you, Mr. Chair. Good afternoon, everyone. Here we are part two of our abbreviated guidance discussion. Welcome. We're going to move right into some of the aspects from last week's meeting that we will update you on as we go through. Primarily was the board's direction, as Kevin mentioned to staff, to come up with option or options recognizing potentially separate COVID rate on the change in charge item. In addition to that, we also had board member Holmes and board member Youssefer ask if we would place into the guidance narrative, a component that asks the hospitals to discuss service line adjustments and risks and opportunities. And on slide three at the very bottom, you can see that we've added those into the guidance. And above that is the slide from the prior week with some of the items that we've considered in the abbreviated guidance thus far. So just to cover those steps real quickly, that's where we are going into this discussion today. So as Kevin mentioned, the board did ask us to come up with some options around potentially a bifurcated change in charge or some alternative given the complexities that COVID has brought upon our hospitals. And we put a lot of work into trying to standardize some options over the last couple of days, and we ultimately came back to the same items over and over again in that the situation continues to be extremely fluid. The details from the hospital side are numerous and therefore a standardized option was not something that we are going to be able to get to because there's so much that goes into the change in charge discussion. There's a lot of unknowns that go into that too as we've stated, utilization is unknown. How long is it going to take the hospital to recover from COVID related financial impacts, et cetera. So we couldn't really get to a standardized option within the work group that we put together. So what we've done is we've put together a list of some recommended assumptions that the board may want to include in a discussion today around the change in charge piece. And that is, as has been alluded to, having the hospitals come in with a regular change in charge increase, which is already built into the guidance, but also adding to that a COVID-19 related charge increase but let the hospitals discuss the assumptions with consideration given to loss of commercial revenue and fiscal year 20, loss of utilization in fiscal year 20. What percentage of that utilization do they anticipate on recapturing in fiscal year 21? What amount of stimulus funds have they received to date? What could possibly come in the future? As we all know, these submissions will be in late July and with a fluid situation, as we've mentioned, there could possibly be more federal stimulus monies coming down as the situation evolves, moving into the early part and middle part of summer. And also, where the hospitals see Medicare and Medicaid fitting into this equation and what will be known going into June and the early part of July as they begin to put together these budgets and find out where the COVID impact shortfall is, how long it's going to last, et cetera. So those are some assumptions that we believe the board should consider. That doesn't mean it should be limited to that. Certainly, whatever the hospitals come to the budget discussion with next year, they will have to describe in detail what their assumptions are as of that point in time. And with the fluidity of this situation, we know that that's going to be difficult and also can change rapidly. So we wanted the hospitals to have the emphasis on this instead of trying to create some sort of standardized model that may not do justice to the entirety of the situation. Additionally, with the change in charge proposal, the board may also want to consider the hospitals' current financial situation, the solvency, what expense reduction plans that they have and long-term strategic and financial plans for sustainability. And sustainability is not just the phrase of the day in the healthcare world right now, but around the country as COVID has not discriminated against its impact on the economy of the United States. So building that into the discussion is also very important, moving into this budget cycle and into the next fiscal year. Also considering insurance information regarding actual and projected utilization and price changes, impact on Vermonters and employers in the commercial market and any other relevant factors that the board may want to consider within this guidance. So to provide an example, probably on more of a worst-case situation is what the hospitals may be looking at and what the board may have to consider with these very difficult decisions is what could the potential COVID impact be on NPR moving from the latter half of March and April through September. And like I said, this is a worst-case scenario, it's simply an illustration. But looking down at the bottom of slide six, there's the potential that in the latter half of the year there could be some major NPR shortfalls coming in. And that right there does not consider any stimulus grant monies that the hospital will have received. So taking a look at the situation as it stands related to that patient revenue and then navigating to slide seven and seeing according to the hospital's payer mix history where that money would trickle down into its various payer silos. Then you add back in stimulus grants to find in the lower right-hand corner a post-stimulus allocation NPR revenue gap. And it is within there that we would think the hospitals could begin to build that COVID temporary commercial increase to try to get themselves as close back to normal considering utilization and other assumptions that need to go into it. And also discussing with the board what's your timeframe to get back to where you were. So this highlights the fluidity of it. It highlights the fact that the board is going to have to make some very tough decisions. But it's trying to consider as many factors at this current time as possible in relation to how to make the best effort possible in coming forth with a COVID-related charge increase on the commercial side. So continuing on to slide eight. These are some of the high-level items that Kevin alluded to earlier that still need to be worked out. The guidance continues on with this discussion. But the big piece here is the change in charge and how the board wants to treat that. So backing up into those assumptions that we've put forward for consideration, the hospitals would have to come forward with those as they bring their budget to the board for hearings. Also the NPR growth target, we left that tabled last week and the enforcement policy as discussed earlier. And also the matter of the budget guidance timeline. We had moved the submission date to the 31st and that's proposed. That has not been voted on in any sense yet. And during the last week, the HCA sent over some comments and guidance questions. And the first was that guidance language should be added. They proposed guidance language should be added around COVID-19 funds that have been received and the use of those funds in any requirements tied to them. So the board need to consider acceptance of that into the budget guidance and then their questions included a fiscal year 20 and 21 commercial rate chart that they sent to us by payer. Financial assistance information during COVID and provider recruitment with the federal J1 visa waiver program. And those documents, I believe have been posted to our website upon receipt. Additionally, as Susan alluded to earlier, keeping the public comment period open until May 26 which I believe is next Tuesday following the Monday holiday at 10 a.m. a potential blurred vote next Wednesday on the 27th and following any vote, whether it's next Wednesday or next Friday, distribute the guidance to hospitals and post the information to our website. So with that, that concludes my presentation. I'll open it back up to the board and if you would like me to toggle back to any of the slides, I am happy to do so. So just to let me know, Patrick talked about a possible vote on the 27th or the 29th. Just to let the public know that we haven't scheduled the 29th yet, but it will depend on how things are going today and through the public comment period. I've asked all board members to set aside the time on the 29th so that if we're not able to finalize things on the 27th, we could come back to it on the 29th in a way to try to give hospitals as much time between when this is finalized and when they have to submit on July 31st as possible. So with that, I'll open it up to board members for questions of Patrick. Did I lose everyone? No, this is Maureen. I'll start off with a couple of comments. Patrick, maybe if you could go back to the slide where it kind of builds the components that could go into the rate increase. I think it's the one before that. The one before that. No, you passed it. Sorry. Is that it? Yes. I guess just a couple of things I also think could be in consideration here. One is the time frame. So, you know, what is the time frame that a hospital is looking at to kind of get back to their historical, I guess, financial metrics? And, you know, there's different ways that could be, right? So one option is that it's really over a multi-year period, so this year it's primarily impacted six months. And then, you know, going into 21 and 22, not sure if the expectation would be that they would be able to recoup everything in one year. It could be over a two-year period. It could be over a one-year period. I mean, that's something the board could discuss about what the expectation might be, although, of course, this assumes that COVID is not having additional impacts, which it certainly could. So I would put time frame out there as a potential thing to look at. Also, on the next page where you talked about considerations, you know, another consideration that the hospitals will be going through will kind of be, are there going to be any permanent structural changes? Is telemedicine going to become, you know, part of what we move forward with? Not everything continuing at the full force, telemedicine as it is now, but will that be a component in the future? And if so, you know, what are the reimbursement? What's the cost for hospitals to do that? Are there benefits? So that's just one example, but there may be kind of structural changes that occur from this, you know, as well as I know we've talked a little bit about confidence of patients coming back in the hospital. So who knows, will we ever regain the levels where we were before at a steady state? And if not, that would also, you know, need to consider some structural changes, not necessarily reliance on fixing it all with a commercial insurance change. And then I'm not sure if we explicitly put in here, you know, we don't know what's going to happen with reimbursement with Medicaid and Medicare, you know, the other payers or if the stimulus funds don't make up the gap that was created there, will there, you know, will there be price increases that will carry for those payers that will help alleviate that in the future? So those were just a few things that I think we should also be, you know, considering. And then if you move to the next page, you know, I think you brought up here, you know, of course, expense reduction plans, you know, anything that can help the hospital get back to where they were financially and offset, you know, reliance solely on rate increases, you know, will be looked upon as well. Because I think we also have to factor in any large rate increases for the COVID piece. I don't know if you've explicitly wrote on this as well that they would expect it to be temporary. So whether that was going to be a one year or as I brought up possibly a multi-year where maybe the increase isn't as large but carries for a couple of years, but eventually we would expect, I believe the board would expect that that would go away. Because as we're thinking about this, we also need to think about what is the impact on the insurance companies because we, you know, there's one expectation that there's going to be a surplus created from this. So how does that roll through? But that hasn't been proven out that there is a start point. And then just one final point I'll make on, you know, this is an extreme example, but if the hospital was down 25% in volume as the example you showed this year because they were down, you know, basically 50% off for half of the year. If that all does come back next year, and that's obviously a big assumption, you wouldn't need a rate increase to fill the gap because you really would just be shifting a big loss in this current year to a big gain in the future year. And that's why it's going to be so important to really have a good estimate on what they think utilization increase will be next year. And again, that was an extreme, I don't think they're going to make all of it up. But I believe the expectation is that some of that will come back and that puts less pressure on having to recoup everything with a commercial rate change only. So those are just some thoughts for people to think about. Thanks. Kevin, you're muted. Well, thank you, Rob. I was trying to figure out where that feedback was coming from. It clearly wasn't from my end, but I was getting feedback when Maureen was talking. I just wanted to say that Maureen's brought up some really great points. And what I think we've learned already is that each hospital is going to be unique. So for example, during regular monitoring calls, Patrick and Laurie and I learned, for example, that at one of our smallest hospitals, that they're seeing most of their numbers coming back to a more normal rate. They're not at 100%, but they weren't hit as hard as when you talk to people like at UVM or Rutland or other hospitals like that. So each hospital is going to be different. And I think that the second part of the change in charge which is the temporary change in charge part really will be determined by the individual hospital based on what they see, because also each hospital is going to have a different ability to meet if there is pent-up demand. They're going to be limited by the members of their staff, by their physical plant, so that where one hospital might be able to immediately meet pent-up demand, it might take another hospital more than the 12-month period to meet that demand. So I think that what I would see this as a temporary one-year increase on that second part, but the board would have to have a discussion as we go forward if there was a second wave or if there was clear evidence that people were staying out of medical care because of fear, that we might have to revisit and have the same opportunity for some hospitals next year to have that second component. But I'm hoping that for the purposes of this year's guidance, it's really a one-year temporary change. That's the second piece. And that's my thought on that one. Questions or comments for Patrick? So this is Tom. And there is feedback there somewhere. Somebody's got a mic open. My thinking on this is this summer period could be very, it's going to be very important to hospitals. And so the issue is for hospital staff, administrative staff, where do they spend their limited time? And I think that we're on the right path of trying to find a very streamlined approach to relating to the hospitals in terms of their 2021 budget because there are so many unknowns. And a couple that obviously we've mentioned Medicaid. We don't know how Medicaid will fit into this in the 2021 period. But I do know that Steve Klein from the Joint Fiscal Office yesterday, I think, basically told folks in the legislature that of the $1.25 billion that has the small-state minimum been granted to Vermont, $1 billion of it is, quote, unappropriated and unspent. Adam Greshan in presentations to the legislature added up all the CARES Act money. CARES won the CARES Act and COVID-19 money and totaled it to $1.59 billion. But on the expense side, and this includes what had been expended through May 6th and projected forward, was only $166 million. So from a hospital's perspective, they, I think, need to have the time to be on that playing field to leverage as best they can any available resources from the federal government to their best advantage. So that's one thing that I'm sensitive to that those issues of how to apply money available to the state. That it's not state money, but federal money haven't been resolved yet, and it will take time on task for the folks at VOS and folks at individual hospitals to make sure that they're being treated fairly in that process, independent of the money they're getting directly, but having to do this one point, this small-state grant. Another issue is I'm very concerned that we don't exit this process in 2021-22 with some zombie hospitals. Hospitals that we know going through 2019, that there were seven hospitals that had a negative operating margin. In 2018, there were eight hospitals that had negative operating margins. And so it's really important for us to kind of appreciate that every hospital has its independent characteristics, which is true, but also as a collective, some hospitals have more advantage than others in terms of issues like pay or mix or issues like negotiating power because of size, et cetera. So our process, I think, has to be sensitive to trying to level the playing field. At least I don't believe the existing, coming into this, that the existing playing field is a level one in terms of pay or mix, the cost shift, and the scale of some hospitals relative to the scale of others. So a big outcome, in my view, is that as we exit this period, that every hospital be on a solvency track or be solvent when we arrive in 2020-22. And if we can achieve that, I think that would be a major accomplishment. So the only thing I would add to your comments, Tom, is that it would, I agree with you except with the one caveat that a hospital shouldn't be made whole just because of the fact that there was COVID-19. They have to demonstrate that they are properly managing their hospital towards sustainability. And so I just don't want anybody to think that there's going to be a free windfall that's going to be on the backs of commercial ratepayers in Vermont. Kevin, I fully agree with that. I just, I harked back to a bit of history in my life where in the recession in 1990, Governor Snelling went to the legislature and asked them for tax increases, but tax increases that had sunset. And then Dean, who accepted the criteria that Snelling had laid down, came in and kept the state its base spending on a sustainable level. I mean, in 91, 92, 93, we went negative a couple of years in order to make sure that we didn't take those extra taxes and grow the state budget. So I do absolutely agree with you that there's got to be some factor in this process that is a benchmark that we want to achieve. And, you know, last week when we discussed this, I was talking about a cap, you know, but with a very small C and very moderate, if any, enforcement associated with it. And, you know, I would feel that if we get through into the 2022 period, and all of the hospitals are reasonably solvent, that will be an achievement. But we do have to get there in a way that respects the long-term statistics that we drive this bus with, which is the 3.5%. Okay, thank you, Tom. Just want to make sure that Robin or Jess have a chance to ask Patrick any questions. If you don't have questions or comments, then I'll try to create a framework where we could start to move towards some tentative decisions, starting with some of the easier ones first and then going from there. So, Jess or Robin, did you have any questions or comments on Patrick's presentation? I have a couple of quick comments, but Robin, do you want to go first or...? You go ahead. Okay, so I just want to say just in general, I support, I think, as I said last week, the abbreviated guidance. And I appreciate, thank you, Patrick, for adding to the narrative the service line, any service line changes and risks and opportunities. I think those were good additions, and not too hopefully onerous. Again, I support the moving back, the deadline, I thought the HCA's questions and requests for more reporting on how the COVID funds were spent were good ones, so I would like to see those added. And in general, I do support this concept of a temporary COVID adjustment that sunsets over some period of time. One question I had for you, Patrick, was whether or not you thought it was possible to adjust that mid-year. So let's just say that a hospital is really bringing back their revenue through utilization more quickly than anticipated. Could that be adjusted downward? Or another hospital that's, you know, really not seeing the volume come back, could that be...? I mean, we always do mid-year upward adjustments. We don't usually do mid-year downward adjustments. So wondered what your thoughts were on mid-year adjustments to the temporary COVID charge. And then, I guess I would say, an echo that I think these have to be, if it is put in there, it has to be tied to commercial losses, and it should factor in any federal and state grants. It should factor in any increased reimbursements that we're seeing from Medicare and Medicaid to ensure hospital sustainability, as those are the other two big payers, and they may be making some efforts here to help our hospitals out. I appreciated Maureen's comments about the discussion of the time period. So I think, you know, note, as I always say, these hospitals are not one-size-fits-all, so I think how this manifests itself may be different for each hospital. I would like to see an analysis from the hospitals on the impact of their commercial charge increase on what they foresee as changes in bad debt and free care, because I do think an increase in commercial charge will have an impact there, and I think it's important for us to understand what that might look like. And I guess, and I'm just, and I'll give you a chance to answer my one question about the mid-year adjustment, but I just, I would say from Tom's point, I do think we all hope that we emerge from this with a high-quality, affordable, sustainable healthcare system. I do think that financial crises sometimes force conversations that are difficult to have, and I hope some of those conversations are around right-sizing some of the hospitals, and I think this amplifies this financial crisis that we're in amplifies the need for sustainability plans and service line optimization and looking for opportunities for efficiency gains. So I know today's meeting is not the topic of those sustainability plans, but I would like to, you know, put that on the agenda soon as we start to think about what it's like to get in these budgets in, and it would be really helpful to be starting to move down the path of understanding how the hospitals are going to see a path for themselves for sustainability. So those are my comments, and I guess my question was largely password about the mid-year adjustment and how you see that being operationalized. Yeah, so from my perspective, which is outsider looking into a hospital, I think it's doable. However, I don't want to say that with a bunch of certainty because I don't know what goes into the having to make the changes to all of the charge masters and schedules and whatever. So I guess there, I would probably ask the folks at VOS if they could reach out to some of the hospital financial leadership to see if that's operationally something that can be done with relative ease, and that really does go back to the fact that not knowing all the work that goes into changing that or the negotiations with the insurers, I think we want to hear some feedback on that first. Okay, thank you. Okay, Robin. Yeah, and just to finish off that conversation, my recollection from a few years ago is that Rutland actually came in with a mid-year charge reduction because they were running hot and they were trying to stay on budget. So I think it's at least theoretically possible for some hospitals. So I agree with us trying to get more feedback on that in terms of from hospitals and also from the insurers. That would be helpful to know their perspective as well. So I first of all, I want to thank the team. I think they did an excellent job of summarizing the discussions that I had with them and that Maureen had with them around different factors to be weighed. And so I feel like I feel pretty comfortable with having kind of the factors spelled out in the guidance so that it allows for hospitals to kind of make their case and also for us to consider hospital-by-hospital-specific information. I do think folks made some good suggestions for some additional considerations that we could add. That's all I have. Thank you, Robin. So it's clear that we have a lot of decision points. And let me try to start a framework where we can start to make some decisions and have discussions about different topics. So first of all, let me start with the most recent option which was proposed to us this morning from VAUS about not having the 21-budget process in place this summer. Is there any board member who would like to make an argument for that option? I'm not hearing anyone making an argument. I'm going to assume that that option is off the table for now. Yeah, Kevin. I would just jump in to say that I'm not comfortable with that option because while I think Act 91 technically would give us the authority to do that, it was not an option that was discussed with the legislature. And it's much more of a process than the different examples that we've been using in the discussion to get that flexibility from the legislature. So part of my discomfort is that I feel like it goes a little a step too far for sort of our rationale for getting that regulatory flexibility. Thank you, Robin. I share your concerns on that. And I do think that now more than ever, as Jess said, we need to have sustainability and this process is part of that plan to get everybody unsustainable footing. So again... I just wanted to make one comment on it as well, which is I'm not supportive of not having a process. I think we try to minimize the deliverables and the hope would be that the meetings that we have with the hospitals in August in person or virtual that would be much more in conversation about what's going on. And probably one of the big concerns would be if there's no budget process what does happen with the commercial rate increases that will be asked because we know typically they've told us it takes about 60 to 90 days to get that through and with the insurance companies which is kind of ties in with that October timeframe so that most of these insurance changes so I would just have a concern if there was no budget what does that mean for what would be rolling through for commercial rate changes so I think we have tried to minimize what we're asking but I'm not supportive of not having a process knowing that yeah, the budget there will be lots of changes the actionals to budgets will evolve every month and that's as expected and it will be more in flux for the next 18 months than historically it has been but it's just a starting point thank you marine so I'm not hearing anybody argue for that option so at this point we'll consider that option off to the side another let's start to talk about enforcement I don't think we officially took a position on 2019 I know I've argued in the past that I don't think there should be any enforcement for 19 or 20 but just for a simple hopefully simple discussion would somebody like to make a motion about 2019 enforcement I actually thought we voted on 2019 enforcement with the first time we looked at the guidance I couldn't talk about it anywhere maybe we did but I couldn't find it this is Mike I believe you did good for 2019 okay so moving to 2020 and again I would use the same argument that the way the 2020 guidance went out if anything the biggest pieces of the enforcement would be on the downward side and nobody should be punished because they lost significant utilization due to the pandemic so does anybody wish to make a motion on 2020 so 20 just procedurally before we I'm happy to make a motion but before we do that 20 we voted on a guidance document for 20 enforcement last year as part of the guidance so I just saw a lot of hospitals left hanging out there thinking that there could be possible enforcement for the 2020 budget year that's where I'm coming from Robin I know that there's guidance that's already been out there but that guidance specifically talks about the variations both to the up and the downside and I think it would give some comfort to hospitals to know that they're not going to have to deal with enforcement for 20 yeah I'm not sure I support the urgency of doing that right now with you know we can look historically at what we've done for guidance for enforcement and there has not been a lot you know a lot of actions that have been done so I wouldn't assume that there would be much done for or anything done for enforcement at the end of the year but why give up that up now something could happen as unlikely as it may be that would create a situation where there maybe should have been enforcement so that's my only thing you know I think we've been I think we've been fairly reasonable on how we've looked at enforcement I'm not saying at all that I'm going to be trying to enforce unreasonably I just don't understand I don't support giving that at this point I don't see the benefit I don't perceive that hospitals are worried that we're going to be enforcing them in 2020 when most of them are probably going to be losing a lot of money but should for some reason there be a windfall on what they're given for stimulus funds and a hospital that we're saying now has come back and all of a sudden they exceed significantly again very unlikely why are we even bringing that up right now that's my point of view and I know it's just one point of view but I don't see why that's even an issue at this point I think it's great let's move forward with 21 I don't know why we need to talk about it but Kevin I'll jump in here I support waiving enforcement for 2020 I think so many things happened obviously beyond anybody's expectations or any way in which they could have planned ahead for a 100 year pandemic and I think it's very unlikely event that any hospital generates such an incredible windfall that they exceed their NPR budget for that year if that happens I think we can deal with it in the next budget year which would be 6 or 8 months later after the time period under which we would be doing enforcement anyway so my sense is to just take one thing off of the table is to not enforce a budget that no way could possibly have been actualized I just want to add one other thing when I've looked at enforcement in the past it hasn't always been just on the upside it's been on the downside as well and those are the hospitals that actually may need more phrase not guidance but may need more in those types of situations and obviously all the hospitals are acting in what they believe is their best interest but there could be a hospital that is making bad decisions because they're down so far and I know we could still have them review things and other things but again I've spoken my piece on it I think everyone's going to be at a different position but I think enforcement is both on an upside and a downside again to protect the interest long term of the hospital solvency as being one of the underlying things that we're looking at I'm kind of where Jess is on this I support not having enforcement in 2020 budget and I think that as we move into 2021 if there's something that happened in 2020 that is along the lines that Maureen might be talking about we can deal with it deal with it then this is a continuous process and it's not just one year so I would rather take it off the table now for 2020 not have hospital worry about it but know that if something does happen in 2020 that we can deal with it in the 2021 process for 2022 process thoughts Robin well I was trying to pull up the guidance because I didn't go back and read the enforcement from last year guidance which makes me a little bit uncomfortable waving it because I haven't read it yet keep in mind that anything that we do vote on would be tentative anyways yeah I mean I certainly I don't want hospitals to worry about it and I do think it's unlikely meaningful enforcement would happen what I just haven't thought through yet is that there is people are assuming that they can then fix that in 2021 which maybe but I think leaving me and if it's clearly related to 20 I just need to think about the legal part of that like I don't know if Mike has any thoughts I do have a I think one of the things that I heard Kevin say was basically enforce two years worth of budgets together right so 2021 combined enforcement at least that's how I understood it so I'm also a little bit concerned about waiving enforcement for 20 when really it's kind of like a combined enforcement for two budget years that's potentially on the table it'll if that makes sense I understand what you're saying Mike but I think that the point I was trying to make was not to have the enforcement be for two years the enforcement is really for 2021 but only it exceeded the two years plus a growth rate and so I didn't really consider that to be 2020 enforcement I guess you could try to make an argument that it could be well I was trying to take easy decisions off the table but sometimes they're not always that easy conceptually I'm on board with what you're saying but just legally I want to make sure that we frame it in the right way so maybe what makes sense is for the legal team to take a look and I'm happy to look to at the night at the 20 guidance and then think about whether that it's a waiver we're talking about or whether we can frame either make retroactively amend the 20 guidance or frame the 21 guidance in such a way that it encompasses the two years I think there are ways to get to the same result I just want to make sure that whatever we vote on is consistent with legally what we would need to do to cross our teeth and daughter rise so we'll put that discussion off till next Wednesday and Robin if you could work with the legal team to those options that would be great so that gets us to 2021 enforcement I've thrown out an idea out there do others have other ideas I know there's one option is what is actually written in the current guidance that has been put out there for comment the second option is the one I proposed which is to add 20 and 21 together and add on additional three and a half percent for 21 and then put the enforcement in that time frame in that financial frame but do board members have other thoughts and ideas? I have one I like the concept of that I guess the question I would have is when do we have to align on 2021 and the reason I bring that up is an example that many of the hospitals don't even come close to hitting that target and that might be okay but so if their budget I'll give the example of if we had $100 million hospital and this year they're at 75 and then next year they could be as high as 126 if you want to be able to have that two year combined three and a half percent and if their significantly, if their budget is 112 and so there's no way they would even hit that cap but that might be okay I'm just throwing out you know then there's not even any chance we would look at that and then that year they they far exceeded that number and it all dropped to profits I'm just throwing out examples I do like the concept of it I'm just saying we might not even be close for any of the hospitals to be able to hit that number that might be okay I just want everybody to think about that because of this hangover where even if there wasn't COVID people might not come back we may not even get close to those numbers that we could say okay that's fine it's still under the three and a half percent caps but then we're not even really looking at what they're budgeting for this year necessarily so I like the concept I just wanted to throw that out so people can think about that as well other thoughts from board members I like the concept I don't have any different ideas just to Maureen's point about the when I think typically we've tried to publish the enforcement policy at the same time as the guidance so that the hospital would understand what the potential enforcement is going into their budget submission so gives them due process for that so I think that's I think it is still a good idea to try and do an enforcement policy that is different than what we've so far put out there and then we should think about what you said Maureen in terms of whether we somehow incorporate that in some way and I guess another thing that just to think about is how it ties potentially to the commercial rate discussion and making sure we're maybe clear on that because if again utilization wasn't going to really come back that much and we're giving this combined 2-year 3.5% you could have a really large commercial rate increase of 20-25% you know a really big number because that would then offset some declines that you had received from Medicaid and Medicare and still fall within 3.5% for 2 years so I think we just need to make sure that we're not giving different messages because if you were to say this is the number you can be at and utilization is only going to be up 5% but I was down 25% this year that could potentially lead to a really large commercial rate that they may request not necessarily approved and then it convinced me you said I could be at this number so just another thing to think about well I think in that way if we had an ability to omit your adjustment then if the volume is coming way back then that commercial rate would have to come down in the middle of the year to make sure that they're actually going to I mean I think that they're leaving us an option for looking in the middle of the year at what's happening and I think I just think of this as in general so much uncertainty what we're going to do here is build some guardrails a framework but you know as you always say Maureen budgets are pretty much obsolete the day that they're submitted and the ink is dry because so much changes and they're the best estimates that people have at the time that they're making them and so I think we're just offering a framework which I think Kevin I think works I think we're going to probably find that there's going to be some things that we have not foreseen helping us and that's why I like the idea of looking mid-year and having that ability to toggle and adjust if we need to but in general I'm supportive of this notion of sort of over a two-year window allowing the hospitals who did not come anywhere close to the three and a half that were in their budgets for this year to recoup some of that next year with pent up demand and still keeping within the target that we've set for the state but I think that mid-year adjustment may be helpful if we can think about that So I think what I'm hearing is that a good possible approach to move us forward on this conversation would be to ask both the finance team and the legal team to work together to draft something this week on those two issues one being mid-year adjustment process and the second being the enforcement process based on that three and a half percent calculation that was laid out and then have them post it online and send it to board members so that we could definitely get public comment within the public comment period so the goal would be to try to have those two changes to the guidance out by Friday. Patrick and Michael is that doable? Speaking for legal I think so Patrick, how about you? I agree Okay Kevin can I add one thing that maybe perhaps could also be put out there for public comment related to this which is the COVID adjustment the hospital team put a list together of the possible factors that hospitals should consider as they're estimating what that COVID adjustment might be that temporary COVID adjustment I think we should put that list out there for public comment adding a couple of the things that we're discussed today. So Josh you're jumping out in front because that's going to be the next conversation about the page and charges Perfect sorry I'm trying to knock out a couple as we go but move forward and also give the public an opportunity to comment today but also to make sure that they know that they have the ability to comment up until 10 a.m. next Wednesday and again Wednesday before any votes would be taken we would throw it open to the public so could I get a is that okay with all the board members that we have the staff work on those post them send them to us send it out to the broad world so that we can get the comment does any anybody object to that that effort perfect so hearing none we will get to that what I thought probably would be the most difficult part of the discussion which is the bifurcated change in charge and so let's let's take this in two separate pieces is there anyone who does not believe there should be a two part bifurcated change in charge of so could you make your arguments now so I'm not hearing any argument so I'm going to go ahead with the conversation about the two parts of the change in charge one part would be the permanent change and what I asked staff to do was to go back and do a five-year cager on what the system wide change in charge has averaged over the last five years that came out to 2.8 percent so I'm hopeful that the base target cap for a change of charge is somewhere around 3 percent and that obviously just like any change in charge that we have considered over the last multiple of years each hospital would be able to make a plea and tell their story about why they might need a higher change in charge but to know that going in where our thoughts are on that base part of the component I thought we should have that discussion and throw it out there so just throwing out where I'm at I'm at around the historical average or a little bit above which would put us around 3 percent I just wanted to get feedback from other board members on that base component anybody can jump in so I'm going to start calling off names in alphabetical order because we do need to continue to progress if we're ever going to reach our goal of finishing this up by a week from Friday so in alphabetical order that would be Jessica I support the idea of a permanent you know when we say permanent baked in going forward the change in charge I think that your target seems reasonable given what we've always done I don't know and I think hospitals will have to tell us and we can certainly you know research this ourselves but how has medical inflation changed as a result of COVID so our supply is driving those prices up the fact that the workforce shortage may be lessened because there's more supply available maybe that's putting less utilization maybe there's less need for temporary staffing I mean there's a whole bunch of factors here that I don't know how COVID affects expenses going forward so I would want to learn a little bit more about that but in general I think that your target area without that information sounds reasonable so I think that's where the hospitals might make a case if they have some particular you know new information on medical inflation as it pertains to COVID and getting you know how has that affected supply chains and things like that thank you Jess Robin so one of I think one of the worries that I have about setting a specific number is that using a historical number doesn't factor in that COVID will still be here for fiscal year 21 and the temporary change as we've just temporary COVID change in charge as we've discussed it was backwards looking in terms of making up for reduced utilization in the past not necessarily adjusted for what is our best guess about what happens in 21 so so I don't have a number in my head but that would be my worry about using a 3% is that if we come to August and we think that COVID you know we see there's another COVID outbreak and that utilization is down and looks like it will be down you know for several months in fiscal year 21 and we know that like that 3% may not be the right number so I just I don't know how to think about it in that sense. Thank you Robin. Tom. Well I think that it's good to have a guard rail and 3% is a fine number with me as long as there's some language that gives the message that hospitals could that the door still open for discussion or hospitals that may need more. I still worry about the kind of chronic disease that our system has in terms of pair mix and some hospitals are you know better situated than others and I would just want to make sure that if a hospital feels that guard rail of 3% is too constraining that the door is open for an enhanced discussion. Kevin this has to do we need to put a number on this? I thought you were kind of throwing this out there as just your general feelings but do you actually want in the guidance to be a number on the base for the commercial rate? So it's not something that I necessarily want Jess but it's something that I thought that the board had decided at a previous meeting that they wanted actual guidance in on the charge and so if the board decides that they don't want to put a number in but just a narrative about that I'm okay with that but I was interpreting what that previous decision from the board was that they wanted some better language on change of charge in the guidance and that's why I was pursuing that. Okay well I guess I'll just say from me personally I like a two-part charge but I'm not sure that I'd put a number on either part and I think I would just say let the hospitals put forth what they think their base charge increase would be as we do in any other year justify it and then put their part two Covid charge that we are saying is going to be temporary and then justify it so I guess that's what I would say. So sorry I think Maureen hasn't spoken yet I jumped in. That's okay Yeah you articulated perfectly what I was going to say as well which is we have not typically given a specific rate for commercial and I think looking at the past and that the five years has been at the 2.9% I think though if we were to go that route I would have wanted to go deeper what has each hospital done some hospitals have had negative adjustments in prior years that brought their numbers down other hospitals have averaged higher so you know your call is very important to us please stay on the line and your call will be handled in the order it was received so whoever that is if you could move your line I guess I'm going to have to do it here and then each individual speaker is going to have to hit number six unfortunately so let me figure out I had this figured out once earlier and let me figure it out again I think Abigail had sent some instructions All of our representatives are assisting other callers at the time your call is very okay so can anybody hear me now yeah good okay so I think I've successfully muted whoever that was and and if you're not listed as one of the presenters if during public comment you wish to comment or speak star six or actually you probably could just unmute yourself if you're on Skype but okay so who was speaking so I was speaking so really I just think as well maybe putting some descriptions in the narrative but not putting a specific number particularly this year since as we've always said it's not really one size fits all and I think just trying to put one number in there when if we looked at each of the hospitals their five year CAGR would be different so I think yeah I don't support being in a hard number but I do support having two components when they come in for their budget one being the kind of permanent rate increase and the other being the COVID temporary yeah and in case I created the confusion last week being a lawyer in my mind guidance is words and criteria and factors not necessarily a number so I hadn't meant to say I thought we should put specific numbers just that I thought we should put some factors in for people to think about and I think Patrick's team outlined those well in their presentation okay so when you go to the words Robin would it would those words say something that the base component would be more directly linked to what has historically been a hospital's change in charge and not that piece as it relates to utilization from COVID and again we've always told every hospital tell their story so that there have been accommodations would you put any of that wording in or how would you phrase it so I think in the I actually started working on a draft with the teams earlier this week and I think the way it's currently we currently started working on it was to have the COVID components be a description of the temporary increase linked to reduced utilization from 20 but that the factors were basically would apply to both components so that when we were looking at either the permanent or the temporary we would be looking at a multitude of factors like we always do right we're always looking at the charge versus utilization how it rolls up to the NPR we're always looking at what's the hospital's financial situation what are their specific circumstances so that's did you have some very clear language that the base component should not contain anything that relates to recapturing a lack of utilization from COVID or anything like that not yet but certainly you know it's a work in progress based on today's discussion so it would need to change anyway how quickly could that be ready for prime time so that that could be shared with the public posted on the website and had public comment on well I would defer to my team but I think since we have this part we've done with it could go out on Friday with everything else but Mike does that seem doable to you yeah yes okay so I think what I've heard from the majority is that they would prefer not to have a specific number does anybody want to make one last pitch for a specific number so hearing none I think that the staff has the charge of what is being sought for and some proposed language that can go out to the public for comment so now let's get to what I envisioned was the hardest part and maybe the easiest part because sometimes it's very hard to predict what will be an easy conversation and what will be a hard conversation but let's start to focus on the second part of the change in charge and this time I'll go in reverse alphabetical order just to give Jess a chance to breathe and Maureen if you could go first with your thoughts on what you would like to see in the second part of the change in charge so I'm not I'm not hearing you Maureen I'm on mute okay I think that the page that Patrick kind of outlined with the specific things we would be looking for I don't think I'm not looking for a hard number for for this piece and it's going to have to be very much supported with assumptions of the hospitals on what this is based on so looking at right loss of commercial revenue as the starting component recapture of utilization in fiscal 2021 the stimulus funds to date and projected I think should be addressed but I also think in context of the commercial rate ask right here we're talking about separating it from commercial revenue and not including Medicaid and Medicare to make that amount up so I'm thinking that the money that they get from the stimulus is most likely going to need to be applied to the loss that they had for those two pieces so we would want to know about that and know if any of those funds are being offset to commercial but that in my mind is not a requirement so I think it's you know they can have it out there is what their assumptions are and then things on the next page as well which incorporated you know the expense reduction you know kind of when I think about the long-term strategic and financial plans you know were they looking at this as recouping everything in a year or was this over multiple years because I'm not know the specifics enough if a hospital was even trying to recoup this all in a year what we have seen in the past is when they take a charge increase it is also not it is often not across all of their services so they may only do hospital-based services and not physician-based services and if there's some limitation as to why they need to do that it could be huge numbers of what they would be increasing certain services by so they may find themselves limited in how much they can increase in a year or would want to increase in a year and want to do it over multiple years so I think the understanding the multiple year factor is important too so you know right now those are the variables I would have that should be considered in their request thank you Maureen Tom I think that the it should be kept as simple as possible in terms of what is clearly COVID related and I think Maureen makes a good point that it could be a multiple year profile but I worry that the language is so general that hospitals will be putting a lot of things in there and so the guardrails around what should be included and I think on the previous slide is pretty clear but even there when you get into pay or mix what about Medicare and Medicaid there's a lot of integration of that concept with what is happening now in terms of the COVID experience so less is more I think here thank you Tom Robin yeah I think I'm aligned with where Maureen is I think it has to be in Tom too I think we're all it sounds to me like we're all pretty much on the same page that we need to have considerations but a lot of flexibility both for the hospital to make their case and for us to take all the different factors and whatever information we have or don't have available at the time so I think that's good on the change in charge I would just mention that I think what we learned in some of our previous reports around rates is that the change in charge typically only applies to inpatient and outpatient hospital services the physician dollars are on a fee schedule so those are not impacted by any decisions we make around change in charge so just when we are thinking about the impacts that's a good thing to remember good point Kay Jessica I don't think I have much more to add I think the time dimension will be important to understand over which time period we're thinking of applying this I think it's important for us to understand if there's any the federal and state stimulus funds in my mind should offset losses from all three payer types Medicare, Medicaid and commercial it would also be helpful to understand any assumptions they're making about increased reimbursement reimbursement adjustments to offset losses that are coming from Medicare and Medicaid so we have all of that information and then to the degree I just mentioned this earlier but what is the impact on bad debt and free care that they're assuming this increased commercial rate might have so that's it for me and I think letting the hospitals do their calculations make their best assumptions and let's see what it is see what it looks like okay so I'll put in my two cents I think I'm the only one so I'm definitely in the minority that would have put a formula out there for the calculation for the individual hospitals basically because I worry that there could be a question of fairness and it just puts more pressure on the Green Mountain Care Board to get to the bottom of this component if there isn't a firm formula and what I had suggested is a formula that basically calculated the loss of commercial revenue and was a way for them to get that back so that we're not pushing the system boundaries because as everybody knows it's really a function of price and utilization and it was an attempt to create sustainability by having a short-term price increase that would be durational in length and would allow that and I think that's everybody still saying that but I do worry that by leaving it up to the hospitals if there isn't a strong formula put in place that we could see some very wide-ranging proposals on the second half of this I guess that doesn't truly scare me because I think we have the financial acumen to get to the bottom of that I just thought it might be more helpful if we were more upfront with what we expected but I can live with it clearly I'm one of five and I didn't hear anybody else supporting that so with that I think that the charge again would be for the legal team to draft language that puts in place the assumptions that are made out and allows for them to make that pitch and so Mike could you also have that by Friday now that we're asking for such a lot? I anticipate yes I mean we can puddle with the hospital finance team today and tomorrow and hammer out some language and I think that's possible okay so Board what are the other open items at this point? What am I missing here? Anyone have anything? I think one potential open item was do we want to talk about we had previously put the three and a half percent in for this year as for 2021 I know we've talked about enforcement being a combination of the two years most likely that three and a half percent if we went on that theory that we thought hospitals might be low in 20 offset by higher in 21 then most of them could conceivably come in with requests significantly higher than three and a half percent for the year so I know it's when we're looking at the two year it kind of comes together but again in that example of a hospital that's at 100 that's coming in at 75 this year under our enforcement they could come in at 125 next year which would be a 25 percent increase over NPR I'm not saying that will be the request but clearly they could come in at 110, 115, 120 and so I think that three and a half percent in there is meaningless for what we would potentially would get for 21 submissions I know we've gone back and forth do we put nothing, do we put something and maybe there's somewhere in between I don't have the answer for what it is but I think that was one of the open issues so again the only reason why I had been pushing for that is that we would expect hospitals if things go well and if people are willing to go back to hospitals for their medical care and we don't see second, third, fourth waves that it would just be a one year opportunity for hospitals to blow through their NPR and so that's why I suggested just using the three and a half percent above the 2020 NPR knowing that nobody's going to be enforced unless they really go above the 103.5% plus whatever drop in utilization they saw in 2020 so that's why I had thrown that out there but I'm willing to entertain any other ideas so we could put something similar in the guidance for the year which would be you know something about that multiyear I mean that could be in the guidance as well right so rather than having it be three and a half percent it would be the cumulative from your 19 budget to your 20 budget to your 21 adding in 2020 it would be the same thing as enforcement in reverse I mean we could incorporate that potentially which would probably be more meaningful than just saying it's three and a half percent or as you said you know you just keep it if we put it in there three and a half percent probably I'm just very ignoring that people will think that whatever that budget number that you give them for the NPR is permanent and that they can work off of that in the future and that's that was my fear and why I put out what I put out so I think that that section of the written document needs to be consistent between with the enforcement policy because the enforcement policy is appendix 5 to the document so it's all one document so I think that when legal goes to work on it they will see that they will need to change the language that's currently in that section in order to be consistent with the enforcement policy so I think it will end up it should probably end up reading something more like what Maureen was saying otherwise we have a conflict in our documents but I also think if we roll it forward so if we go all the way out to 2022 so again using that 100 million example so this year they come in at 75 I'm just going to be extreme for illustrative purposes next year they come in at 125 the following year we would expect them to be about 107 right so that would be the three and a half percent each year so it's a decline from 21 to 22 of a fairly big number so we're not going to want to have three and a half percent in there per say that year it's kind of this you know again we're trying to predict a lot of things but if we said next year's was a temporary both a temporary rate change and a temporary utilization increase for the loss utilization this year then the following year would go down so I'm just trying to think about it going forward too so that year we wouldn't want to put three and a half because that three and a half would be you know would generate 130 well that's exactly the point that I was trying to make that they need to know three and a half percent in this year it's the same they're going to expect my expectation is if we just plug in three and a half every year then why wouldn't we do it the next year if we know this year won't be three and a half if we believe that they'll get some utilization and put the hefty commercial rate in why not put what put something in there and then the next year it goes down. It's creating a floor for the 22 discussion that's the only reason to put it in there is it creates what we'll be talking about for increases for the 22 budget because if you don't put some language in there and I think that we're kind of saying the same thing but we're going about it a little bit differently but I think if you don't put some language in there we're going to have changes with people's interpretation of what their base is for 22 and I think at the end of the day we're coming about it to the same point the only slight correction that I would say to you Maureen is it wouldn't be a straight 107 because there would be natural compounding. No I know but my point is it would be that like this you mean for 2022 correct. 2022 would have been 20 if we started at 100 then 2021 should have been 103 and then 2022 1.035 is 103.5 times 1.035 is 107.1 so it would be 107 but what we're really thinking will happen is it'll be 75, 125 and then 107 so the 107 divided by 100 that's what I'm agreeing with you on it doesn't matter how it gets worded as long as it's understood by hospitals that a component if you want to go the route that you're talking about say the hospital lost the 75 made 75 and lost 25 of the 100 that was proposed for this year so you're giving them a budget for 125 plus the the growth factor for next year then as long as there's some language in the guidance that reverts it back to that base which at that point would be the 103.500 for that hospital example scenario so I don't in my mind it doesn't make a difference which way you do it whether you do it through what you're proposing or what I'm proposing as long as it's clear in the guidance that in the end the component that is above the call it the 103.500,000 example would would revert back to that for the following year and I think luckily we only have 14 hospitals and I think they're all run by smart management people and I think they'll understand this concept so whether that year we actually would have said you have negative 15% year over year if we kept to a budget to budget or something like that but I think we're saying the same thing I'm just saying I don't think a 3.5% increase over their budget this year is really relevant under the conditions and I like what Robin's saying which was kind of tie it more to what we're saying for enforcement and then we can think by 2022 so much will have changed over all this COVID stuff we'll either know is it gone, is it still here what's going on you know which will impact what the rate would be but what the percentage increase Any other thoughts? Can I just get clarification so when we're writing this for Friday the direction is to change the NPR amount now not the enforcement is that the direction folks are going? I think that the enforcement part has to be changed and that the NPR has to be in alignment with that I think that the enforcement part is the 3.5% over the two years but whether you tie it to what Maureen has suggested with a dollar figure for 21 that gets a portion of which gets rolled back or you do it as a percentage base what I propose I'm fine with doing it Maureen's way as long as at the end of the day everybody's aware that they're getting back to that same base for the following years budget Talk to Mike about this why don't we do two year budgets I think we may have to do it the enforcement way because then we are looking we're not prospectively setting two year budgets we're just talking about how we will enforce the way they roll through but I need to talk to Mike and team about that why don't we try to take a stab to get us there and then make a public comment and that might help us refine it and Robin I don't think we're trying to do I'm not suggesting we do a two year roll forward suggesting that for 2020 sorry for 2021 we don't just put in 3.5% over 2020 we put it in as which we could calculate the number 2020 it's really more off of the 2020 actuals compared to their budget plus the new 2021 number would be a number and then I just gave us the example that in 2022 if nothing else happened and everything had kind of resumed we would expect that there would be an inflated number in 2021 because of the utilization that didn't get happened in 2020 that moved to 2021 and the temporary rate change that would create a situation where there would be a negative NPR budget to budget but that will deal with the 2022 in another year I was just trying to be illustrative to say I have a concern about just keeping a 3.5% because next year we wouldn't I don't think keep the 3.5% in there because it would be off a very high number so that's exactly the point I think we're saying the same thing Maureen but I think that this could be drafted in a way that it's clear to people and it's almost in the same way then as I see it the way you're proposing it Maureen the NPR for 2021 would almost have two components which would have a base and then the lost revenue from COVID component that would be allowed in addition to that and at the end of the year it would go back to that base I think we're saying the same thing but maybe we're not Yeah, no, that's what it would be but I didn't think that was expressed when we say an NPR of 3.5% which is what we had previously approved as the guidance I think we're saying the same thing but we're going about it differently Okay, that's fine So Mike, do you have enough to take a stab at that? I think so, Patrick You good too? I'll likely have some clarifying questions offline but yeah, I'm good So other than NPR and change and charges are any other parts of the guidance that a board member wishes to discuss? Hearing none I'm going to throw it open to the public at the beginning of your chance to really give us some strong feedback and you know so please don't be shy and is there a member of the public who wishes to comment on the discussion they've heard and the proposed guidance so far? Kevin, this is Susan I did hear that for folks who are on Skype and not on a phone they still may have difficulty getting in so I will unmute the audience Great Mr. Chairman, this is Jeff Thiemann if you're ready for me I can comment I am ready Jeff Excellent, thank you I know that I'm not always the brightest bulb but this conversation was a little hard to follow today and I think it shows the complexities and the moving parts that we're all managing and that's kind of a segue that I wanted to make which was to provide just a little bit of context for the Board and the people attending this meeting about the letter that we sent earlier today and the reason we suggested in our letter to dispense entirely with the sort of routine or normal budget process is that it is predicated on an environment where assumptions and healthcare business planning strategies are applicable and reliable in a normal budget process we may not have perfect information but we do have some reasonable degree of certainty and confidence in our assumptions that is clearly not the case now as I think this conversation even demonstrates and I think the hospital budget process can't possibly account for the environment we're in and the difficulty it's created in predicting volume, revenue costs, special circumstances still to come for example a surge of patients or the need to curtail non-urgent procedures again so it just occurs to me that carrying out the routine budget process right now is kind of like driving in a rainstorm you sort of know where you're going but it's really blurry and really easy to get off course and it's much safer to pull over and just wait out the downpour the only specific comment I want to make and my colleague Mike Deltreco might have others is on the attestation requirement which was also something we mentioned in our letter PAC 91 does give the Green Mountain Care Board the authority to eliminate that requirement in the current situation and we think you should CEOs quite simply should not have to swear that the budgets they're submitting which are pretty wild guesses at this point would be totally and completely accurate just given all of the uncertainty so all of that being said I would like to express gratitude for the board's work to simplify the guidance and work through these hard issues and if you do it sounds like we're going to proceed with the regular process and as that continues Vaas will certainly continue to react to the topics raised today on change of charge, NPSR cap hearings and so forth so we'll be in touch as this continues to evolve and thanks for hearing my comment Mike as a favor could you forward to the board the language that's in the attestation so that we could look at that and possibly have a discussion on it next week? Yes. Thank you. Okay, other members of the public? Hello Kevin, this is Mark Mark Stanislaus. So I too have had a challenge following these conversations and particularly from the perspective on what doesn't mean to have financially sustainable health system and and I think looking at it the way we've done it in the past is going to take what my personal belief is before COVID was on a very clear downward trend of being very clearly unsustainable and we need to find a way to stop thinking about how we've done things in the past and I would just like to throw some numbers out there and I'm referring to the total health system in 2016 we had a margin of 3.9% 2017 2.7% 2018 1.1% 2019 0.7% FY20 a loss of 0.5% Okay, and there's been a lot of discussions about sustain or impact and the impact on the commercial payers and I have to throw out there from my 25 or 26 years of professional modeling experience with hospitals and working with the radiancies multiple times I mean I've had 50 probably discussions with radiancies and I've had a lot of discussions with the radians that they have to do something to keep them sustainable that trend is not financially sustainable and I know we're talking about FY21 process but I just have to get that comment out there I just have to and and so you know that's the backdrop good before. And, you know, COVID just added to that. And there is a known that we have from the COVID. The hospitals and the providers in the state were called to action and they stepped up to action. And we were fortunate to avert the global health crisis, but all of the providers in the state stood ready and made investments with people, management and staff. And, you know, and without a financial sustainable system, you know, that readiness is going to be severely, severely, we know the expectation is going to be less and less and less. So, you know, I am very worried about this historical trend and carrying over the way we thought about things in the past to the future. And so, as I think about the future, we really need to make this about an ongoing conversation. We are not going to have any idea what the changes in the payer mix are going to be until three to six months into FY21. So, you know, trying to pick a number on a cap for FY21, I think some understanding needs to put in there. You know, as Maureen, we know put forth, we need to make this about an ongoing conversation. And the ongoing conversation needs to be not only how do we recover from this, but how do we make a sustainable healthcare system because we really don't have one today. And, you know, that's my personal opinion and I'm respectful of those that feel differently, but, you know, we don't. So, you know, from a cap perspective, you know, I do think you, if you have to have a cap, you have to factor in any difference in FY20 into that cap. Make the conversations only about FY21. It seems to me we're having a lot of conversations with about FY22 and we don't even know the unknowns to complete FY20. So, let's make the ongoing conversation about FY21. And, you know, from a rate perspective, it completely makes sense to split it into two distinctive components and not have, you know, limits on that. And, you know, particularly on the base because, you know, if you look at that five-year average over that base, that's partly what led from that operating margin from a little under 4% to a loss year-to-date December. That simply isn't going to cut it to create a sustainable system in the future. So, you know, I know that we need to work through a budget process. I know there's many connectivities to that, you know, budget process. And, you know, some of them are written in statute. So, you know, but I would stress we need to make it about an ongoing conversation. We will need to learn how to adapt on the fly both up, down, you know, but part of that conversation needs to be about sustainability for these hospitals. I've heard in these conversations a lot of time about the commercial payers. We need to get back to sustainability about the providers because if there's nowhere to provide the care in this state and the residents of Vermont have to continue to increase to get more care out of state, out of state, I can assure you that cost will be greater. So, you know, so what I can put out there, make it about an ongoing conversation. There are so many variables out there. And let's focus to FY21 because, you know, I mean, you know, we can't even get through FY20 now. So, you know, well, I believe some of the discussion points about FY22, they are things that we are going to have to tackle at that point. I don't think now is the time that we need to have the answer to those. So, I mean, thank you for this consideration. Thank you, Mark. Other members of the public? Other members of the public? I just checked to make sure that it was still unmuted. It is. I didn't want anybody to be shut out. So, I'll just give it one more chance. Other members of the public for public comment. And again, written public comments will be accepted up until the 26th at 10 a.m. And there will be another period of public comment at the board meeting on Wednesday the 27th. So, one more time. Any further public comment? Hearing none, is there any old business to come before the board? Hello. Yes. Hi. Hi. This is Susan Arnauth from the Vermont Developmental Disabilities Council. And I was trying to get in for public comment. Certainly. Go ahead. This can be captured in the budget process. If not, it could be captured somewhere. I think it would be really good information. And it goes back to the perspective payment. Particularly, though, is I just really want to speak about Medicaid. It's really the program of most interest to the Developmental Disabilities Council. So, a lot has been made of, you know, the new attribution methodology and lots more people in for Medicaid. And so, the perspective payments that went out, like, it's great that that provided a bit of a lifeline to our hospital. But I keep wondering how as a payer, Medicaid will be made whole, if ever, because Medicaid was paying all those per member per month and the admin fee and everything else has gone out the door for services that, as we know for understandable reasons, have not been provided. But at some point, you know, hopefully people will come back into the system and Medicaid will, you know, will have a with everyone who's lost their insurance as a result of losing employment, no doubt will have, you know, perhaps the service of Medicaid. So, anyway, I'm wondering if there's a way in the hospital budget process that the hospitals can account for the payments received through the perspective payment system by payer for services that were not provided. It's like how much they received in their inbox because of the perspective payment system that we've heard so much about. So, that would be my comment. And I will try to put that in writing between now and the due date, which if you could remind us all when that is, that would be great. Thanks. The due date for written comments is Tuesday, the 26th at 10 a.m. And you'll still have an opportunity for oral comments at Wednesday's board meeting. Keep in mind that we always take written comments into consideration, even if they're late. But if you want them to have a thorough and thoughtful review, it's much better to get the written comments in under the timeframe that's there, which is the 26th at 10 a.m. All right. Thank you, Mr. Chair. Thank you, Susan. Did I miss any other members of the public? Okay, so I'll call for old business again from the board. And I'm just going to call on a board member to confirm that the system is still working. Robin, could you just say a word? Hi. Thank you. So, hearing no old business, is there any new business to come before the board? Hearing none, is there a motion to adjourn? So moved. Second. And I believe General Counsel Barber that this doesn't have to be a roll call because of, unless it's a non-unanimous vote, is that correct? That's correct. All in favor of adjourning, signify by saying aye. Aye. Aye. Anyone opposed? Thank you, everyone. Try to get out and get some fresh air. It's a beautiful day.