 All right, folks, it is officially 8.30. So I can give my official good morning and welcome. My name is Jessica Holmes. I'm currently serving as the interim chair of the Green Mountain Care Board. But as most of you probably know by now as the news is out on October 1st, we will be welcoming a new chair, Owen Foster to lead the board. We're really looking forward to meeting Owen and our other newly appointed board member, Dr. Dave Merman. It'll be nice to be back to full strength. And of course, Tom Pallum, we're gonna miss you. I hope you've started booking your tea times for October 1st already. And Robin, obviously I'm really happy to continue working with you on the board as well. So the first item on the agenda is the executive director's report, Susan. Thank you, Chair Holmes. Brief public service announcement, which I've stated several times as we've come together here on our website are links to how folks can save money on the, if they buy their individual or family plans on the exchange. Please, please, please spread the word for folks to take another look and reapply as through the exchange through Vermont Health Connect as the Inflation Reduction Act has both expanded and extended those subsidies through tax credits. I know we'll hear more later in the year from the healthcare advocate and from folks at Vermont Health Connect but really just spread the word for anyone you know who buys their insurance that way they could save money. So I will turn it back to you, Chair Holmes. Thank you. Great, thank you, Susan. The next item on the agenda is the approval of the minutes from both August 31st and September 2nd. I think we'll, I'll just take two separate motions on that. Is there a motion for approval of the minutes of August 31st? It'll move. There's a second. Second. Thank you. Any discussion on the motion? All right, all those in favor, we say aye. Aye. Any opposed? Hearing none. Okay, so let the record show there was unanimous approval of the minutes for August 31st. Let's do the same for September 2nd. I just need a motion for approval of the minutes of September 2nd. It'll move. It'll move. Yeah. I think Robin Lund is moving it and Tom Bellam is seconding it. Any discussion of those minutes? All right, all those in favor, we say aye. Aye. Aye. Aye. All right, any opposed? Nope. All right. So again, we have unanimous approval of the minutes for September 2nd. I think that's all of the sort of transactional basic business of the day. Our big obviously agenda item is continued deliberations of the fiscal year 23 hospital budgets. I'm going to turn it over to our lead here on this, Sarah Lindberg, to pick up where we left off. The remaining hospital budgets up for discussion today are UVMMC, CVMC, Brattleboro, North Country, and Springfield. So with that, I'm going to turn it over to you, Sarah. Yes. Thank you. Good morning. Just one moment while I hopefully don't crash lately when I've been trying to share my computer crashes. So I'm going to close a few programs to mitigate that risk. And it's Monday at September. Hello. Sarah Lindberg for the record. So that has now finally closed. I was running an intense background process, apparently. So let me share my screen. OK. And I will present from the beginning. OK. Am I still with you? All right, success. All right. So we are going to start off by just kind of covering some familiar territory. So we had the submissions come in July 1st. We presented a preliminary review July 27th. Deliberations began the week of August 15th. And we are here today. And if needed, we also have Wednesday available to make decisions on target by September 15th with written orders issued by the 1st of October. So to frame the staff recommendations this year, we implemented a decision tree. You can reference our presentation on August 31st for more detail. But essentially, we said, was the request for the increase in net patient revenue and FPP within the guidance of 8.6% for the two fiscal years? If so, let's investigate the assumptions underlying that if those check out is the charge request supported by the submission supporting a operating margin that seems in line with the board's objectives. And if so, approve is submitted. If at any point that isn't met, we just take a deeper dive on that area. And so we've made it through all those who came through that first kind of happy path. And now we're looking at those whose growth rates exceeded 8.6% in net patient revenue for the two fiscal years. Another reminder that each of these decisions comes with a set of kind of generic budget order conditions. We've been over these twice before. I'll leave, I think we're familiar with them. So if anyone is not, feel free to read that in your free time. So again, we had five hospitals whose fiscal year 22 projection to 23 budget exceeded that 8.6% for the two years. So that's who we are looking at today. And we thought that we would start with the University of Vermont Health Network. They are the lion's share of provider for our health delivery system and thought it made sense to look at them. So if we remind ourselves at the time that the budget was submitted back in July, the projection to budget was at negative 5%. But if you look at it from their fiscal 22 year to fiscal 23 year budgets is a 10% increase. So we were thought that due to all the uncertainty that projection to budget was more meaningful than even typical this year. And then one thing that is a little different about these network submissions is that they not only include the request for the change in charge for that overall charge master but they also include what they call the effective commercial rate. That might be the commercial effective rate. I'm not always sure that I get the sequence correct. So forgive me if I aired there. However, that's kind of meant to be what the actual effect is intended to be on the commercial contracts between the network and those health plans, which is not usually the same as the charge. They're very different numbers and are getting more and more different over time. So I just think that's a really important thing to keep in mind. And I think it's helpful that we have this to talk about for the network. So if we review the tests from that decision tree, again, that projected growth for this fiscal year to 23 was at 15.7%, which is the max that we saw. However, the compensation growth from fiscal year 21 to fiscal year 23 is within the range as kind of developed by us is in the terms of acceptability with help from the state economists. So that is, again, the top but under that 13.8%, which is given the unbudgeted increases, that was comforting to me to see that that is still like within standards that we might expect in these unprecedented times. And then the other component is after we try to tease out the labor as much as we can, what does the other inflationary growth look like? And again, we turn to recommendations from the expert economists to see what a reasonable threshold there. And so budget to budget, we're looking for growth less than or equal to 14.5%. They are quite modest at 3.3, quite near the median and compared to what we saw from other hospitals. The utilization from budget to budget is 7.7%. And so there we're looking for support in the submission and it's aligned with market share and historical accuracy. Here we saw ample testimony about all the measures in place to meet this target and this looks different projected to budget as well. Then that 19.9% effective commercial rate is the max that we saw. However, the operating margin targeted of 2% is right near the median of what other hospitals had in their 23 budget. So seemed supported in the submission and reasonable in terms of what we saw. So here, the kind of two inflationary medical measures that the economists said were most aligned in spirit with what we would expect in the hospital budgets was the personal consumption expenditures and the producer provider index for hospitals. So here we can see that compared with two different values. The top is that charge master change in charge which we saw is not so related to actual commercial revenue. So much more closely related to that will be the bottom chart which is what the change in the commercial rate is. And we wanna note that that 0.7 in fiscal year 18 was what was submitted and approved. However, that was predetermined and is not necessarily what would have been requested for their actual inflationary growth. And I do think some of the pressures experienced by the network today are still being felt based on that. So I just, that really was a heavy hit. And so that is maybe not the most helpful data point in terms of measuring the inflationary pressures on a system. But we do see that fiscal year 21 appears to be more in line with what it was prior to fiscal year 17. And fiscal year 22, we don't have the comparison point yet. So hard to assess that objectively. So again, there's two ways to think about revenue. One is if you're trying to measure kind of the mix of what's being done. That's when you look at the gross patient revenue whereas the net patient revenue after those deductions is what is actually collected by a hospital. And we know that that doesn't look the same depending on who the payer is. So we can see that over time for this hospital that GPR has grown more, that the net patient revenue has grown more than the gross patient revenue. But we also have to remember more than other hospitals that a goodly portion of this revenue is off the chart now. It's been moved to those fixed perspective payments. So that's a different payment mechanism and that's gonna distort some of these numbers. And here is that difference. So the orange bars are the, if you look at up to the top of the whole bar, that's that gross patient revenue. And the part that's filled in is the net patient revenue. So we see much less of the money is, much less of the bar is filled for Medicaid than some of the other payers. And notably Medicare also has a very low filling of that bar. So this gives us a sense both on what a hospital is doing and how that is affecting the revenue they're collecting. So these are a couple of key financial metrics we've been looking at for hospitals that exceed that 8.6% threshold. The days cash on hand as was discussed took a very uncomfortable dip in the projections for fiscal year 22. And you can see that despite the ask, there's not a huge ask in replenishment here for fiscal year 23. And we also see that the operating margins never really wanna see negatives in those numbers, but we do see that in the fiscal year 22 projection as well as the total margin of almost negative 8%. So again, the rebounds here are pretty modest at 2%. That's very lean. And so we spent a lot of time last time talking about this and kind of making sure we're clear on our understanding of this. So because of the mid-year increases, UVM tried to frame this as here are the costs that we still started to incur in fiscal year 22 that are gonna carry forward into fiscal year 23. And here's the even additional new costs that we're expecting in fiscal year 22 to fiscal year 23. So they kind of bifurcated the portions of that rate. And when we asked for more detail, they further broke out an existing response to some questions from the healthcare advocate, including some traveler expenses. So as you can see, they've already set a really ambitious target for themselves to not have any additional traveler inflation in fiscal year 23, but recognizing that a portion of what they've experienced in 22 is not likely to go away. They have set some targets for themselves here and they already have some risk in not meeting those goals for cost savings related to travelers in particular. So we wanna remember that not all the cost inflation is in this commercial rate that they've taken on a substantial amount of risk to meet targets there. I've also highlighted the retail pharmacy supply line because that won't be part of the commercial ask so that is covered in non-operating revenue. So that is not included in the submission for the commercial rate. And so then the other thing that I think is really important, we talked about this very briefly, the first day this was introduced, but there was a request that UVM restrict, self-restrict $21 million to help support inpatient mental health capacity at this point as of February of 22, $19.1 million. It still is available to our knowledge. And so the Green Mountain Care Board had sent out a letter to say that we thought sufficient progress had not been made and the network responded that they are working closely with the Department of Mental Health that is continuing to happen. And I think there's active thought about the most efficient way to address this critical need to the community. And so the board had always said when this was originally established that if sufficient progress weren't made that it would be returned to commercial rate payers to reduce on the increase. So that feels relevant to the conversations today. So I just wanted to remind us about that. And I'm gonna pause because I think precision is really important here and ask Russ McCracken if I did that justice or if there's anything you care to add to make sure I set that correctly for everyone today. No, thanks, Sarah. I think you hit all of the big points. The language on the screen that you're seeing here is from the 2018 enforcement action that allowed UVMMC to provisionally self-restrict the surplus funds for inpatient mental health. And the last sentence there is that if the board determines insufficient progress has been made it may order that UVMMC use all or a portion of the self-restricted funds to benefit rate payers through commercial rate reduction. And as Sarah mentioned that the health network did come in in April with an update on the inpatient, sorry, psychiatric inpatient capacity project which the Health Networks finances that some of the takeaways from that presentation are that the Health Networks finances would not support that project currently. And so it is definitely on hold. And then as Sarah said, the board followed that up with a letter noting that we determined insufficient progress was being made but encouraging the Health Network to explore some other options. So that's all I maybe that clarified a little bit but Sarah, I think you got it all. Okay, great, thank you. So then essentially the other thing that we wanna remember is that when the UVM Health Network presented, they said, hey, we know there's a lot of moving pieces right now in particular, we think that given all these uncertainties if you could use your COVID flexibilities to just approve the budget in November we'll know a lot more there but that we fully expect that there might be some change here. And so this is designed to just lay out some of the moving pieces of which we're aware and have been introduced into the record. So the first that we'll talk about is the fiscal year 23 dish estimates. So for UVM Health Network, their budget is very close to what the estimate from Diva was. So there's really no recommended movement there that we would envision. So for some hospitals that wasn't true they either budgeted more than it looks like is estimated or less but in this case, we're very close. And then the Medicare final rule for inpatient did come out and here's where I made a mistake and misunderstood the information. So I'm so glad that we clarified this because UVM Medical Centers budget is pretty much on the nose so their budget was 2.62 the estimate from what actually was issued is within a hundredth of a percentage point. So that's not gonna really have a material effect on the budget. So and when I say ops, so what that's really shorthand but it's really more impactful are the 340B pharmacy rules. So there was a Supreme Court decision issued and it's very uncertain how that might be executed by the federal government. So because of the size and the amount of that uncertainty it's a dramatic window here of how this might play out for the Medical Center between an additional one to 11.1 million dollars which they budgeted 0.86 so there likely will be an effect to their budget but it could be anywhere from that one to 11 million dollars which is a huge range. So if we look at what that would do if you applied it to the commercial rate that could lead to a negative 0.18 to negative 1.94 different. So again, that's a big range for us to be talking about of uncertainty that is not knowable until November. We also were kindly informed by our partners at the Department of Vermont Health Access or DEVA that they are able to provide an additional graduate medical education payment. We originally had neglected to account for the expense side so that needs to be matched in order to be realized so once you account for that, that's 11.9 million dollars that is subject to authorization by the state legislature. There's not state money on the table so we think that there's a good likelihood that would be approved but we don't know that today and then the funds would not be distributed until fiscal year two or three of the hospitals fiscal year. So if that all pans out that would take 1.56 points off the commercial rate if we were to put it right there. And then if those mental health funds were released not saying that that would have to happen but that is certainly a factor that might be worthy of considering in your deliberation today. Again, as of February, there were 19.1 million dollars available and that would have a theoretical rate impact of minus 2.51. So again, these are all just factors that are all in the mix when we're thinking about this. And so this is how that all sugars out and I know it's a lot of numbers so we can kind of just step through it but the submitted commercial effective rate was 19.9%. I think while unauthorized the graduate medical education is a pretty solid likelihood nothing's certain but if you were to apply that that would reduce that rate to 18.34 which is taking 7.8% off for that budgeted revenue effect of 12 million off. And then if you also were to factor in the release of the mental health funds which again that wouldn't be happening that's just something that might be possible to help fill that gap that would take it down to 15.83 which is a 20% drop or $14 million of the revenue. To be clear, this does not affect the net patient revenue for the network that is unaffected. This is just saying how much of that would be through the commercial rate increase. So these aren't cuts. This is just where the revenue would come from a different place. So just wanna make that crystal clear. And so then the last two boxes are looking at that range of potential particularly 340B revenue impact which would be 18.16% at the most conservative up to 16.4% for that full amount if it went back to the original rule. If you also factor in the release of the mental health restricted funds that range would be 13.89 to 15.65. So that is a series of options. The outpatient is the least certain but will be knowable as soon as November. And I think that again I would not suggest that we order the release of those funds at this time but just say that that might be an option on the table for consideration. And again, the key here being offering some flexibility with all these uncertainties. So I think that's what I wanted to tee up for UVM Medical Center. So I'm gonna pause here. Thank you, Sarah. It is a lot of numbers. It's a lot of potential decision points and I appreciate all the hard work here. I think at this point I'll open it up to board members for comments, questions for Sarah, potential proposals. Anybody have any comments they'd like to make questions for Sarah from the board? I'll go ahead and jump in. So I'm just gonna restate sort of how I'm thinking about this Sarah and you can based on what you just said. So I think what you're recommending is not cut to the net patient revenue. But a shift from commercial rate to potential other sources. You have a few ideas of what those sources could be. There are I think other potentials as well. For example, it's my understanding there was also some additional fiscal year 22 dish that isn't in the consideration which makes sense because it's the current fiscal year but it is money that will be coming in and will have an impact on this year's budget and potentially cover some of the increased expenses. You could think of it that way or it could fall to the bottom line and improve the margin this year. There's a lot of different ways that could flow through the budget. I think from my perspective, one of the concerns that we've had in the past with UVM is that and I think they spoke to a lot of the efforts they're gonna be trying to make this year to allow for more patients to get in the door with shorter wait times, that kind of thing. So I think to me that it seems like there's room under the NPR around utilization. I certainly hope they are successful in those efforts and that if folks can get to their appointments quicker than the utilization might be an increased access in this case really is what I think we're talking about. So increased access is in my opinion, a good thing. So just in kind of talking that through, I think for me, I'm comfortable not cutting the NPR. I think there are enough moving parts that I'm, I think that UVM has the potential to meet that NPR even though it is quite a big leap from their current projected with other in the past in particular with some of the smaller hospitals we have had concerns about approving NPRs with such a large gap from projected because it kind of sets up that hospital to potentially set their expenses high and then have a loss resulting. But I'm comfortable with this hospital given sort of the dynamics and the initiatives that they spoke to during their budget presentation of approving the NPR as submitted. I think the other thing that I am thinking about for this hospital is whether it might make sense to approve a range and allow for some negotiation in the commercial sector. So I'll just throw that. I can't remember if we talked about that last time because it was a week ago or not but I think just making sure that idea is out on the table. So I think I'll stop talking there and let other people chime in. Thank you, Robin. Any other board members have comments, questions, thoughts? Tom, Tom Callum. Well, I'll start, I have to say that Robin did a great job of mind reading. My thinking is in the same vein. I look at this as an issue between ratepayers, commercial ratepayers, facing high double-digit increases. We know that also from our rate review process and coming out of a pandemic which is a very difficult period historically in the lives of our healthcare community but also keeping in mind that the medical centers request for additional NPR for 2023 over 2022 was $152 million. So this is an up and $39.3 million is 2% of their total operating funds. So I don't think that we're in an impossible situation. I think there are some unknowns I don't think we should, I think that we should be clear about saying that the NPR that will be affected here is the commercial NPR. And so if there is a reduction in commercial NPR, there will be offsetting, there can be and will be as this table illustrates offsetting increases elsewhere. I also think that in the overall budget of UVM for 2023 is $1.96 billion, $39 million is just 2% of that. In my experience, I don't view that as a difficult hill to climb. It's always difficult but to some degree but as the year unfolds and we can see this in terms of UVM's medical centers 2022 projected budget versus its 2022 budget as approved, a lot of movement. There's a lot of movement here. And I also know that the UVM medical centers financial team is a strong team, talented, smart, aggressive. So where I end up is thinking that the opportunity here is to reduce the commercial NPR by $39 million. And then for me, the issue is should the remount and care board be prescriptive as to what the substitutes might be or should we leave that knowing that all of these are out there in play, leave that to management. My inclination is to leave it to management. UVM medical center has a well-staffed capable management team and things can go south but they can also go north. I mean, we could in some hospitals are seeing reductions in travel costs. So there's a lot of movement here. This is not a stable situation and people are gonna have to be quick on the feet as time goes by. I think the restricted funds for the mental health facility, that's a tough call, but when that was approved by the board to allow the UVM medical centers to kind of keep that on their side of the table, I voted against it. I had a different approach, but we are where we are now. I think $19.1 million there and personally, I can't say, well, I opposed reserving it back then, but I don't now. So I think the staff has laid out a solid and nuanced presentation. I'm personally not a stymied at all by a $39 million movement of NPR out of commercial. And I also think that is somewhat consistent with our rate review decision where we basically presumed that the hospital's budgets as presented would be reduced by 17%. I know that the linking of those two is a little difficult because the processes aren't tied at the hip, but that is a decision that we've made in an order that we have enacted. So that's what my thinking is. I want to keep in mind as we go through this decision that even if this $39 million is the number, the ratepayers are still facing a steep increase in the 11 to 12% range. And so they've got lives to live as well. And somewhere we need to find the right balance and $39 million, 2% of the operating budget seems a reasonable balance to me. Okay, thank you, Tom. Tom Walsh, did you have any thoughts or comments? Nothing additional right now, thanks. So I guess I'll weigh in here. I think with respect to the NPR, if we're talking about the NPR, I think given the long wait times and the excess demand for care at the medical center, I think we've heard that significant efforts underway there with their patient access service center and other efforts underway to optimize their scheduling, hiring more providers. My hope is that they're able to meet these utilization targets that underlie their NPR FPP request. Frankly, I hope that some of the throughput issues that are system-wide are addressed perhaps through some of the initiatives that are being pursued right now by the Agency of Human Services such that I really am optimistic, I tend to be optimistic that those utilization estimates are met and maybe even exceeded to the degree that there is access to man for care at the academic medical center. So I would not adjust their overall NPR FPP. My hope is that it arrives through increased utilization through some of the scheduling and other initiatives they have to reduce their wait times. UVM, I think, has made the case that it needs to generate a margin of 2%. Tom, I think what you're suggesting is to zero out their margin, give them no margin by removing that 2%. I think a 2% margin is reasonable. I think it's actually slim when you compare it to national benchmarks. I think about this as our state's academic medical center. We need the medical center to be able to invest in the technology, the physical infrastructure and the workforce necessary to meet our most complex healthcare needs. And the hospital does need to cover its operating expenses or there is potential that services will be cut or care will be compromised in that process. And we've already seen they have significant access issues. So in my mind, a 2% margin is reasonable. The budget that was submitted by UVM relied on this 19.9% effective commercial rate increase to cover the significant growth that they're seeing in expenses. We heard from the economists, state economists, these are national trends, expenses that are driven by inflation, by supply chain disruptions, by workforce shortages that are nationwide. So we know this inflation is real. I will say though, the 19.9% was submitted at a time with a certain information set. New information has been revealed about higher than expected Medicare reimbursements, additional funding from Diva for GME. So those additional and different funding sources can mitigate the need for commercial payers to shoulder the expense burden that we're seeing. So I would support adjusting the effective commercial rate downward based on the newly available revenue sources in the form of these higher Medicare rates and additional GME. I'd also support frankly, and this may surprise folks because I really was part of that decision to set aside the $21 million to expand mental health capacity back in 2017-18, but I would support a release of those funds if needed, if it's the only way to mitigate the need for a commercial rate increase so that rate payers are not shouldering this unprecedented expense growth to the degree that's being asked of them in this budget. So given the uncertainty around the fiscal year 23, Medicare OPPS rates and the potential for the 340B revenue to be addressed through that Supreme Court decision, I like the idea of approving an allowable range for the effective commercial rate. I think it offers time for payers to negotiate. I think there's some more information that we still don't know that potentially could become available from the federal government. So I would support a range. I think if the OPPS rate is lower than expected or if additional GME money is not appropriated by the legislature, UVMMC can come back, request a rate adjustment. If they need to use some or all of those mental health dollars that have been restricted for that purpose, they can request that release and I would personally support it. So when I'm looking at this chart, I'm thinking about a potential range that's inclusive of releasing those Medicare restricted funds and acknowledges that there is a range for these OPPS minimum and maximum. So some range in there that's probably in the 13 to 15% range would be reasonable for me to consider allowable and then allow the payers to work that out, to have UVM come back and say, yes, in fact, there's no other way for us to generate the cost savings required. So we will need to release those refunds which honestly breaks my heart, but it's, I think to the degree that we need to offset some of this commercial rate burden it may have to be the case. So those are my thoughts at the moment. If I can just make one comment on that, I'm not opposed to a 2% operating margin. I'm just saying don't create it or fill it with commercial revenue. And so if you look at UVM's submission, they are looking for an increase in commercial revenue of $152 million, which is almost their entire overall 23 over 22 increase. And then in terms of Medicare and on their payer mix table that they've submitted to us, they're looking at Medicaid revenues dropping by just 4.4 million and they're looking at Medicare revenues with just a 1.74 million increase. So basically the entire $150 million increase that UVM is looking at is being funded by commercial. So on the income statement, we already have line items that we know will probably be receiving NPR money. The first two lines at the top of the income statement, one of them is for this graduate medical school education and another is for DISH. So as you, it seems very reasonable to me to say, we can move money out of the commercial NPR column and expect to have offsetting increases in other areas of their income statement as is laid out right before us right now. Now, none of these are guaranteed, but I think there's a high probability with a lot of these big money ones that if the management team needed to have a little wind at their back in terms of finding another $39 million, we're looking at a lot of that wind at their back right now. Any other thoughts or comments from board members? So I'm based on your very articulate outline, Jess. I think I'm comfortable with the commercial range of similar to what you indicated with the NPR staying the same. I do think, I do agree with Tom that I don't want to micromanage substitutes. So I think, and I don't think you were suggesting that, but just to be clear, I think these happen to be certain items in the record where we know income and revenue is changing or has the potential to change. As I said, I would also include the 22 DISH in that category, as well as some other potential moving parts. But I don't, I think I just want to be clear. I don't want to say you have to do X, Y, and Z. I just want to approve a range based on a rational approach and then give UVM the flexibility to manage their budget. We do not micromanage budgets. So I certainly wouldn't want to get into that. So I think that's where I'm at in terms of a decision. That makes sense. As we look at this chart in front of us, Robin, and I am looking at it more closely now, are you thinking of a commercial rate allowable range of say 13.89 as the bottom and a 15.65 as the top or 15.83 as the top? What are you thinking about as the allowable range there? I would include, I think I would do 13.89 to 15.65. But I'm open if other people have other ideas because we do need to compromise with each other. Right. So I'm wondering if any other board members have thoughts on this approach, recognizing that. Well, I came at it a little differently. I mean, this chart is not something I fully agree with. I embrace it, but I fully don't understand the pluses and minuses in it. But my calculations at the 39.3 million is that it gets the increase in commercial down to the 12 to 13% range, this range. And so that's where I think that we should be. I'd also keep in mind that this isn't cast in stone over time this year. UVM Medical Center came in for a mid-year budget adjustment. We do live in volatile times if the decisions we make now clearly are trending kind of in a different direction than we hope there's time to remedy this. I just think that we need to keep the commercial ratepayers, those businesses and individuals in mind and a 12 to 13% increase in their premiums is still a steep hill. So it's just to clarify, it sounds like Tom, your preferred approach would be to approve a commercial effective rate in the 12 to 13 range, not necessarily create a range, like Jess and I were talking about necessarily, but approve, let's just say 13% because that's close to everyone's, but that would be your number. You wouldn't necessarily do a approved range. Okay. I think as you start to climb with the range that you're just referencing, you're staying pretty close to where we are now. And it's just not a statistic at 13% that still is a steep climb for ratepayers. But in my view, it is a reasonable number for the UVM management team to achieve. If I could share a few thoughts. I think I'm more aligned with Tom here that I'm personally skeptical that approving a range will allow for negotiation. I don't know that payers have much leverage with UVM for many of their services. So to imagine that we would approve a range from 13 to 16 and someone would be able to, a payer would be able to negotiate the 13. I'm not sure of that dynamic. I think whatever our upper range would be, we'd end up more closely there. And I think Sarah's done a great job outlining how possible ways to make the budget work with an NPR at basically 14, 13.89. One thing that we haven't discussed that I see in my newsfeed every day are struggling rural hospitals and academic medical centers talking about making cuts to their executive compensation and not filling vacancies in order to be able to prioritize patient care during difficult times. So I think just to say that there are things not on this slide that can be done to keep caring for patients while there's a lot of inflationary pressure, while it looks like the inflationary pressures are easing. So where I'm at is more with the 13.89 being the top end if we were to do any type of range. Okay, I just wanna acknowledge though that the 13.89 assumes the maximum for the OPPS. So one of the things Tom you said was Sarah has outlined ways for them to get to the 13.89. Some of them at this point is out of their control because the OPPS is that's the maximum that they might expect if all goes well with the federal government, the Supreme Court decision. So they may or may, I mean, to the degree that the way this is outlined that may not be achievable. It's not up to them in terms of the federal decisions coming down. So I just wanna acknowledge that this is, that that is in some ways that uncertainty is what moved me to a range. I understand and appreciate your thoughts. Sarah Lindberg, do you have any thoughts as you're listening to this conversation? Yeah, so I think there's plenty of uncertainty. The 13.89 to 15.65 I think would isolate the specific uncertainty related to the 340B decision which is huge. And yeah, I think that here's what's really funny. Not funny, ha ha, but funny odd. So normally, you know, you would say that releasing the mental health funds is not necessarily in their control either. And I worry that it's also not necessarily in the control of the four people making the decision today. And so that's just like a weirdness here that I think that makes me even more unclear about where this might trigger out. And so I think in the spirit, so you know, UVM said give us all the flexibility until November under a 19.9. And what I think the kind of compromise that I am trying to help you guys figure out which is not simple is like, how can we offer some of that flexibility but with a ceiling that is lower? And so I don't wanna set a ceiling that is completely not feasible. And you know, that 13.89, like I don't run the UVM Health Medical Center. I don't know like how, like, like I would probably be stressing out if I had that as a ceiling in this situation. Nothing says that the network couldn't come back. The math won't have changed. It's just we will know more in November. And so if they would need to come back and ask for more money, I guess I would just worry that some of these concerns wouldn't be reflected in a future conversation. I don't know if I'm being clear here, but I just think, you know, 13.89 to 15.65 is something that feels clearer to me than under 13.89 from the evidence I've seen in the record. So that said, you know, there's no right answer here. These are very difficult decisions. Thank you, Sarah. Is there any other board conversation or just somebody want to make a motion? We can try it that way, see what can fly. Yeah, I mean, I'm happy to make a motion based where I'm at, which does, you know, based on our discussion, sounds like we'll be a 2-2 vote, which will fail. So, but I'm happy to do that so that we get that on the record. And then we can, obviously we need to get to an approval of the budget. And so we're going to have to figure out how to continue to compromise. But let me go ahead and do that so that we can be clear whether or not that's the case. So I would move to approve University of Vermont Medical Center's budget with a 10% increase from fiscal year 22 to 23 budgeted NPR FPP, a 10.1% increase to overall charges and an increase to the commercial effective rate within an allowable range of 13.89% to 15.65% subject to the standard budget conditions as presented to the board. All right. Is there a second to that? Well, I can second that. So I will. I'll second that motion. We can open it up for discussion from the board at this point in time. At least we'll know where we all stand on that particular motion. Yes. For discussion, Jess, you mentioned you talked about the risk with the O P P S. We all deal with risk, right? And we risk being in an accident or getting sick. And so that it's not as though UVM is burdened with more risk than any place else. Right. There's an opportunity that that money may may come through. And there are a lot of hospitals that are struggling and people and people. Policy makers and regulators trying to find ways to help. Our state. We're asking for commercial rate payers. To shoulder. A lot of financial burden when they're already facing all the inflationary pressures that healthcare delivery systems do. And they have their health. That's never a guarantee. So I think I know the risk argument. Doesn't. It doesn't sway me to try to go higher. Yeah, I just want to clarify one thing. Sorry to interrupt. But, you know, this, this assumption before we even get to this table assumes that they're taking $50 million of risk already. And so this is saying, are we going to add, you know, another 30 million to that? So they've already, you know, we're compounding. They, they, I just don't want it to be. Missed that this is adding to the risk that they've already taken on. And I'm not. Advocating for anything here, but I just don't want to forget that the, you know, this is on top of 50 million. They've already budgeted to, to meet. Any other board discussion or staff. Comments. I'm going to open it up for public comment at this time on the motion on the floor. So. Is there any public comment on the motion on the floor? Mr. Gove, I see your hand raised. But now I see it down. Oh no. Okay. Sorry. I just took it down. So it wouldn't stay up. Sorry. Thank you, Madam chair and good morning to the members of the board. Happy Monday. I would like to make a few comments on the deliberation that's going on this morning. I think first overall, I'm gravely concerned about the conversation. The idea that the academic medical center could budget plan for no margin. That the academic medical center could have put forward a budget with numerous risks in it, in addition to what's been laid out today that are not a piece or a part of the conversation concerns me. And I'm sure it concerns every teammate that I have on the call. I do want to talk a little bit in specific about a few things. First, the mental health restricted funds. Member Pelham went back in time and I thought that was helpful. And I think we all have to go back in time to that moment. When that occurred, the UVM medical center had achieved a margin above its budget for a period of years. And the feeling was that the commercial rate was too high. And it was creating a surplus. But the margin of a nonprofit that was higher than the regulator's thought was necessary to fund ongoing operations and capital needs. If that logic was true and commercial rates should have been adjusted back then, our negative margin today must factor into the board's thinking. It is not fair to only look at margin when it is positive. There is a responsibility of the regulator to look at it when it is negative. That money was intended for mental health. And the problem still exists and we're working on it. I would ask the board for patience in this area because there's good work underway. I would also again mention as evidence our days cash on hand, which in fact did go down in July again, that these dollars are in our days cash on hand. These are not separate and apart from that balance sheet. What you're doing here impacts our margin with one time money to replace ongoing funding. We'll have to come back next year for this exact amount of money. Also, we'd like to talk about the amount of money that you're talking about because we'd like to reconcile it just like we have everything else, but also have a deeper conversation about what we've spent on mental health care throughout the pandemic, being a partner to the state, and some things that maybe you're not aware of that we've done. Next, we've put access front and center in our budget testimony and in the budget that we submitted. We cannot accomplish the plans that we have laid out with an academic medical center that is underfunded continually by our regulators. And this is what has occurred over a period of years beginning substantially in 2018. We have come forward with a very transparent budget. We gave you the idea that in November reconciliation would be appropriate at this time because we felt that there were enough balls in the air that we should reconcile for November. We still feel strongly that that's the right thing for the commercial payers, but leaving the academic medical center out of margin cannot be the policy of our state's regulator. You've got to help the academic medical center at this time have a stable and sustainable budget. Thank you, Madam Chair. I appreciate the opportunity to speak. Are there any other guests? I see Rick Vincent. Your hand is raised. Good morning. I just wanted to add one other risk factor for the record. So Sarah spoke to the $50 million risk that we have in the budget primarily related to travel utilization coming down, which isn't coming down anywhere near at the pace it needs to come down to make that budget assumption real. The other assumption that we have in our budget is that Medicare or Medicaid redeterminations would increase or create a shift to exchange plans, which our assumption was that that was going to begin in July, which hasn't happened. So that's almost a $22 million assumption that we have in our budget that may or may not materialize. So even before we get to this point of discussing the commercial rate, there's over $70 million worth of risk in our budget that I feel we've been very transparent about through this process. Thank you. Thank you, Rick. I see Mike Fisher. Your hand is raised. Good morning, everyone. I feel compelled to restate my concern about the range or my recognition of the likely outcome of the range being at or very close to the top. And I also want to add in the reminder of it wasn't all that long ago that we had a negotiation between a major health insurer and UVM, the United Health Care and UVM. That was not so much fun for anyone. And so I just want to remind us that when we're out here calling for a more robust negotiation that that's not easy. On the other hand, if there is new information available at the time of negotiation that UVM could be called upon to recognize, I'm talking about the 340B in its negotiation with the carriers, that that is interesting to me. And I don't know about the board's sort of ability to do that. I want to state, others have stated it, but I just want to say clearly for monitors can afford a giant rate increase due to the enhanced premium tax credits that Susan is so aptly reminded us of at every meeting. This is not going to be felt at least in the next couple of years on the individual market. It will be felt in the small group. And just to, you know, clearly state, you know, it's fairly predictable when health care becomes more and more expensive at a faster rate than real earnings than more and more people can't afford to get care. It's just straightforward in my mind. So those are my comments. And thank you, board, for this tough work. Appreciate that. Thank you, Mike. Is there any other public comment at this time on the motion on the floor? Not seeing any. I'll kick it back to the board. Any additional comment there based on what you heard from the public comment? I'll just jump in briefly. You know, I obviously have been in the past and continue to be very concerned about commercial rate pairs and affordability, but affordability is not a criteria legal criteria in the decision today. It's an economic and efficient operation of the hospital. So, you know, we, we as regulators need to be mindful of our legal responsibilities in terms of applying both the guidance and the legal criteria and the statute. Thank you, Robin. Any other comments or any questions about that comment would it be helpful to have Russ weigh in on that in terms of the legal criteria before us? Sure. Okay. Russ, are you, are you able to do that at this time? If not, we can, we can table this and move on to another hospital and come back. But Russ, do you, are you prepared to talk about that at this time? It's a fairly broad question. I don't, I'm not sure specifically what to say that would be helpful for this discussion at this point. We have a statute that lays out certain criteria for the board to look at. We have a rule that lays out additional criteria and we have guidance. I guess I'm, if there is something specific you'd like me to speak to, I may need a minute to prepare it. That's fine. Tom, well, I saw your head shaking as if you wanted a little more clarity from perhaps Russ is there a specific question that might help? I don't have a specific question. I thought I was interested to hear whether there was something that Robin said that Russ would respond to directly. I don't see that. I think the table before us outlines a path, one path while there are aspects of running efficiently running a health system that do not appear here, that there are other options about the way organizations are run. I trust, like others have said earlier, that there's a talented team at UVM that can face risk and find ways through, that it's possible. I don't think the range at a higher level, as the HCA has said, as others have said earlier, the ceiling will end up being the floor in those negotiations. I'm still inclined to be at the low end of this table. I'm not sure. I don't feel compelled that a range will be meaningful to Vermonters or to negotiation. Thank you, Tom. I think what might be helpful, and Board Member Walsh prompted, I think maybe directed the focus a little bit. Board Member Lange is absolutely correct that there's no affordability. Affordability is not specifically called out in the rule as a criteria that the Board uses to assess the hospital budgets and say affordability, meaning patient affordability. There is an element in statute that the Board shall, as Board Member Lange said, establish budgets that promote efficient and economic operation of the hospital. There's also a criteria in the statute that the Board's goals here are reducing the per capita rate of growth and expenditures for health services in Vermont across all payers while ensuring access to care and quality of care are not compromised. And I think that is part of the balancing that the Board has acknowledged and looked to. If there's sort of more of a specific question or like a more complete presentation of it, I might just need a couple of minutes to pull that together. Thank you, Russ. That was helpful. Does the Board have, would the Board like that? Or are you any more discussion? Are you prepared to vote on this particular motion? I'm ready to vote. Okay. So all those in favor of the range as outlined by Board Member Lange is a motion of between 13.89 and 15.65. Please say aye. Aye. All those opposed. Sorry. I'm sorry to jump in again. We should do a roll call vote. Okay. Russ, go ahead. Take it away. Great. Thank you. I'm going to go in alphabetical order to vote on the motion as presented by Member Lange, which is the motion to vote on the range and commercial effective rate as outlined. So Board Member Lange. Yes. Board Member Pelham. No. Board Member Walsh. No. And Chair Holmes. Yes. Okay. So the motion fails. We need a three, at least three votes in favor. So that motion is now off the table, so to speak. And we can either somebody else can propose a different motion. Or we could potentially realizing that maybe we need all some time to think about this. We could also move on to other hospitals, see where we can get with other hospitals and come back this afternoon and revisit UVM. Does anybody want to make a motion or shall we move to other hospitals and return to this this afternoon? Realizing that we may have to think about how we're going to come to a consensus with three votes on the UVM Medical Center budget. Well, in a spirit of trying to get to get to three, I would what it would take quite honestly for me to get to get to yes would be no range and closer to the 13.89 than away from that number. So are you would you be proposing a split the difference midpoint between those two? Is that a mechanism by which we can get some consensus here? Yeah, I'd propose that. Okay, do you want to make a motion? I'm not sure that I'll get the language all as nicely done as Robin. The math is 14.77 is the midpoint. I was going to do 14.5. So I move that we approve an NPR of 14.77. Can I make a suggestion that we take a five minute recess and Tom you talk to Russ and he can help you get the motion. Yes. Okay, we will just take a five minute recess. We'll be back in five. Consider it also a bio break for anybody who needs it. So Tom Walsh, did you want to pick up where you left off with a motion? Yes, after some help from Russ. I moved to approve the University of Vermont Medical Center's budget as modified here by with a 10% increase in the school year 2022 to 2023 budgeted NPR, FPP, a 10.1% increase to overall charges and a 14.77% increase to commercial effective rate and subject to the standard budget conditions as presented to the board. Thank you, Tom. Is there a second to Tom? Member Walsh's motion. I will second the motion. Great. I think we moved and seconded. Is there any board discussion at this time on that motion? I guess what I would just notice. Oh, sorry, go ahead, Tom. Well, I was just going to say I would love to vote for it, but I'm not. It's, you know, it's, I think it's a difference, a distinction without a difference. This is still real money out there in Vermont's real world to small businesses and individuals. We're talking here about an increase. And in a very volatile environment where there are no guarantees at this point. And, you know, when UVM medical center submitted their budget back in July, they were looking at a reduction in Medicaid of 4.45 million in NPR and a small increase of $1.74 million in Medicare. And the whole time goes by and there's now GME money coming out of diva. There's additional dish money coming out of diva. Robin, you talked a bit about some 2022 dish money. And I just think that there are opportunities ahead to keep commercial payers in a little bit better position than we're heading. And but, you know, it's, you know, it's difficult to want to say no here. I do, I mean, Tom Walsh, you know, made the point that, you know, looking at other hospitals throughout the country, people are making difficult decisions, you know, and in Vermont, by experience, in terms of the state budget, were decisions that were not even entertaining here. You know, we had hiring freezes. We had vacancy savings freezes. We made the state police drive in palace rather than Chevy than Lincoln town cars, which was a favorite cars. I mean, it was, it was, you know, a management challenge, you know, over an extended period of time. And I just don't think that we have challenged the UVM Medical Center team enough yet to say that it's okay to, to place upon a commercial rate payers of 14.77% increase. I mean, we're certainly not going to get to a zero increase. So there's, there's some point here, but I think the difference between 19.9% and 14.77% is there's still a ways that we could go. Thank you, Tom. I know Robin, you had, you're going to speak as well. Yeah. So I don't actually disagree with many of the considerations you've laid out, Tom. I think it just for me, it's a different way when I think of my responsibility is ensuring access and the economic and efficient operation of the hospital. Hiring freezes and vacancies mean patients don't get care. And so given that we are still coming out of the pandemic, we're, despite the fact that I think many of us would like to be out of the pandemic, we're not there yet. That means that there are continued to be unknowns and challenges at the hospital that quite frankly, I think we don't see in our day to day lives. I think that folks in the hospital are still living with the pandemic and those of us who don't work there or need to go there, you know, we have more freedom and we're not experiencing that in the same way. And so for me, I want to make sure that our hospitals coming out of the pandemic are strong because we have hard work to do with hospital sustainability, which is going to require creative thinking and really doing a lot of work on ensuring that we're moving forward with a different way of providing services in the state. And so to me, I want to make sure that UVM and the other hospitals aren't in the red moving into that because I think if you're just trying to make the basics, it's going to be very difficult for people to focus on transformation in the future. So for me, I'm going to support the motion. As I said, my preference had been to give a little more flexibility, but I can let go of that and we need to compromise in order to get to a decision. Thank you, Robin. I appreciate that, Tom. I appreciate that, Robin, and I hope we do get to consensus. A couple of things that I just wanted to speak to from your remarks. I personally have not been deeply involved with UVM or in it or no, but I have been intimately involved and in hospital operations day to day for over 20 years and in senior administrative decisions for the past seven or eight. So I have a good sense of what can be done. Your point about not getting care when vacancies aren't filled, that's true, but there's also more than ample evidence that patients don't go to the doctor when their prices go up. They self-restrict. So that's a substantial worry of mine. So I wanted to say that. And Tom, to your point, I understand where you're at. I'm trying to find a way to compromise that we can get something passed. So I appreciate your comments, both of you. Thank you all. I think we can all appreciate there's a reason this is a difficult decision. There's a reason we need to compromise. There's a reason this doesn't feel good, frankly. We know the impact that it's going to have on commercial repairs. We also understand the impact that restraining resources for the medical center might have on patient care. So in my mind, given the incredible headwinds that we know are coming their way in terms of inflationary pressures and expense growth, the erosion of days cash on hand already, the financial losses, which are tremendous for the UVM Medical Center for this year already, and the unforeseen challenges that they face with provider burnout, national wage pressures that may not be alleviated anytime soon, and the wait times that we already know exist and the need for them to have funding to be able to hire more providers to be able to mitigate those access issues. So I think we have to come to a consensus here. We have to pass a budget. We don't have much time left. And so I appreciate this compromise offer by board member Walsh here. So with that, I think I will open it unless there's any further discussion from board members. No, not seeing any. I am going to open it up for public comment at this time. I see Mr. Gobe's hand raised. Chair Holmes, thank you again for the opportunity to comment. First, I would just like to state for the record, in terms of member Pelham's comment on hiring freezes and vacancy freezes, we did discuss with the board and we are currently in the midst of what we call a position control process where we do have hiring freezes and vacancy saving freezes across the network, but only in nonpatient facing roles. And what I would also add is that it's important to remember that we have 2000 open positions within the UVM health network that we are trying to fill. And so it is the backdrop of a workforce crisis where we talk about, you know, what labor is costing us versus where we cannot hire and have some savings. And so we're trying to delicately balance that so we maintain access in the way that was described. That's the first point. The second point is that you have the authority in your rule under letter E to adjust for changes in commercial, Medicaid or Medicare. You have that ability. What's happening here this morning is the University Medical Center is being treated differently than the other hospitals that you've regulated so far. And I want to call that out and I'd like that to be on the record that you are not doing this fairly as compared to the hearings that you've already held. The same conversations have not occurred with the other hospitals. We think you've got to value the Academic Medical Center and the conversation this morning does the opposite and will leave it in a weaker position and it will not be able to meet its mission or serve the region the way that we all want it to. Thank you, Member. Thank you, Chair Holmes. Okay. Thank you for that. Is there any other public comment at this time on the motion on the floor? I just like to add one brief one. Sorry. May I just ask for just... Okay. Did you want to respond to Mr. Govay? Well, I just want to say that I in no way would be urging hiring freezes or some of the things that we did back then. It's an entirely different environment and entirely different necessary services that the people in Vermont need. I would say though that UVM Medical Center is different from the other 13 hospitals. UVM Medical Center occupies about 50% of the healthcare budget, NPR budget, and the remaining 50% is spread across 13 hospitals. And so UVM Medical Center does have a lot more leverage and opportunity to, you know, within the healthcare community. And I don't see them as an equivalency with the other smaller community hospitals in Vermont. Great. Thank you, Tom. I guess at this point, maybe I will just ask our legal counsel here, Russ, to weigh in on this as well. Sure. Thanks, Chair Holmes. I think the board should take very seriously its obligation to treat hospitals consistently and fairly. I do want to add in that the hospitals that have been approved to date, the nine so far, came in with budgets that were either at or under the board's NPR FPP growth guidance as that was put out in the guidance and adjusted by the board. So there's a rationale for taking a closer look at the hospitals, including UVM Medical Center that came in with budgets that were in excess of that guidance. Thank you for that comment, Russ, in clarification. Is there any other public comment at this time? Okay. I'm not seeing any. All those in favor. Oops. Excuse me. Well, is there a public comment? It went up and went down. Mr. Del Treco, did you have a comment? I do. I just want to start by saying we've done a lot of work at the association and in this whole budget process to make the point that this is about patients, staff, and communities. I think you've, you're struggling with how do you manage these things in this moment? I think the Medical Center offered the best solution and I've listened to all of these hearings. Their solution was put forward and improve the budget as submitted. Let's figure out all of the noise that you're debating over and then make a decision in November. I think that's the most eloquent solution. I know it's difficult. I hear the debate that is happening. And I just think it's the simplest path to one, allow the organization to evaluate all of the moving pieces and parts that are coming before them. We talked about Dish. We talked about medical education. We're talking about changes to the ops rules, all unknowns at this point in time. I think that's the solution the board should strive for. It allows the organization to meet their need. It allows the organization to meet access, meet patient care demand. The notion that we don't have a capacity crisis is something we also talked about. These organizations are already running in the red zone every day with at capacity in their, in their emergency departments, at capacity in their inpatient floors for medical surgical activity, ICU capacity every day. I think to jeopardize and make a decision, jeopardize those things and make a decision today without all the facts is problematic. You've heard about mounting losses. You've heard about days cash on hand. Why would we want to only add to that problem in this moment? So with all due respect, I hear you grappling and struggling. I think it's best to move forward with an approval as submitted, allow the organization to manage all the uncertainty and come back with the appropriate information when that's available. There's no need to, there's no need to make a decision that might seem arbitrary in this moment. So thank you. Thank you, Mr. Jetraco. Any other public comment at this time? Okay. Any board discussion at this time? I would just say, you know, I appreciate Mike's suggestion. I suspect there weren't, there won't be free people who would support that. But, you know, I would also say that the hospital budget statute and rule do allow hospitals to come back for adjustments. And that is actually not something in the statute or rule that the board triggers. It's something the hospital triggers. That was a specific legislative decision way back when. So, you know, I appreciate the sentiment, but, you know, I think that there are ways to address some of the uncertainties, even with an approval as modified today. Thank you, Robin. Any other board discussion at this time? Seeing none. All those in favor of the motion on the floor. I think we should do a roll call, Jess. Yeah, that's true. Thank you for reminding me. Russ, would you be able to do that for us? Could you repeat the motion on the floor too? Yeah, I'm happy. I'm happy to do that. Was that the hand? I'm sorry. I saw one hand go up. Was that Mike who just made that comment? Yes, correct. You can read the motion. All right, just checking. The motion on the floor is to approve the University of Vermont Medical Center's budget has modified here by with a 10% increase from FY 22 to FY 23 budgeted NPR FPP, a 10.1% increase to overall charges and a 14.77% increase to commercial effective rate and subject to the standard budget conditions as presented to the board. So I will call the roll in alphabetical order. Board Member Lunge. Yes. Board Member Pelham. No. Board Member Walsh. Yes. And Chair Holmes. Yes. Okay. Thank you, Russ. Let the record show that we're three. We're in favor. One was opposed to that motion as read. Okay. At this point in time, I think we can move on to CVMC, Sarah. Yes. So to remind ourselves, CVMC is also below budget by 3%. So the request from budget to budget is actually within guidance, which is 10.3%, but when you factor in the projection to budget, it climbs to 10.7% growth in NPR FPP. The overall change in charge is 10% in the commercial effective rate, 14.52%. Again, their growth is within guidance from the budget to budget, not projected to budget. Their compensation growth is below median at 5.2%. And they actually are showing a reduction in other inflationary growth, which is near the minimum. They do have a utilization decline slightly and 1% operating margin. So really the only thing to investigate was that net projection to budget increase as well as the effective rate. So here again, we see that change in charge for master over time and how that compares to the change in the effective rate. These two lines are more similar than they were for the medical center. And again, that 0.7 was requested and approved, but likely is not what they would have asked for based on inflation at that time. Here we see that gross patient versus net patient revenue growth. And in this case, gross patient has grown more than the net patient. So that means that they're capturing less of the gross revenue. That's going to be influenced by a pair mix. So here we see that their buckets are not very full like all the other people for Medicaid and Medicare, but also the commercial is relatively a little bit less full than some of the other hospitals we've seen. So here we see a more precipitous decline in the days cash on hand starting back in fiscal year 20. So the budget at 81 days cash on hand is a value that is not comfortable. Like that's a very low amount for a facility this size. We also see very concerning operating margins and total margins in the projection for fiscal year 22 at negative 5% operating and negative 6.7% total margin. We do have again that framework where we looked at the costs that have persisted since their mid-year ask and will persist into fiscal year 23 as well as the additional growth that was not envisioned at the mid-year for going into fiscal year 23. And the breakdown of those including the travelers costs. So again we see that there's no assumption for additional growth in travelers cost other than what appeared in the current fiscal year. So again that's some of the savings that they're trying to target and is at risk in the budget as presented. So here we see that the budget is a little bit higher than what the estimated dish payment is. So that is material slightly to the CVMC budget. So if we were going to adjust for that we would increase the rate by 0.17. And here is where that misunderstanding of mine about the final rule for inpatient care is very important because this will make a difference for CVMC. They had 1.44% in their budget whereas the current estimate is 4.29 which translates to an additional 1.1 million dollars coming from Medicare which would have a rate impact of 1.04 percentage points. And here we see it's the same amount of uncertainty but since the 340B program is not as large that range for that rule is narrower from negative 2.75 percentage points to negative 3.47 which translates to a 2.2 to 2.7 million dollar increase coming from Medicare. So looking at a similar framework the commercial effective rate as submitted 14.52. If we adjust for the inpatient final rule which we know that's certain at this point that knocks off the rate that will reduce the amount of the commercial rate. So again not touching NPR or fixed perspective payment but just saying how much of it can come from the commercial rate can be reduced to 13.65. And if we just look at the range for that inpatient final rule the range would be 10.18 to 10.90 a much narrower range due to the uncertainty. And if we were going to apply a similar principle and look at the midpoint there it would be 10.54 for the midrange of that uncertainty. Thank you Sarah. Does anybody from the board have any questions or comments for Sarah at this time about this analysis? Not seeing any hands raised from the board. Is there any board member that is interested in making a motion at this time? Sure. So I certainly hear like the range idea is not going to fly so I'm not going to start there again. But I do think similarly to UVM because of the guidance I do think it's important to take a deeper dive as Sarah has done compared to the hospitals which we had approved before. I think what I would suggest would be I will move to approve CVMC's budget is modified with a 7.3% increase from fiscal year 22 to fiscal year 23 budgeted NPR FPP a 10% increase to overall charges and a 10.54% increase to commercial effective rate subject to the standard budget conditions that's presented to the board. Thank you Robin. Is there a second to that motion? Second. Second. Thank you very much board member Walsh. Any further discussion on the motion? Not seeing any from the board. At this point then I think I will open it up for public comment on this motion. Is there public comment on this motion? Mr. Gobi. Thank you chair Holmes and thank you members of the board. I would point out to the board that CVMC is an institution that has not had a positive margin for years. Their charges as one of the board members pointed out last year on the commercial side are lower than most hospitals in their category and this cut will mean that you are leaving them in a very continued weekend state. Their days cash on hand is perilously low and you should have grave concerns about the cuts that you're putting out. I do not believe that it is right or appropriate to treat CVMC different than Rutland Regional Medical Center and I don't understand the logic as to why when a hospital has seen the type of regulation that this hospital has seen over the years there's no way for it to actually have a margin and this should concern the board. Thank you. Thank you Mr. Gobi. Is there any other public comment at this time? Is there I will kick it back over to the board then is there further board discussion on this point? Do we want to have any questions for Sarah on that point? Is there any other discussion based on the motion on the floor? I'll just say for me I have been and I remain concerned about CVMC because to Mr. Gobi's point they have had they've struggled in the last few years. I do think however when we understand that public payers are stepping up that that should translate into commercial relief. So you know I am concerned about them and certainly I think as part of our standard budget conditions we should be keeping an eye on the situation and maybe you know I don't know that it's necessary because I think the budget conditions allow for some flexibility on terms of how frequently those you know we meet with specific hospitals or the chair meets with specific hospitals but you know CVMC would be a hospital that I'd want to keep a close eye on. Mr. Gobi. Member Lunge I appreciate those comments. What I would say though is that history is not an indicator of that. We came before this board with CVMC's budget at the mid-year and we were told to wait until the summer. It's summer and we're here and it's still raining and so we need the support of the board and these adjustments are far from certain. You're cutting this hospital below the level it needs to be financially sustainable. I can't say it any more simple than that and I'd ask you to reconsider your thoughts. Thank you. Thank you Mr. Gobi. Mr. Vincent. Similar to the UVM Medical Center. So this is another organization that in terms of risk also has in it in its budget a Medicare or Medicaid redetermination assumption that may not materialize same assumption in terms of traveler reduction. And to the point that Mr. Gomez just made if this was a normal year in terms of the commercial rate you know this is definitely a year that we would have tried to make some movement for CVMC to the point that's been made that right now the rates that we're generating for CVMC will make it very very difficult to get them back into a positive margin area. Thank you Mr. Vincent. I would just say that for the record if this were going to be treated the same way that Rutland was we did adjust Rutland for the 23 dish and we did adjust for the inpatient adjustment so that would translate to the 13.65 for this hospital. Thank you Sarah. Sarah can you just pull up for my benefit can you pull up the days cash on hand slide? Yeah. Okay so for me I just do want to sorry would you say Sarah? I cleared my throat all of reaching for mute. Apologies. Yeah I did just want to comment on the days cash on hand coming down to 80.1 for this institution and that is worrisome and that is something that I think we should consider as we're contemplating what this rate might be so it has come quite significantly down from 2020 and I would put 81 days cash on hand in the worrisome vulnerable category so I want to add that to our discussion here. Any other board comments or questions? I think for me I'm just going to say that I think the range idea was helpful that doesn't seem to be flying as much as I had hoped given all the uncertainties we see. For me I am worried about this hospital so I may potentially vote no on this in the sense that I think they may need something a little bit higher to make sure that they are able to maintain their days cash on hand actually increase their days cash on hand and given the low prices at this hospital already I may be in favor of a slightly higher rate than as proposed. Just wanted to add that commentary. Anybody else have any thoughts? Well I mean I appreciate what you're saying Jess because I'm looking back at the central Vermont trends going back to 2021 and their NPR trend over since 2020 21 has been just 8.8% but their expense trend has been 6.5% so here's a hospital with a track record of frugalness so I appreciate what you're saying. Well I certainly don't mind getting voted down if that's the will of the board so don't worry about that. Consider a friendly motion. My Robert's rules are terrible I don't know how that works. Or I can withdraw it if someone else would like to make a motion. Why don't I do that? Because it sounds okay like there's you know it's hard when we don't discuss prior to the motion so why don't I withdraw it and then we'll see if someone else wants to take a shot. Thank you Robin I mean that's what motions are for you throw some things out there you see where the board is and motions can be withdrawn or they can be voted upon so I will take that as a withdrawal of that motion to somebody else from the board want to make another motion. And I would say people should feel free to ask for a recess to discuss it with Russ if they're feeling shy. I'd be glad to work with Jess I just don't know technically what I would insert you know as a substitute value and so we would need some time to explore that. I think one approach could potentially be and correct me if I'm wrong but the language is there the suggested motion language is there and then where the double X's are if you're comfortable with a 13.65 which would adjust for the fiscal year 23 dish and adjust for the known IPPS that would get you to 13.65 that's one possibility but all the rest of the language would say the same we would keep the NPR where it is you know my feeling is again similar to UVM and see that given the way times given the access issues at the network and the greater network integration anticipated for fiscal year 23 I'm comfortable with the CVMC utilization aspect of their NPR so to the degree that we keep the NPR where it is and hope for the best in terms of increased utilization I'm you know that might be an approach that you might take Tom. Chair and other board members so that it's the OPS that is most at risk here and if we removed a lot of that risk but not all of it we would be in a place of would we be in a place and ask Sarah about this too splitting the difference between the 10.9 and 13.65 end up at a place around 12.5 so I'm looking you know at central Vermont relative to its kind of commercial track record and I don't want to get the percentages mixed up with UVMMC because they are two different animals I mean one is 50% of the entire hospital budget and so I'm looking at the in 2022 commercial central Vermont with 7.9% of the total commercial NPR and for 2023 they've dropped down to 7.4% of the total commercial NPR so they're losing some ground there and I haven't thought far ahead far enough how to fix that but I do see them where UVM medical center is picking up ground in terms of its share of commercial central Vermont is losing share of commercial I didn't expect to be in this position so I have not thought this thing through and I'll be that's fine Tom did you have then a motion that you would want to put forth there for consideration sure for consideration and move to approve central Vermont medical center's budget as modified hereby with a 7.3% increase from fiscal year 2022 to fiscal year 2023 budgeted NPR FPP at a 10% increased overall charges and a 12.5% increased commercial effective rate and subject to the standard budget conditions as presented to the board thank you Tom is there a second to that motion seconded by Tom Pelham okay is there discussion on that motion seconded by Tom Pelham and the board any further discussion on that so effectively what that does is it holds the NPR the same it reduces the commercial effective rate by the addition of the fiscal year 23 dish the adjustment for IPPS and accepts that there will likely be some adjustment for OPS coming down the pipeline and or there might be some other discussion on that as well I think it would be a good idea to go to the hospital to identify revenue sources that may offset the need for the commercial rate increase as submitted is that a fair assessment yes okay so any other board discussion not seeing any I will open it up for public comment at this time again I think that we need to go through the narrative everything that we said in our testimony and everything that myself and teammates have said during the the hearings which would not support the motion that you have before you it appears on the face of it to be arbitrary and I can't link it to anything mathematical this is a hospital with 80 days cash on hand and if you're expecting the University Medical Center to weaker position than it was earlier this morning before the hearing started. So I'd ask you to really consider just exactly what you're doing here. You are leaving a hospital that has not had a margin for years in a weaker position than we as the people that management feel it needs to adequately meet its mission and be financially sustainable. Thank you, Madam Chair. Thank you, Mr. Gabay. Any other public comment at this time? I'm not seeing any other public comment at this time. Kicking it back to the board. Board discussion. Okay. I'm not seeing any. So at this point, Russ, I will ask for the roll call vote on the motion. Thanks Chair Holmes. I'll call the roll. Board Member Lunge. Yes. Board Member Pelham. Yes. Board Member Walsh. Yes. And Chair Holmes. Yes. Okay. Thank you very much, Russ. Appreciate that. Let the record show that it was unanimous in favor of the motion. At this point, I will kick it back to you, Sarah, to talk about Brattleboro. Okay. So this is the first time we've turned our attention to Brattleboro. They actually are running pretty close to their budget, relatively speaking, 0.5% below. So their change budget to budget at 13.3 is very similar to the projection to budget 13.8. The overall change in charge is 14.9%, which ends up being closer to 10.5 according to staff estimates when we try and estimate the commercial effective rate. And so just stepping through the tests we did, and here's where I pause and say that, you know, there are a lot of new people working on the budget, not only on Brattleboro side, but on the Green Mountain Care Board side. So we did a lot of work in the interim to make sure we got all the information we needed. So we've plugged in some of this missing information that we'll go over, but the growth rate was 10.5%. That's kind of at the 75th percentile. The compensation growth is well within the range that we would expect to see for the assumptions at 6.9%. We'll talk about the other inflationary growth and utilization assumptions momentarily. And that 10.5% rate, effective rate estimate would be supporting a 0.7% operating margin. So, you know, well within reasonableness. So if we look at their overall change in charge. So here we don't have the benefit of seeing that effective commercial rate longitudinally. We just know how the charge master has changed over time. And we see that that's been, you know, was above inflation in fiscal years 13 and 14, but has dipped below that and is dipped below that for the fiscal year 16 rate that was approved as submitted at negative 1.2%. And since then has been relatively close to that medical inflation line. So here we see their growth in that gross patient revenue versus the net patient revenue and NPR has grown slightly more than the gross patient revenue for this hospital. And when we look at the pyramid, we see that, you know, relatively tall bars for that Medicaid, but we also see, you know, very high bars for the Medicare. And that is part of what supports the Medicare dependent status for this hospital. So that's an important point. So if we take out kind of the employment related costs for inflationary growth, you know, the only other main thing was a fuel increase at $700,000. That was in line with what we saw from other hospitals, given their size and didn't cause staff to recommend any adjustment based on their assumptions there. As far as utilization here, when we look at where they're projecting the fiscal year to end and where the 23 budget is, it's a 0.8% increase, which is reasonable. A lot of that is increases in the lab and they were able to hire a new orthopedic provider. So that's going to drive some of that as well as the pharmaceutical costs associated, particularly with infusion and chemotherapy. We heard about some providers not being able to provide that service. So these all again seem within reasonable assumptions and we did not see a reason to recommend a change based on that. So here we see, you know, that that pattern where the days cash on hand have gone down, they're projecting 149 in fiscal year 22 and actually declining in fiscal year 23. That's getting to levels that we wouldn't like to see. So that's something we'll obviously be monitoring in partnership with Bridalboro in that operating margin of negative 3.5% is building on another negative margin from fiscal year 21. So we'd love to see that bend back into the positive direction. So fiscal year dish, they actually estimated more or I'm sorry, the estimate from diva is lower than they budgeted. So inconsistent with the other hospitals in this camp. We would recommend to increase the rate by 0.7% to account for that. And if you look at the estimated impact of both final rules, that would be $234,000, which would decrease the rate by 0.36. We do want to remind ourselves that their designation as a Medicare dependent hospital and the additional payment they get for being low value low volume. It would mean that they would be facing a $3 million deficit. This is my first time through this I gather that this is an annual renewal. So this is always a concern. And so we just, you know, it's a it's a significant concern. So we just want to lose sight of that. But that's also a consideration here. So if you're so we don't recommend a change to the NPR or FPP. And for the charge increase, you know, there's a potential adjustment for that under estimate for the the under over budget of the 23 dish and the Medicare final rule. Theoretically, there's an option to reduce that to 14.61%, which would be about a 10.21 estimated effective commercial rate. Thank you so much, Sarah. Is there a board comment or questions on on the Brattleboro assessment here analysis here and proposed language. There could you just speak to a little bit in terms of. You know, in previous hospitals, we were used to looking at the 2 different components is this rolled into 1 because they're the only Medicare designation. Like they have they have this status that's different than the others. Or could you just speak to that a little bit as background. Yeah, when I reached out, that's the was seemed to be the simplest way for them to revive that estimate. So yeah, so that that's what we've got. So I'm not quite sure how that triggers out between the inpatient and outpatient estimates. Any other board questions for Sarah or comments. Does any board member wish to make a motion at this time. So, I think with Brattleboro. I am concerned about their financial situation. They were positive in 20, but my recollection is they were actually negative before that. So 20 seems like an aberration due to the federal relief funds. But also, so I, I wish we'd had sort of more granular detail on the Medicare rules, but given that it's a very modest shift. What I will move is that we approve Brattleboro Memorial Hospital's budget is modified with a 13.3% increase from fiscal year 22 to 23 budgeted and PR FPP. Sarah, do you know what the increase to the final charges is 14.61 if I go with the adjustment? Okay. 14.61 increased overall charges. I'm sorry, at 13.3 increased NPR a 14.61 to overall charges with the effective rate being approximately 10.2% and subject to the standard budget conditions. Thank you, Robin. Is there a second to that motion? Second. Okay, it's been moved by Robin and seconded by Tom Walsh. Any further discussion from the board at this time on that motion? Okay, I'm not seeing any. I think I'll open it up for public comment at this time. Chris. Thank you all. And I want to thank Sarah for an absolutely wonderful assessment. Sorry for the confusion. Thank you for your patience with us. I just wanted to clarify some of the Medicare rules. As Member Lunge had asked, so the O PPS right now is not being applied to Medicare dependent hospitals for some reason. There could be a decent amount potentially. We're hopeful, but right now it's not being applied to Medicare dependent hospitals. I mentioned the risk of the Medicare dependent hospital low volume status is incredibly important to us and incredibly risky to us. There is a bill in the Senate and the House to make that a permanent status, which we're hoping for. We just got Senator Leahy to actually be a co-sponsor. And Walsh has been a co-sponsor in the House. There's also a secondary bill just in case that doesn't work, that would extend it for five years. So we're incredibly hopeful. We still are in a risk situation. And we're very hopeful that O PPS will break in our favor. But right now, for some reason, Medicare dependent hospitals have been excluded from the O PPS. Not sure why. Thank you for that clarification. Yeah, I appreciate that clarification. That's very helpful. Any other public comment at this time? So I'll take it back to the board for any further board discussion at this time. Shall we ask for a role? Maybe we should ask for role just to be consistent. Russ, do you want to do the role on this motion? Thanks, Chair Holmes. I'm happy to. Sorry, I do see one hand raised, but perhaps that was Chris from earlier. Oh, Chris, did you not lower your hand? Yes. Okay. I think we're good. Nope. It's back up. It's down. It's up. It's down. Okay. Got the time disease. Go ahead, Russ. Okay, so I'll call the role on this motion, which is to approve Brattleboro's hospital Brattleboro Memorial's hospital budget is modified with a 13.3% increase in NPRPP and a 14.61% increase to overall charges with effective rate being approximately 10.2% effective commercial rate being approximately 10.2%. Board Member Lunge. Yes. Board Member Pelham. Yes. Board Member Walsh. Yes. And Chair Holmes. Yes. Okay. Thank you very much, Russ, and let the record show that we had unanimous support for that motion. At this point in time, I'm going to, why don't we take a 15 minute recess so folks can get up and stretch and do whatever needs to be done and we will come back at 11am to talk about the next two hospitals, which are the last two hospitals, North Country and Springfield. So we will be back at 11am for after our recess. Okay. It is 11 o'clock. We are back. I see Robin. Is that right now? Wait, hold on. Yes, I do see Robin. Okay. See Tom Walsh. Tom Pelham is back. Excellent. So Sarah, why don't we pick up where we left off with North Country? Okay. I'm hearing distortions on my end. Are you hearing them from my voice? Okay. Perfect. I will be fast on the mute. So we're turning our attention to North Country Hospital. Their budget to projection, so like a lot of other hospitals we saw previously, their projection is 2.3% above their 22 budget. So the budget to budget increase of 12.5% reduces to 9.9% after you factor that in. And their overall charge increase is 12.5%. So when we look at them for the kind of components of the decision tree went through, we see that their compensation growth at 1.7% is quite modest. The other inflationary growth at 4% is below the threshold, but close to it. Part of that has to do, again, a lower amount of money. It's easier to get higher proportionate growth. So it's, you know, their budget is lower than some of the other hospitals. And then their utilization is actually looking at a bit of a decline overall. So that leads to the 8% effective commercial rate increase based on the estimate of what the 12.5% charge increase would actually do for a 2% operating margin. We can see that their trend looks quite a bit different than some other hospitals we've seen when we look at the approved change in charge over time. And particularly the last 2 years have been at or near the, you know, again, we don't have the reference point for fiscal year 22 yet, but likely it's going to continue an upward climb. So their medical inflation comparatively to the charge has been different than we've seen statewide. So this is the hospital where the NPR growth and the gross, the gross patient revenue have grown at a similar amount. And we have $10 million that have come off this chart for fixed perspective payments. And when we look at their mix here, we see relative to the other pairs quite high bars of gross patient revenue for that Medicaid population. So that means that the amount of care they're providing to the Medicaid population is quite high. And so as we've seen that that trickles down to major differences in what the net revenue looks like. So they have also see a decline in their days cash on hand from fiscal 21 to fiscal year 22. 223 is one of the relatively higher amounts of cash on hand that we see compared to other hospitals and plans to keep that stable into fiscal year 23. However, we do see again that troublesome negative operating and total margin in fiscal year 22, which were the intent of the 23 budget is to bring back up to 2%. So for the North country estimate compared to the budget for their 23 dish payment. So the estimate is a bit higher than North country budgeted at $99,000 in their favor. So the rate impact if we were to apply that would be a downward address adjustment of 0.21 percentage points. And that would mean if we were to apply that the change in charge would be reduced to 12.24%, which would be reducing the estimated effective commercial rate down to 7.8%. So that is North country in a nutshell. Thanks Sarah. Is there any board discussion, comments, questions for Sarah on the North country and assessment. I have a quick one. So in my notes on North country from their pair mix. I had Medicaid and Medicaid budget to budget increase of 30% going from 12.9 million to 16.9 million. And as I recall, there was a response to that but I didn't write it down I guess at the time so it's still an open question. So that's a big increase year over year. Yeah. And I think that, you know, as you can see, I think part of that is the, you know, if you look at the, the, the height of the yellow bars between 22 to 23, you also see a big jump. And so, I think that's part of where that commercial ask probably originates. Any other board questions for Sarah or comments? Does any board member want to make a motion? I'll move we approve North country hospitals budget as modified with a 12.5% increase from fiscal year 22 to 23 budgeted NPR FPP, a 12.24% increase to overall charges and subject to the standard budget conditions as presented to the board. They're a second. Seconded by Tom Walsh. Any further discussion? Okay, this time I'll open it up for any public comment on the North country motion. I'm not seeing any public comment no hands raised so I'll kick it back to the board. Any further board discussion at this time. I would just like the only thing I'd add about this hospital is that I, I think that they've done some good work around their emergency department utilization and looking to shift that to other more appropriate settings. So, in another budget that utilization decrease would I be a little bit worried about that as an assumption. But I think given that work it is supported in the record and I think they should be applauded for that work. Thank you, Robin. Anyone else comments. Okay, well all those in favor of the motion to approve North country's budget with a 12.5% increase from 22 to 23 and NPR and FPP and a 12.24% increase to overall charges, subject to the budget conditions. As presented by the board, I think we could we'll say all those in favor please say aye. Aye. Aye. Any opposed. Okay, so this one let the record show that it was unanimous to support the North country budget with those slight modifications. All right, I think we're up to Springfield then. Yes, so this is the final hospital for which the board must set a budget for fiscal year 23. So this is a situation where the current projection is below the 22 budget so they're about 5%, 5.5% below the budget. So their budget to budget growth 7.5% is within the guidance much like CBMC, but the projection to the budget is 13.6. So that makes it above the guidance. They are submitting a overall change in charge of 10%, which is expected to be applied pretty uniformly to their gross charges. So when we look at the other assumptions behind this budget, so we see a compensation growth of negative 12.8. That's the lowest we've seen. So I think that that is part of kind of their efforts to right size the services that they're providing. And then when it comes to other inflationary growth, they're quite modest at 0.7%. So clearly a focus on reducing expenses is evident in the materials and the utilization assumption of 1.59. That is ambitious. They have testified under oath that the staff they have in place and the utilization assumptions that they made are due to existing demand. It's not that they're trying to find additional utilization. This is pent up demand due to trouble filling some vacancies. The effective commercial rate is 6.4% based on that 10% charge increase for 0.7% operating margin. And so, you know, Springfield not surprisingly has a much different trajectory when we look at their approved charges over time. So, you know, they've had a much different path than other hospitals in recent history. So I think that it makes sense that this would look a lot different than the other hospitals. And here we also see some of that volatility in that there's a lot of ups and downs in the gross patient revenue. So, you know, that's going to have to do with changing patterns of care. There's been some significant changes to the services they've provided over time. So, you know, you can see a hospital that is actively adjusting to the community need. But we should say that, you know, for fiscal year 23, there is another 3.4 million off this chart that they're getting through the fixed perspective payments. And then here we see that that payer mix. And so, you know, very evident here in the past couple of fiscal years as we see, you know, that shift with more and more Medicare. Part of that is the Medicare Advantage class classification being moved where it needs to be. So that makes some of this longitudinal information a little hard to interpret. That's one on the punch list for things that we can improve and get corrected in our records here. And so here, you know, very, very low levels of cash on hand. It's been, you know, between 40 and 50 since fiscal year 20. You know, that that's a concerning level for sure. And, you know, that big bump in the total margin in fiscal year 21 is all about relief that, you know, that that's all gone away. So seeing them, you know, likely, you know, their projection has them finishing in the black this year with an increase to 2.8% for fiscal year 23. And when it comes to dish, their budget in the diva estimate are pretty much are pretty close difference of $32,000. So we don't recommend any adjustments based on that for Springfield. So when it was really helpful for me when I think about this hospital to remember the recent chapter 11 filing and so the dark solid blue line is their actual NPR FPP performance and the dash line is what their budget had been. And so, you know, there was obviously a big delta there leading up into filing for chapter 11. And we see a rather dramatic change where they were able to hit that target for fiscal year 21. So they're 5% low for fiscal year 22. But this is a case where the additional bonus dish payment in fiscal year 22 should actually get them very close to the budget again. So that'll bring that right very close if not overlapping that budgetary line for fiscal year 22. And I think that they also have shown so this takes a minute to digest. So basically what we're just showing for each fiscal year that dark blue line is how the actual to budget has looked for Springfield. So if it's below zero, that means the actual was below budget. If it's above that line above zero, that means that they were able to net more than they budgeted. The dashed white line in the middle is how cause in Vermont performed overall with a gray shaded area of plus or minus three standard deviations. We set a new benchmark starting in fiscal year 20 as the volatility significantly changed with COVID. So we can see that, you know, that 5% delta, you know, is, you know, within that range for this year. But that, you know, that kind of being far below the line. If you factor in the chapter 11 filing, you know, hasn't been true. We don't have a lot of data yet. So it's still really early days and trying to see where this thing will be heading. But, you know, in conversations, not only with the testimony, but we are in monthly monitoring meetings with Springfield Hospital and they are transparent and active partners in that. They are talking about the investments they're making to improve the recruitment. They have some providers in place. They've put some new software in place to help make sure that they're getting all that they are owed for their commercial contracts. This is particularly notable for the Medicare Advantage plans, which tend to be slow and reluctant to adopt price changes. So that's going to be a major significant change for fiscal year 23. They have been able to put new staff in place that are ready to go and expand access and, you know, just constantly addressing the needs of their community and figuring out, you know, some really tough decisions, but, you know, not having any more chemotherapy there, I think was a very difficult decision for them to make, but one that they, you know, were in close collaboration with their community to address. So for these reasons, you know, staff didn't see reason to recommend a change. And, you know, but, you know, I think that there's probably some discussion to be had about this hospital. So I'll leave it there for now. Thank you, Sarah. Open it up for the board for discussion on Springfield's hospitals budgets. I have one question back during the hearing. I asked the question about how they calculated their provider tax, because the math on their provider tax was such that it was exactly like with to the dollar equal their 2023 provider taxes to the dollar equal to their 2023 npr time 6% and but the formula for the provider tax is not the current year is the prior year and the prior year they were trending at 51.7 million. So the provider tax difference would have been to their benefit of for about 425 $425,000. And I'm just wondering if that got cleaned up during the process. And that is a good question. I have a memory of looking into that and resolving it, but the details I would need to refresh my notes on. So I apologize that I can't speak to it at this moment. Thanks, Sarah. Tom, do you have another question for Sarah? Yes, Tom Pelham. No. Okay. Any other board comments or questions for Sarah or board discussion? Thoughts on this analysis. This is Tom Walsh. I appreciate the analysis. As always, it's insightful. Earlier in earlier today, there was a public comment about a struggling hospital and that regulator should approve the request because it's struggling. And I struggle with that type of comment because the business model is struggling. Raising prices is rarely the solution to save the business. So in this particular case, Springfield's been struggling for a while and raising prices may not solve fully the issues that they have in front of them. But in those same lines, one of their initiatives is with their electronic medical record and using that particularly with Medicare Advantage to get what they're owed, quote unquote, to make sure that they're diagnosing properly. That technique can go awry. And then it's termed gouging. Medicare Advantage has a known issue with this, with up coding and using that to their financial advantage. Given Springfield's financial stresses, I hope that in our monthly meetings with them, we watch for that. I really struggle with what as regulators we can do to be helpful to the situation facing the hospital in Springfield and the people served by the hospital. Thanks, Tom. I'm happy to jump in here a little bit in case it gives some time for other people to think about it. I appreciate Sarah's analysis on NPR. I remain really concerned about Springfield. I think we all do. I think this has been a concern for several years. Their days cash on hand are dangerously low. Their margins may be improving, but they're still thin. There's a lot of volatility. It doesn't take much to tip them right back over. And they do, I appreciate the assessment of their NPR relative, you know, actual to budget it. But there are some misses there where NPR certainly missed the target. And then their expenses were too high. And that was in a sense clearly what's leading to those operating losses. So this budget includes a 13.6% growth in NPR from fiscal year 22 projected. And that's twice the median growth rate in the state. I appreciate that some of the, that's based on the fact that they're missing their budget this year. And when the fiscal year 22 extra dish will actually make them whole, that will be less. I see that and I recognize that it still worries me. This budget still feels a bit aspirational to me in the sense that trying to go back through the record, they're starting a pain management service, which will certainly help revenue. But the increased in utilization also comes from two extra days a month of podiatry, which doesn't sound like an awful lot. A future recruitment of a general surgeon who's not on board yet. But it's currently that service is currently being covered by a locum. So it's not clear what the actual Delta will be there. The transition from, I think, two part-time GYN docs to one full-time GYN doc. Again, what's the Delta there? I couldn't quite figure that out from the record. But a potential recruitment of another part-time GYN provider. But again, some of this is covered by locums already. So I worry that some of this is relying on recruitment, which we know is a challenge. And particularly the piece that worries me a lot is that I think Springfield will be one of the hospitals that's affected by the expansion of Dartmouth-Hitchcock in the current year. And Dartmouth-Hitchcock has just expanded their ED, whose big announcement last week with 11 new beds that's adding new capacity for mental health borders. Thank goodness that will be helpful. Again, I would say not the appropriate setting, but will be helpful. But also, more importantly, they're opening up 65 new inpatient beds. That's going to draw patients and that's going to draw my other worry is workforce over the border. So are they going to have even more difficult time with recruitment and maybe retention of providers? So I just want to share some of these concerns because I do think that this is a hospital that when they miss their NPR target, their operating expenses exceed that target and or exceed what they've retained in revenue. And they don't have a cushion in terms of days cash on hand to weather that storm. So these are my worries about aspirational budgets. It may not be aspirational, but it's still a budget that relies on some recruitment and some utilization to be coming back into the hospital and relying on Dishnow to even make their budget for this year. So I want to just throw that out there. One possibility would be to adjust their budget to the 8.6% growth in NPR that would have been projected from Fiscal Year 22. That was more in line with the board's guidance. Have them adjust their operating expenses accordingly. If they're exceeding that cap on a quarterly basis after quarter one, we can revisit. There's hope that if they can meet that target, that's great. But maybe a more conservative approach given the history here might be warranted. I'm actually comfortable with the change in charge given that it's a really a 6.4% effective commercial rate, which is within the bounds of what we would expect around inflation and other commercial rate increases that we've seen. So to me, it's about the NPR and being able to make that target and the associated expenses that lie below it. So I don't know if anybody has any other thoughts or comments, but welcome them at this time from the board. Okay. Well, does any board member want to make a motion at this time? Sure. So I share your concerns about the NPR. So the motion that I'm going to make addresses that and keeps the change in charge at the 6.6.4% effective commercial. So I would move to approve Springfield Hospital's budget as modified with an 8.0. Actually, I need help with the math, Sarah, because it's not an 8.6 increase budget to budget. It's an 8.6 increase projected to budget. I apologize. I shouldn't have that ready. No, it's okay. That's a 2.7% increase budget to budget. So I'll start again. So if we approve Springfield Hospital's budget is modified with the 2.7% increase from fiscal year 22 to fiscal year 23 budgeted NPR FPP a 10% increase in overall charges and subject to the standard budget conditions. Is there a second? Second. It's been moved by Robin and seconded by Tom Walsh. Any discussion on this? Motion thoughts on this motion. On board members. I don't really have anything to add. I thought you articulated the aspirational component. Well, Jess. And that's really what's what's driving my motion. I think maybe do we want to add, I mean, I think part of the issue is want to make sure that if we do adjust the NPR that we're also adjusting the operating expenses below it to retain the margin. That they asked for. So there might have to be some additional language in that motion. You can make a, you can propose a friendly amendment, Jess. Okay, I can do that. I would propose a friendly amendment that is moved to approve Springfield Hospital's budget as modified with a 2. Sorry, what was that again? 2.7. 3.7% increase from fiscal year 22 to fiscal year 23 budgeted NPR with a commensurate reduction in operating expenses to retain the margin as submitted. A 10% increase to overall charges and subject to the standard budget conditions as presented to the board. So I will accept it. I will second it and accept it as a friendly amendment. Okay, thank you. Any other discussion on this? I think the idea for me here is that this, you know, this budgeting, this modification to their budget, we will look and come back. Let us know if it if it is in fact you're exceeding the Springfield Hospital is exceeding this budget after quarter one. Let's revisit in it in January. I just my sense here is that a conservative approach given the hospital's history may be warranted. So that would be my only other addition I would add to that discussion. I will at this point open it up to public comment. I'm not seeing any additional public comment at this time or any public comment at this time. So kick it back to the board. Any other comments anybody wants to make before we ask for the vote? No. Okay, all the Bob at I get at cops. I see your hand raised. Hi, thank you, Dr. Holmes. We appreciate the board considering our request. I think we would. I missed the beginning very beginning of the meeting where Sarah was going through the graphs. Could you clarify for me the impact of how how this modification affects what was originally requested? Yeah, so the idea is to take in, you know, one hard thing is it's the projection at the time you filed your budget. So I don't know if that's changed since then I house for a lot of hospitals. And then using that, which would be a 56.2 million dollar budget versus the filed 58.8 million dollar budget. So playing an 8.6% increase to the projected for fiscal year 22. Yeah, so it's a delta of 2.6 million dollars on NPR FPP with a commiserate adjustment to make sure the operating margin stays the same. And Sarah with that fiscal year 22 is that inclusive of the fiscal year 22 dish that was added. So I think that is reasonable in my mind to that is fiscally our current information on the fiscal year 22 projection should be inclusive of the fiscal year dish payments that were added. Does that change our motion that does change the man. So that would be in a 56.9 million dollar budget for a growth rate of. I'm feeling a little nervous about making a mistake and doing the math this quickly. So if it's all right, I'd like to have a recess to make sure we get these. No, that's great. Why don't we take, we'll take a 10 minute recess and we will come back. Okay, I appreciate it. Yes. Thank you all. Thank you for addressing our question. I'm going to give Sarah enough time to be able to Sarah, you're back. I think so. I apologize. Technical difficulties. I was just consulting with the business office about how to rectify that. Okay. So, let's see. All right, is that coming through and are you able to hear me. Yes, and that is the fastest chart making in the history of the Green Mountain care board. Yeah, I definitely, I think I've got this ticked and tied. So basically 8.6% growth from what the first column would be the fiscal 22 year budget which actually would be an increase in the 23 budget. So that's not what we're talking about an 8.6% growth from the projection at the time they filed their budget in July would mean a 2.7% growth rate from budget to budget. Which means they would be cutting the proposed budget by 2.6 million or 4.4%. If you want to include the bonus 22 dish, then the growth rate from the 22 budget would be 4.1%, which would be cutting 1.8 million from their budget and 3.1% from the growth rate. So, I hope that makes it a little clear. That's not necessarily the most easy to interpret way to go, but. Yeah, I think the critical question here is, do you include the 22 dish in the 23 base? We have not updated this for what the current projection is for fiscal year 23. So that might be worthy of pursuit. I don't know. Super helpful. Super fast seeing it in front of us. I think in either case, I think I should withdraw the motion and we should have the discussion and then I should redo a motion. So let me withdraw the motion. Consider it withdrawn. Thank you Robin. So what discussion, where do we want to start this discussion? I think the concern is that we're worried about the top line being too high and potentially. The expenses underneath that top line being too high and then this hospital. You know, not having a lot of wiggle room with respect today's cash on hand. If they don't miss that, if they miss the top line, that is, I think that's the point that board members have expressed. So what. What is the pleasure of the board with respect to this chart? Or Springfield hospital. So personally, I don't want to put Bob on the spot, but if he has any thoughts or comments, it would be helpful, I think to understand. His perspective and to Sarah's point if. The projection is wildly different than what. We saw in July. If that would be okay. Now that'd be really helpful. I think that's a great idea. Well, well, thank you. I'll just comment that, you know, the hospital has been through a challenging number of years and during that time. The hospital has had financial difficulties. Leadership turnover restructuring has been through and emerged from chapter 11 and has also been through COVID. So the hospital has been through quite a bit of. There's been a lot of action here in Springfield the last 4 or 5 years, and this has been a phenomenal team that's been very resilient and has responded to the needs of the community. Time and time again. So, I mean, I would like you to take that into consideration as you think about our request. Because what we are trying to do is stabilize the hospital and rebuild the volume that is needed in the capacity for taking care of that volume for our community. And, you know, that's what this budget is intended to do. We have been blessed with some really good locums providers this last year, particularly in GYN and in general surgery. They have helped us maintain those practices, but I don't believe that I believe we're going to have a lot more growth and a lot more capacity to meet the needs of our marketplace with permanent members of our family providers here. And we have we filled that recruitment need with GYN and I am optimistic that we will we will recruit a general surgeon. You know, we projected to do that at the beginning of the second quarter. So we still feel good about that even though we haven't signed that provider. And I think it's just, if you look at what happened to us last year, 12 months ago, we were feeling really good about the direction we were going in in terms of the volume in the way it was picking back up in our marketplace. Then Delta and Omicron hit and really knocked our legs out from under us and it really affected our volume and our revenue. And I think that's what's affecting our projection for FY 22. Now we feel like we're back going in the right direction again. We did 90 surgeries in August. We have had we have had we've had a slow summer, but August is was back in September. First half of the month looks like we're back in September as well. So just keep that in mind as you're thinking about what we're trying to accomplish here in terms of returning the hospital and giving it the muscle it needs to meet the needs of our community. And particularly regarding our expenses, because we do have to compete in terms of the amount we're very cautious with all the dollars we spend here. And we're trying to spend those dollars to rebuild the hospital and take care of our staff and provide the competitive salaries and the benefits we need in our marketplace. So I appreciate you stopping in in deliberating us and thinking about it. But, you know, we are trying to do the right thing for our community. So thank you. Yeah, and I think Keita might be on as well. I don't know to put her on the spot, but I didn't know if you knew how that 51.7 million dollar projection for the current fiscal year looked today. Hi, yes, I am. Sorry about that. There's some feedback. Hopefully that stopped. I have not redone that projection since. I know our net patient revenue for August is going to be a lot higher than what we've seen. Am I still hearing of feedback somewhere. Yeah, if you've joined from both your phone and your computer, it can do strange things. I'm not out of my phone. Shoot. It may even be twice. It's not my phone. I'll just talk but if there's going to be terrible feedback. I have not redone the numbers since this projection, but I know our August and PR is going to be significantly higher than what we've seen in quite a while. Like Bob said, we were probably our highest or cases this year. We had high visits. We had high ancillary volume, pretty much across the board. So I know August looks like a great month. September is looking like a good month as well from what we've seen. As with last year, this year is kind of similar where the last the first half of the year was really a lot slower. This year we were hit pretty hard in January. Even February, March, April, we had a hard time rebounding to the higher levels that we were at before we got hit with the COVID variants in January, but we're already seeing in the last month or so, higher volumes. So we could redo that projection and see where that comes out. If that would help. Let me see if I can get figure out this feedback. Thank you, Kate. I apologize for the feedback if it's happening from our end. This is always a tough one every year. I mean, I so I recognize that if you know if there's been increased volume and it's been consistent since you submitted this budget that the projection may in fact be higher. There's a couple of ways we can go here. I suppose we, you know, if the board is willing, we could approve the budget as submitted. We could make a slight adjustment. If we prove the budget as submitted, I would encourage perhaps a visit, you know, we're doing monthly monitoring. Perhaps it's worth having Springfield come back at some point after the first quarter, you know, when the annual fiscal year 22 books are done and one quarter is in the in the books for fiscal year 23. So there's multiple approaches to this. I'll throw out to the board. Yeah, this is as always. It is hard and it's hard to know, particularly when the volatility is on the utilization side to know whether or not that rebound will come through. I think in not specifically with this comment referring to Springfield, but we have in the past seen smaller hospitals not being able to meet their top line when it was too high resulting in negative margins. So I think our concern is coming from a good place of being worried about ensuring Springfield can rebuild. I feel like I could be comfortable approving as submitted if with with an explicit condition potentially that we would have the staff take a look after the first quarter to see if they're, you know, where things are at. And I think, you know, the other issue to the extent that the volume issues were with COVID, I'm not sure we know how this winter is going to go with COVID and so we could see the same pressures over the winter as well resulting in the same sort of volume issues. So I really could be flexible and go either way. Approve is submitted with an explicit condition that we could reconsider after the first quarter if volumes look slow or do the 4.1% change from budget, which would be a slight reduction, and which then of course Springfield always has the option of coming back should there be a material difference. So I'm comfortable with either approach. So I'd love to hear what other people think. Tom and Tom, any thoughts here? Well, I'm not going to be around. So I feel a little like I'm weighing in on something that I really don't want to influence because I'm going to be not here, but you know, I mean, I'm kind of a channeling marine here. And you know, as you know, and my general sense is that the top line should be reasonably conservative and not overly optimistic. It's better to have good news and bad news. Tom Walsh, I see you shaking your head and unmuted yourself. Did you want to add to the conversation? I think it's better to be conservative. I think there are, you know, Springfield's in a, for Vermont, it's in a rather unique situation. Patients have more choice, have more options. And it makes a plan relying on growth and utilization more challenging. And I would like to see that. I think it would be wise on, from our perspective, to be conservative about what's going to happen. Thank you. Is there any motion that a board member wishes to make or further discussion before we make a motion? Well, if Robin's ready to make a motion, I'm ready to listen. It would help me to see what the language would look like, translating this chart into what the motion, the actual motion would be and what the more conservative version versus as submitted. It'd be good. I'd like to see that if we could please. So maybe what I'm going to suggest is that it is lunchtime. I don't know if you can hear the chimes in the background, but it is literally exactly noon. What if we were to take a recess for lunch and come back at one o'clock with potential language and maybe a little bit, you know, looking at the two approaches here or three approaches or any other approaches that board members might consider over lunch. We can come back at one o'clock and discuss. Does that make sense? Is there any objection to that? Okay. Seeing none, I think that might be the best way to approach this. So with that, I'm going to take a recess and we will come back at one o'clock and continue discussing Springfield Hospital. So I think it was probably a good idea that we took a little recess. It gave a chance for Sarah Lindberg to give us a little bit more information that I think may impact our decision. It may impact mine, certainly. I think it already has. So, Sarah, do you want to share what you've pulled together over our lunch break? All right. Am I still here? You can hear me. You're here. Okay, great. So just as a review, we were talking about, you know, doing the growth at 8.6% and there was some question about whether that would be, you know, from the current projection or including that bonus dish. And with the intent of preserving the operating margin, that means that the 2.6 to 1.8 million would have to come off not just their budget, but their operating expenses. And when I looked at that in context of their current operating expenses, that would mean the 23 operating expense growth would be negative 0.1% to 1.3% growth, which does not feel like we're setting anyone up for success. And so, you know, our approved budgets to date have allowed a total of 4% in operating growth expenses to account for inflationary growth, particularly as it relates to workforce. And, you know, the proposed budget is right in line with that at a 4.5% growth rate. So to me, like, I just worry that this would really make a vulnerable hospital even more vulnerable. If we were going to make that adjustment now. But if I did lay it out what the options are, so, you know, there's approving it as submitted, we haven't had any discussion about addressing the change in charge. But if you look at the budgetary growth from 22, as submitted is 7.5, which is 13.6% from projected. If we use the variance of the 8.6% growth, that would be 2.7 to 4.1% budget to budget growth or 8.6 to 10.1 from the projected to the budget. So, so I would say that the staff recommendation stays the same in that, you know, this budget is approved as submitted that we would continue our monthly monitoring, which is always, you know, candid and transparent. And, you know, make sure that we notify other interested parties about the fact that, you know, this is this is a hospital that's still in a recovery phase and very vulnerable so that we're not the only ones who are aware of the struggle. Thank you, Sarah. I appreciate that. You know, this is obviously one of our challenging hospitals. They're facing challenges. I know they're working really hard to overcome those challenges. I still think the headwinds are strong. I still think that it's possible, even perhaps likely that they don't make that top line. But I recognize you're concerned about cutting and having them find 1.8 to 2.6 million dollars in operating expenses at this time. I know they've tried diligently to cut expenses since coming out of chapter 11. So I just want to my I still have red flags. I want to say that for the record I have significant red flags about this. But I also recognize that this budget cycle we're trying to do short term stabilization. And so I think we'll see where other board members are. I think I could approve the budget as submitted with some serious concerns and a request for a check in with the full board after quarter one continued monthly monitoring. Absolutely. But a check in after quarter one, you know, if if the monthly expenses are, you know, growing and there are revenue shortfalls below which they anticipated, there is no buffer here. Their days cash on hand are already low. So there is no buffer to draw down from. So I think, you know, if at the end of quarter one, they are not on target to meet this budget. I think we'd have to make some serious adjustments at that time, but maybe giving them an on ramp to get there. If as Kada was saying their August projections and their September projections in terms of patient revenue are higher than anticipated, they may make it. So I guess that's where I sit after this, but I just still have serious red flags. I want to make that very clear and part of the record. Yes, I have a question for you. It sounded from what you said, like you would want the board to be able to initiate an adjustment after quarter one. Am I understanding that correctly? I would want the board to be able to have, I would want, I want a full board meeting. The monthly monitoring happens between staff and the chair. And so I want to have a full conversation with Springfield in January, basically. But I think my question is, do you want to be able to act on that? Or is it okay to wait till the end of the year? Because the current currently under current law, the hospital can initiate an adjustment. The board can initiate an adjustment in enforcement at the end of the year. So if what you're saying is you want as a board member to be able to consider making an adjustment in January without the, I mean, Springfield might come in and say, yeah, we'd like an adjustment. But if they didn't, if you want that, then we need to add that as a special condition. I like the idea of that as an additional condition. And I'm not trying to influence one way or the other. I'm still processing myself, but I just wanted to be, make sure I understood what you were saying so that we can. Yeah, I appreciate that. Well, as I said earlier, I'm, you know, I think they said earlier I was open to approving as submitted with a condition that the board would reconsider in January. Tom and Tom, do you have any thoughts or comments at this time about what you've just heard from Sarah or any of our comments? This is a tough one, I know. Well, I definitely think a check-in is in order. I'm looking at my little chart here that I keep and see the Springfield and since 2021 there, annual trend on expenses has been 5.3%. So, you know, there's not like it's a, you know, a steeply inclined ramp coming out of bankruptcy. But I think they're still in a very tender place. And it's good to have them in the context of messaging, you know, that there's still a ways to go. And it's not, what's that game used to play as a kid, ollie ollie and free, you know, kind of thing. It's still a time to be diligent. Thank you, Tom. And I guess if, you know, I'm not the lawyer here, but if the action of the board is allowed to buy action of the board, the board becomes allowed to make some adjustments in the beginning of the calendar year. I'm not going to be around, but I can support that. I mean, what good is it to know there's a problem and not be able to address it. But I, that's a question I totally would defer to Robin on. Any other comments or questions and we can ask Russ that question as well. In fact, Russ, do you want to weigh in on that possibility that the board might add that as a condition here. The condition that where this is being discussed is that after the first quarter, Springfield Hospital comes in before the board does a presentation. I understand showing sort of actual performance for Q1 against the budget. And then as it works currently in the rule, if there's some variation there, Springfield can certainly ask for an adjustment to its budget one way or another. I guess I'm not. I'll put the question back to the board. What are the parameters to the board making a change mid-year that is not requested by the hospital? And to take an example, if the board approves Springfield's budget as submitted and Springfield comes in after the first quarter and they're tracking that budget, it seems like there's a position where the board should be making a mid-year change kind of of its own initiative. So I'm a little bit, I'm wondering if the, you know, the hospital gets a budget approved needs to be able to rely on that budget. I'm going to set some parameters around how the board might make changes. I guess the more specific those parameters are, the less uncomfortable I feel about the idea. I understand. From my perspective, if the budget's on track, I don't, I would not have any interest in making any adjustments. I think that concern articulated is that the top line may be aspirational. And thus, you know, expenses flow to the top line and then that sort of setting the hospital up for a negative margin. So I think we could limit it. I mean, it's always tough because there's so many moving parts on a budget, but I think that one idea in this may take a little time to develop. But one idea could be to set a parameter by which if the, if the hospital is under budget by a certain amount, the board could consider whether or not it's likely the hospital will make that up during the remainder of the year. With that said, I think what's tough about the mid-year adjustment if it's down is that that's, you know, I think that's tough on the hospital to make a mid-year expense reduction that wasn't anticipated when the budget was approved. And if I can throw in just one other thought that the way the rule works now, the board can, you know, the board can really encourage the hospital whose actual performance is far off of its budget. The board can encourage the hospital to request a change to the approved budget. And part of that encouragement is that at the end of the year, you know, the board could take some kind of enforcement action and the way that the hospital can help avoid that situation is by making a requested change to the budget mid-year. I think typically the enforcement action occurs when the hospitals are exceeding their budget. And so the worry here is that they will be under budget and they'll be generating losses. But I hear the concerns of our legal counsel. So is there something for us that you would recommend that we do other than is it enough to do, you know, the monitoring, monthly monitoring that we have and a request for an update from Springfield County? Is there, is there, is that enough, do you think, to ensure that we're doing our proper job here in making sure that our hospitals are, you know, operating, providing access to care are not financially compromised? My worry is, you know, I think the obvious one is that this hospital doesn't have the buffer to be able to draw down from day's cash on hand. And so I want to make sure that we have enough time, notice and opportunity to adjust midstream and we're made aware of those and we can be helpful to a hospital that may be struggling and financially compromised. So that's, I'm trying to get to a place where we can, we're not waiting until the end of the fiscal year at enforcement time to pivot and make changes to ensure that this hospital is able to provide care to its community. I would just add that I think a lot of the issues you're touching on are exactly the type of thing that inspired our redesign and thinking through, you know, what is a more meaningful mechanism for enforcement in either direction. And, you know, looking at, you know, budget to budget growth isn't always the most logical measure, but that's the one we have for this year. Sorry to interrupt us. No, that's fine. I appreciate you buying me a couple more moments there to think about it. Certainly the board can increase our meeting frequency with Springfield both on a staff level and a full board meeting individual board member level that can all be done. A lot of it is supported already in the kind of structure there is in the standard budget conditions. We could potentially build those out to put some specific dates around meetings like the Q1 review. I think if the board is really concerned that the kind of top line of the proposed budget is unachievable, it might be more appropriate to reduce that budget, reduce that top line now. And then if the hospital's revenue is exceeding that part because of utilization or some other factor, then it's easier for the board to kind of increase an NPR cap mid-year. Then my sense is that it is to reduce revenue and expenses mid-year as board member lunch noted. And I think the last part is, and maybe Sarah will jump in on that one. Springfield's leadership team has, I know, worked very closely with Sarah and with Sarah's predecessor. And so I think that, you know, for the board to continue that partnership is a key element in understanding the hospital's progress and its financial situation and kind of working together on whether changes to the budget are appropriate or helpful mid-year based on how the hospital's finances progress. So I don't know if that is all helpful or not. I have some concerns about the precedent that might be set for the board to say, you know, we establish a budget now. And we reserve the right to change that budget mid-year. And so I'm trying to offer some other ways to make sure that we're kind of in close communication with the hospital and helping the hospital to drive any necessary changes to its budget. Okay, that makes sense, Russ. I appreciate that. I have a question for Sarah, if I might. Sarah, with the analysis that you gave right after we returned from lunch, was that with the 2.7 or the 4.1? Yeah, so the 2.7 would lead to the negative 0.1% expense growth allowable. The 1.3 is with the 4.1. Okay. Yeah, and again, so I don't have the trend, but unlike most hospitals, their expenses go way down during the Chapter 11. So, you know, some of that is kind of recovery. Yeah. Well, I don't want to be in a place of regulating negative growth and expenses like that. I think, but I also don't understand the value of when we're meeting monthly already to have an additional meeting if they're not meeting their utilization targets. We can't regulate more utilization. And so that leaves me at around the, that leaves me around the 4.1. Yeah. So I would say, so Tom, I think the additional value of what Jess is proposing, which is a full board meeting is that the monthly meetings are between staff and the chair. And so the rest of us may get documentation of that, but we don't have the benefit of actually hearing from the hospital and understanding in depth what's happening. Obviously, if there's a problem, the staff will talk with each of us, but because of the open meeting law requirements, the only way for all of us to really get that deep dive is, you know, to do something like this where they come in front of us. So to me, the value is that there's two things. One, it allows each of us to ask our questions and make sure that we all feel comfortable. And, you know, the benefit of having five people is you have five different perspectives potentially and you lose that in the monthly staff chair meetings. So I think that's a benefit. And then I think it also allows for, you know, the public to have some understanding of what's going on and ensures that other interested folks, you know, also get some sense of what's happening. So for me, that's what's beneficial about it. Given where I'm sort of at, I think, is that I would approve as submitted, have a full board meeting check-in after there's some experience in terms of how things are going. Given this leadership, because we have had a lot of, as Bob mentioned, there's been leadership changes, significant leadership changes over Springfield's recent history. And I think given their close work with our staff, I'm going to assume that if things are really not on track, that Springfield will come forward and ask for a modification. And so I think I'd be comfortable approving it, sort of trusting that this leadership team would do that. Should it be necessary and should it come to that? So I think that's where I am. That's helpful, Robin. Thank you. I wouldn't want to be presumptive here, but I would also think that would be good for the new board members. I mean, this is a hospital that has had a problem and they're going to be very busy trying to learn a whole bunch of stuff. And having that meeting in January at the board level would, I think, engage them into whether or not Springfield is still problematic. That's a good point, Tom. The other thing I'll say is part of what got me there, quick, frankly, is the 1.3%, even the 1.3% growth doesn't seem, it seems extremely modest given the current inflationary climate and the uncertainties around workforce and the workforce challenges. And so I just, if it was a more normal year with less inflation and workforce issues and COVID being outstanding, then I could probably get there. But just with all those factors that I think make the budgeting so challenging, including on the expense side, that's what really, I think, made me change my mind about the 4.1. Before lunch, I was at the 4.1. I'll just say, but in part because of the challenges with the adjustments, but now I'm, I've moved based on that expense analysis. Thank you, Robin. And I guess I would agree with you that's where I've moved as well. And I like the direction that you're going. So I don't know if you want to make that into a formal motion. Sure. And we can see where we land. So I move we approve Springfield hospitals budget as submitted with a 7.5 increase from fiscal year 22 to 23 in budget at NPR, FPP, a 10% increase to overall charges subject to the standard conditions as presented to the board. And with an additional condition requiring, for lack of a better word, a check in with the full board after the first quarter performance is available. Is there a second to that motion? Second. Okay, it's been moved by Robin and seconded by board member Tom Walsh. Any further discussion on this particular motion, this approach to the Springfield budget? Okay, I'm not seeing any board members with any additional discussion. I will at this point open it up for public comment. Is there anybody from the public that wishes to comment on the motion at hand? Okay, I'm not seeing any public comment. No hands raised. So back to the board. Anything else we want to say about this before we take the vote? Okay, I think Russ, I'm going to ask you to do it as a roll call vote. Sure. I'll take the roll. Board member lunch. Yes. Board member Pellin. Yes. Board member Walsh. Yes. And chair Holmes. Yes. Okay, thank you so much. I'll let that record show that there was unanimous support for that particular motion. Wow. Okay, that's 14 hospitals. This is your last hospital budget cycle Tom Pellin ever. Let me take it. Unless I'm a patient. I'm staying away from hospitals. Great. Well, I want to, you know, take this opportunity to recognize all the hard work that's been done over the past few months really by the hospital leadership across the state to prepare and submit these budgets by our staff. Sarah Lindberg and Russ McCracken, Matt Setter and Flora Pagan. And also all of you board members. This has been hard. It's been challenging. I think this has been a year like no other. Our focus has been on short term stabilization. I think we can, you know, our efforts now have to turn to some of this work that has been mentioned is actually 167 work, which is really trying to find new ways to ensure sustainability of our hospitals while seeking efforts to improve affordability quality and ensuring equitable access and I think the road is long, but I'm optimistic. So I just want to express my sincere thanks to everybody for all the work that's been done to get us to the point where we're at today. So that pretty much concludes our hospital budget process. We have an agenda item. Is there any old business to come before the board? Is there, well, there is, I see a public comment. Mike Del Treco, did you want to make a public comment? It's okay. I know you didn't call for it, but I didn't want to. I just want to check in, see if it's okay. So first, Tom Pelham, congratulations on your last budget cycle. And if you show up at a hospital, it doesn't matter. You'll get the best care. It doesn't matter your decisions. I think sitting through this entire process from the start to finish, listening to the hospitals present their needs based budgets and listening to the deliberation. I think we have a significant opportunity to improve on consistency in how you handle specific items. I understand there's unique challenges that each hospital face and they present those in great detail. But the handling of similar circumstances, whether it be I PPS changes or O PPS changes, the handling of fiscally or 22 dish, there, it was inconsistent. And I think we need to improve upon that. I think we need to improve. I'm very pleased that the decision that was made in the spring field process that there was not a space where the board would come in. Midstream to make a change to a budget process. I think the relationships that you have with hospitals, every single leadership team allows for that really important discussion in those monthly meetings and in the style that you've developed through your through your report. So, so as we move forward, I would love to see some progress and I know there's going to be some additional work in this space. So appreciate all your help. And through this very long and exhausting, almost a month now of reporting and deliberation. And again, Tom, congratulations that you don't have to do this again. Thank you, Mr. Del Treco appreciate it. Is there any new business to come before the board and back to the board members. Okay, is there a motion to adjourn. Take it from Robin as a motion and a second by Tom Walsh. All those in favor of the motion to be before we vote. I just want to say just you've done a great job. I mean, you've, you've, you know, you've stepped in at a very difficult time. You know, when the board was going always also going through some transitions and, you know, I've just admired your, your demeanor and thoughtfulness and energy. You know, as the board traveled through this so as my last few words, thank you. You're welcome. Thank you for the compliment. Well, all those in favor of adjourning, please say aye. Aye. All right, I did not hear any opposition to that. I'm going to take it as a unanimous passing of that motion and have a good rest of your afternoon everybody and thank you all.