 Okay, welcome everyone to the Rebound Care Board meeting. The first item on the agenda is the Executive Director for the Board. Susan Barrett. Thank you, Mr. Chair. I have a few announcements. First, a couple of upcoming meetings. Next week, April 3rd, we are having a meeting in this auditorium at 9 a.m., so it's a morning meeting. And we're, we put together a panel to discuss rural, hospital, and healthcare challenges and opportunities. So it should be a very lively discussion. We have some folks, the panel hasn't been finalized. We hope to have it finalized by this afternoon. And we'll also be sending out a press release. But we do know we have a national speaker who is coming from Maine. And then we have the head of VAAS, Jeff Thiemann, and then a couple of other CEOs from Vermont hospitals. Oh, and we also have Kevin Stone from the ACO. So stay tuned for that press release this afternoon. We hope to see everyone there next Wednesday. The other announcement is we are having a traveling board meeting. We do these twice a year, usually in the spring and in October. So we have decided we are going to Gifford Hospital and Dan Bennett is in the audience and he knows we're coming. We just haven't finalized the day yet. So sometime in May. So stay tuned for that. We'll have the meeting at the hospital, but then we'll also be out in the community visiting with other healthcare providers in the Randolph community. And then last, just to update the board and the public of a couple of other committees of the board who have met and are meeting next week. Last week we met with the primary care advisory group and we had a very lively discussion with that group. And at the end of that meeting, the group decided that the focus of their work going forward is going to be on healthcare workforce. So I thought that was a very good result of that discussion. And then next Tuesday, the data governance council meeting will take place in the pavilion on the fourth floor. And I can't remember what time, but it is on our press release. I think it's two o'clock, I'm seeing. And for any new folks who haven't already done this, please sign in at the table in the back. And that's all I have to announce. Thank you. Did you want to mention that all job openings? Oh, that's a great idea. I would like to mention a job opening. I had actually a perfect time with a lot of the hospital folks in the audience. So as many of you know, Pat Jones has moved on to another position over at Diva. So we do have an opening for the health systems finance director position. And it is to lead this remarkable team of Kelly, Lori, and Agatha. And the focus of that job is the direction and leadership for the hospital budgets, as well as the accountable care organization budgets, and looking at the system as a whole, as well as the work we're doing on the out there model. So it's a really amazing opportunity for the right person. And the posting is on our website. So please share that widely. Thank you. Okay, next item on the agenda are the minutes of Wednesday, March 20th. Is there a motion? So moved. Second. So moved and seconded to approve the minutes of Wednesday, March 20th without any additions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? So at this point, we're going to turn it over to the finance team to lead us through, really the whole afternoon. So. So. That's correct. I'm Lori Perry, and this is Kelly Theroux, I'm back at the Tesla. And we unexpectedly received a amended rate request for budget 19 from Springfield last night, so that is going to be on our agenda today. So Springfield hospital has sent us a letter as of last night, requesting a rate increase of 5% over their current 5%, they have a rate of 10%, and they would have affected from May 1st. The increase would increase their estimated, their NPR, an estimated 438,924, and annualized that would be 1,173,417. Their hospital trustees did approve this request on March 12th. The reasons they gave for this request was their negative margins, and they've been trying very hard to have constant payment, but they're still in a tough cash position. And then they recently terminated their childless services. To date, from our information that we have, we had proposed, had a submitted budget from Springfield last year of almost $60 million, and this was a change of 1% to their NPR. They asked for 5%, and they're also, are participating in all ACO programs. Then the board approved that particular project, and there's a change in the charges of the 5%. This is the chart that we wanted the board to be aware of because of current information, September to January, or year to date, 19, their operating margin is a negative 11.6%, total margin negative 18.1%, days cash on hand is 17, days payable of 69.2, and day receivable of 56.2. At this time, staff does not have a recommendation because we have to go through our analysis. And Laurie, what I would ask is if you could reach out to the CEO at Springfield and find out what would be a good dating date in the future so that we could have a hearing with them on this. I think that not only the board, but the citizens in the Springfield area, and even the citizens of the state of Vermont are looking for as much transparency as possible and learning about how the turnaround is going, and so on. So if you could do that, then we could set our timeline from that, unless any board member has any objections. Thank you. We also have a discussion on that. Laurie, we just went through this with Gifford and we submitted a bunch of requests for Gifford to submit. So you may want to follow that to a request. We asked Springfield for that in advance. That's some of the materials that are on that table and you should have received it in the past. Thank you. So the next item on our agenda is the possible budget guidance and hopefully a possible vote. This document is going to be trying to show you the changes from our last meeting of March 13th to the budget guidance. We also received public comment today from Boss and then we'll also give you the next steps on our budget guidance. This particular slide is showing the first section in our NPR fixed perspective payment guidelines have been changed and we're asking the board is establishing the maximum growth target of X percent of the individual hospitals net patient revenue fixed perspective payments for fiscal year 2020 over fiscal year 2019 budget. Should hospital budgets appear to be trending in 2019 and 2020 in alignment and with the overall payer model target, the GMCB also established a tentative maximum NPR FPP growth target of Y percent for fiscal year 2021 or fiscal year 2020 budget. Each hospital is required to submit an annual budget for each of the two fiscal years like July 1st of the preceding year. In addition to considering the fiscal year 2020 growth target the GMCB will consider and each hospital should carefully consider the hospital specific financial circumstances including actual fiscal year 2018 NPR FPP and expenses. And it's year to date projected fiscal year 2019 NPR FPP and expenses. It's historical ability to manage its budget, its community needs, its operational investments for successful participation in the ACO program and other relevant circumstances. The other portion of the guidance that changed is involved the bottom of this paragraph for hospitals with projected fiscal year 2019 NPR FPP that is greater than budgeted. The GMCB would not expect to see fiscal year 2020 NPR FPP greater than X percent unless it's really just. Rather than going further, I think it might be good that the board is starting to make a decision so that they don't have too much on the table for discussion in the possible volume. Would anybody like to make a motion at this time? All right, everybody's looking at me, so I think I'd like to make a motion at this time. So what I would move, I would move that the budget guidelines as revised with a maximum per unit of 3.5% for individual hospitals, net patient revenue and fixed perspective payments. And that we establish, that would be for 2020 as well as for 2021. So the 3.5% would be the X and the Y in that first paragraph. Do you want me to also ask the second paragraph Kevin or do you want to do this one at a time? I think the two are related so you might as well keep going. Okay, and that we include that for hospitals with projected 19 NPR FPP that is greater than budgeted, we would not expect to see greater than, I think what we, that what had been discussed or thrown out there in a previous meeting was 5% and less clearly justified. Not for the second, I guess I'm not clear on what that second actually mean myself, so I would want to have a discussion about that. I think the intent is it was 3.5% per hour. The 5% was if they were below or below, like more than 2% then you could go with 5% increase. All right, so let me just give myself straight here. Okay, so let me start over. I would draw my motion and now I will move that we accept the revised budget guideline with the 3.5% target for each of the placeholder items. Is there a second? Second. It's been moved and seconded to accept the recommendations of staff on the budget guidelines and inserting wherever there is an extra Y, the figure 3.5% is their discussion. Tom. I'd like to say I like this format much better than the original proposal because it embeds the budget process much more directly than the all-pair model construct and that's a good thing and I think it's a good thing to get hospitals much more lead time to kind of manage their affairs and think about the moving parts within their hospitals and how those might play out over a couple of years rather than a 12 month period. What I am concerned about is the 3.5% and 3.5% although I recognize that this language allows us, we aren't wedded to the 3.5% necessarily in the second year after 2021, but I worry about the message that 3.5 and 3.5 give is because that's at the maximum of the all-pair model and I'm just kind of looking here at context and in terms of some of the other data that we will be, we have or have been given in that we're looking at the five year trends in terms of NPR growth at 3.8% and the expense trends at 4% with both are in excess of 3.5% and this is at a time when the trends on acute admissions are at 1.7% and an outpatient visits at 4% and then you have the biggest kind of boat in the harbor so to speak that even though in 2018 we were looking at an overall NPR growth of 3.1% at UDM which is near 50% of the total NPR was at 3.5% 2018 over 2017 and their 2018 over 2017 expenses were at 5.8% so we're not, this is being presented in the context where the tailwinds are still rich I would say relative to the 3.5% target so I would feel much more comfortable. We know that last year collectively overall we came in with budgets at 3.1% growth and for me and you discuss it with the board I feel more comfortable with something less in the first year of 2020 say at 3.25% or something that basically says that 3.5% in the following year is our target as long as we are somewhat more constrained less constrained than last year but more constrained than the overall target. I just think it's a time that we don't have enough. We only have in terms of hard data we have 2018 which is the first year of the all fair model and we have two quarters of 2019 and so by the time we get into the budget process deeply we'll have almost three quarters of 2019 and be in a much better position to see how things are trending so I guess that would be, I would be comfortable if other members of the board agree to have the XB 3.25% and the YB 3.5% Is that an amendment that you are offering? You don't put yourself so much on the line that you pick an amendment but I'll move that as an amendment to Robin's motion. So I'll start the discussion. I just think that as I stated in the past I believe that the next two years it will be critical to the success of the all fair model and that hospitals need to have the ability to continue to make the investments that over time are going to reap benefits and this is at a time where they're facing such incredible pressures on wage inflation and it's across the board with docs seeing some of the highest wage pressure but it's true of nurses, techs, cafeteria workers, you name it where you are going to be saying huge pressure I think that the initial data through Q2 shows that we are in line and I don't think that we should be creating further roadblocks for hospitals to make the type of investments necessary to be full for investments. I just wanna say that I also don't view it as quite as wishy washy a target in the second year. It's one thing if there are unforeseen circumstances and I think it is but the whole point of having a two year target is to provide certainty and predictability for the hospitals and I think that we will be falling back if the second year was just a number to place on the wall and I think that there should be a larger commitment from the board to stay the course unless there is something that I think that the hospitals and the board would all agree upon is an unforeseen situation. So that's my take on it. I'll just add a couple of comments. I support some of where you're going. I mean the past two years, the actuals have been 2.8% overall, 3.1% overall but the other part that I see kind of coming down the pike is that some of the hospitals are exceeding their performance in 2019 and the fact that we will be holding them to three and a half percent against their budget, I think we'll end up seeing that actuals year over year probably will come in lower and I'm hopeful that the hospitals that don't grow at three and a half percent, their budgets will come in lower so that in total we very well could as a system come in below the 3.5%. I think the challenge is again, since we give out one target for everybody and everybody's not the same, that creates some of the big issues that we have. So I mean I totally understand Tom what you're saying and I was pushing for that as well before. I don't think we're gonna get that through to be honest but still I'm kind of willing to say if we go with the three and a half there were a few hospitals that came in lower on their budget rates year over year for 18 to 19 and are already exceeding so I think they're gonna be challenged to stay within three and a half percent and I brought that up at the budget meetings and we'll see what happens there. So I think we're gonna end up, actually again, below three and a half percent if we stick with that to budget right now so. Anyone else? I'm no, go ahead. I'm comfortable with the three and a half for two years because I agree that we really are at a real place in moving our delivery system reform where we are starting to see some early results and change on the ground at the operational level and I think that's really the hard work of this model. By setting a statewide high level, the total cost of care targeted three and a half percent, I think we've actually used the low end of the all-care model range which is actually 3.5 to 4.3 which was again as Tom knows because I know he checked it that that range was used because it was the historic economic growth in the state and depending on the time period you can fall in where in that range. And we've chosen to really focus on the lower end of that range at 3.5 percent. So those are the reasons why I am comfortable with those targets. Yeah, I guess I would just sum up here everybody's comments and I appreciate them all. I appreciate Tom, your legality here. I do think that our workforce pressures are really systemic across the entire state and it's putting upward pressure on wages at all levels of the hospital delivery system. And I also think as Robin was saying and also as Kevin was saying, the all-care model requires major transition in how we deliver care in the state and the hospitals need headroom. To the extent that we are at 3.5 and that some hospitals are gonna have a hard time meeting at 3.5 because they're already over and other hospitals are not actually gonna make it 3.5. And again, this is a target for all hospitals that we are realizing we are gonna be looking at individual budgets during the budget process. So this is a target that we're putting out there but we reserve the right to look at individual budgets to see if this makes sense. So I'm comfortable with the 3.5 over two years. So I guess part of the commentary is there a second to the motion to amend? Can you second to a motion? Of course I will. That seems to be the only option here. I'll withdraw the motion just because they can count heads. Thank you, Tom. Appreciate that. I think that everybody understands the spirit in which the met was offered and I think we agree with the spirit. So with that, is there further discussion on the motion? Seeing none, all those in favor of the motion signify by saying aye. Public comment. I'm sorry to do that. So I think our office would like to see two things. Is one that the board recognizes that this is a ceiling and they expect, you all expect that and hope that hospitals will negotiate to bring down costs. We ask a similar thing of the payers of Blue Cross and MVB. And I think, as we've heard in last year's hospital budget, said this is treated as a ceiling and they are going to the max. And I think we should say that this is the highest things can go in recognition of the workforce challenges and the importance of continued cost containment investments, what our office would suggest is that there's a 2% cap and if hospitals can show that they're making workforce investments, development investments and or cost containment investments that they can then go up to 3.5 provided that the 1.5% is due to additional community health investments and workforce development investments. Thank you. Thank you, Eric. Is there other public comment? Yes. Yeah. Please don't want you to just- Just because- I wonder- Louder, louder. Louder? Louder, please. I don't get to ask that very often. Sorry about that. Based on what he was saying, just an afterthought. Because of the workforce challenges, I would also want a base projection of what workforce is going to cost because I want to know how close those two are coming and if they're gonna flip because the way workforce is going if we get into a situation of there's so high cost coming out and what they paid for the education, they're limited as far as how low they can go, which is gonna raise what that base is that you've got to pay to get your workforce if it's even available, which is a market driver. So I worry about those two getting too close together. Does that make sense? I think so. I mean it's clear that we're all very concerned about the wage pressures that not only the medical community is facing, but it seems to be affecting every sector of the online economy. So is there other public comment? Yes, Walter? Just really a comment, just to pick up on what Eric and Dale have said. I'm glad you're having discussion and just please remember that the people that paid for these raises don't also get raises either and the wage pressures may, the hospital may be going up or down or whatever, but for us, it doesn't go up. And if it goes up, it's insignificant, usually. And I really appreciate what you said, Walter, because one of the things that is troubling is that we're tasked really with a triple A. It's not just about cost and attainment, it's about access and quality of care. And if there aren't workers, you're not gonna have access and you're not gonna have quality of care. And also what we hear repeatedly in the budget process is that because the hospitals know their commitment to provide the healthcare to the community, they're paying twice as much for travelers and locals. So we could put our heads in the sand and say, okay, nobody's gonna get a raise in the state of a lot, but that could just come back and fight us too. So I'm actually in favor of raises for hospital workers, people. It's just a very fine line. Jess, you want to say something? So I was just gonna say what you said, which is that it's not just about raises of current workers, it's actually about there are waiting lines in some of these providers, and it's because they can't fill positions. And so we need to give them the ability to be able to hire those additional positions so we can reduce waiting lines and increase access. And to your point about locals and these temporary workers, hospitals are paying two to three times what they would if they could fill that position. And in the long run, that's actually not cost effective. So how do we start to think about creating a stable workforce so we can provide quality access to all remoders? And I think to the extent that we're facing a serious workforce shortage in the state, we need to adjust for that in the budget process. We're allowed for that in the budget process. Other public comment? Yes, Mark. Mark Stanislaus from the University of Vermont Health Center. This is a very good step in the right direction to align a strategic approach that Vermont has chosen to take along the journey of the all-parent model. Okay, you know, it still doesn't align them perfectly. In the all-parent model, it's a 3.5%, no rate of growth, not a total growth. But this is an excellent step in that direction. So, well, so thank you. And I'm just thinking out loud as we think about the financial challenges that the hospital has, all the hospitals have across our state. And as I think about this, and as I listened to some of the percentages that were referenced, that created some concern, the statement that I didn't hear that creates cause some concern that when you look at 2018 actual and you take out as a total health system and you take out the University of Vermont Medical Center's margin, that the other hospitals combined for a loss of $20 million, okay? We're all in this together and so hospitals are not gonna be able to create increased access if their margins are in the red and they can't continue to invest in themselves. So I know this is a balanced conversation. There's a lot of pieces. We know that when you move one piece, it impacts the other piece. So, and then the other thing that I wanted to make very clear, number one, I'm not a clinician, okay? But if the patients show up at a hospital, the hospital's gonna take care of that patient's needs. So the hospitals don't turn patients away and if by virtue of doing that, that causes them to go over a budget to budget guidance limit. We need to be able to have open conversations about what is driving that and understanding that. Because we certainly don't wanna get into a circumstance where hospitals are turning patients away just to manage to a budget to budget targets. So, I mean, those are just some thoughts. I'm not looking for answers, but this is a very good step to start to align the strategic approach to the state of Vermont is taking towards healthcare for its total population. Thank you for the other comments, Jeff. Thanks, Mr. Chair. Just a couple of comments really to piggyback on what Mark just said. I think this is directionally correct and we appreciate the acknowledgement of all the challenges and pressures that hospitals face. I think just to add a little, a tiny bit of context to it is that we think about the all-payer model work that's sort of the centerpiece of how we're trying to change both the delivery and the cost side of the healthcare equation in Vermont. And you have a lot of hospitals, small, critical access, medium size who are taking big risks to do this, making really strategic important long-term investments. And people in other parts of the country or other types of hospitals or big systems might look at that and say they don't even understand how such a small hospital without being anchored by a system could venture into that territory as confidently as we are here in Vermont. So I think that's just an important thing to acknowledge. Also, just a couple of days ago, I guess last month, the CMS Office of the Actuary came out with spending projections in the healthcare industry. And just a couple of ones I wanted to cite. Medicare spending is projected to grow 7.4% between now and 2027. Medicaid at 5.5. Prescription drug spending at 5.6. Hospital overall spending at 5.6. And physician and clinical services 5.4%. So again, just acknowledging those over that time period. But in any case, helpful to see the board acknowledging these pressures and understanding the affirmative work hospitals are doing to succeed in the model. Thanks. All in common. Seeing none, all those in favor of the motion signify by saying aye. Aye. Any opposed? Thank you. Lori? The topic is enforcement. But we still have other things on the... On the total cost of air spending. Yeah. Excuse me. And I think we also need to do an overall vote of reading the project. Correct. I think that's a total vote. Did you want to talk about changes to the appendix? There really wasn't any changes to what was sent previous meeting. That I know of, if there is, I'm sorry, I didn't include that. I'm happy to comment on the hospital care. I know there was some public comment from the boss with a request to eliminate appendix 11, which is the total cost of care chart that we added. And I appreciated the letter, but I feel strongly that we retain that table. Actually, as Jeff Tina just said, the all-payer model is the centerpiece of what we're trying to achieve. And I think we need to move closer to regulatory alignment with that all-payer model. And our contract with the federal government obliges us to keep, remember, the month total cost of care growth from 3.5% of the state level. We need to understand what's happening in smaller geographic areas if we're gonna meet those federal obligations. And we need hospitals to help us unpack what's happening in their communities to assess how they can contribute to bending that cost curve. So by including this chart, I think we're really just asking hospitals to review their communities per capita spend and its growth rate. And if they're above average on either to dig a little deeper. And it could be the demographics in their community. It could be referral patterns in that community. It could be the cost of delivering care in their hospital. And it could be not enough primary prevention in their community. I mean, it could be a lot of things. And I think we need to understand that. And to the extent that the hospitals can help us understand that, I think it's important. There are resources available to help lower the administrative burden to hospitals that are meeting that request. I spoke to Beth Kandwin this week from the blueprint and she's willing to work with a small group of hospitals to unpack total cost of care with their data analytics group on point and try and help understand what's happening, variations in total cost of care by HSA. So I think that's an excellent resource and it's a very generous offer. The blueprint community profiles are incredibly helpful for understanding what's happening in communities. You can actually, for example, look and hospitals with high total cost of care spend in those community profiles. You can actually see that some of those hospitals are high on advanced imaging. They're especially imaging for low back pain. They're high on all cause readmissions. They're low on vaccination rates and preventable admissions. So there's things that you can start to unpack to understand why perhaps total cost of care variation might be happening. And it's important that we start to do that if we're gonna actually align with 3.5% across the whole state. I also spoke to Kevin Stone from OneCare who offered his help as well to anybody a part of the OneCare network to try and understand what's happening in total cost of care in communities and to unpack data there. So I would say any hospital that is concerned about the administrative burden of trying to unpack that total cost of care numbers in those charts to please contact me and I'll help facilitate some additional resources there. But I wanna reiterate, this is part of the budget process because we need to align our regulatory functions and we need hospitals to be thinking about the all-pair model financial and quality targets when they're setting their budgets. We need everyone rowing in the same direction and we need to understand that. As far as the data, V-Cures is the best we have. It's the same source that we're gonna be using for the all-pair model and the calculations that our data team did for VHSA are the same ones we're gonna be doing for the state. It is the spend that we as a state are gonna be held accountable for. So again, not meant to be punitive, just meant to be informative and we need to make sure that all we're all working together to achieve the goal of low cost high quality care for all the monitors and this chart is a step in the right direction of trying to understand them. So my feeling is, despite the request to omit it on our hospital budget guidance, I would like to keep it in. Thank you, Jess. Other discussion by the board? I agree with Jess. I think that we do need to have been working in various ways internally to align regulatory processes that aren't particularly transparent I think because they're really more staff analysis and breaking down internal silos and that kind of thing. And I agree that it's time that we really move forward in aligning in a more public way the processes. Also, this really is our venue for collecting information from hospitals and getting their pick on what's going on in their communities, financial and otherwise. So, I agree, I don't think we want to see this as a punitive kind of issue and we would certainly understand, at least I'm speaking for myself, I would certainly understand if the analysis in the first year is not particularly deep quite frankly because I think this is a new process and it makes sense that there would be some learning curve around that and maybe we'll be able to come up with an even better process next year. So, I would encourage hospitals to see this as a test in a pilot and to not worry necessarily about getting it perfect because I don't think, at least for myself, I don't expect that. I'm really just looking for some initial reactions and thinking based on data that is really available. So, I met with Dan Bennett earlier in the week and really the first time that he had gotten a chance to see the total cost of care where the numbers that were presented and he didn't feel that speaking for himself and I'm sure all their hospitals will agree that he wasn't convinced it was gonna be a meaningful dialogue because they didn't have the tools to really address the question of the appendix unless there was access given to the database which is a complicated issue in and of itself but the fact that it's non-punitive, the fact that it's the beginning of a discussion, the fact that we all know that as a state we're really focused on really the per capita cost of care. I think that this is a good starting point for the discussion and I don't think that anybody's looking to punish any hospital that can't give us better data and we're not asking you to, well, spend money chasing the information but I think that really the burden is gonna fall upon us and I think that Jess mentioned some great assistance that's been offered to us by both the blueprint and by OneCare to try to get better information and I would think that it's gonna create more work for us but I do think that it's work that's valuable, it's work that gets to everything from variations of care variations of pricing and everything else so I think that over time it could become meaningful but again, I would hope that none of us would make a budget decision this year based on appendix 11. Tom? When I first saw Justice Chart, I thought this is a good thing and it is a good thing that my sense is in terms of managing a lot of budgets in a complicated environment is that things get tougher over time as you try to kind of bend the spending curve or hold the spending curve to a kind of read upon line and so here we are barely into the second year of the all payer model and my guess is and we've been managing the approach from basically a top down kind of point of view like we just did in terms of voting the NPR, thresholds, off the top side, top end operating margins and that is one arena that is powerful and useful but another is working with our clients to find opportunities where folks can share good ideas and work more organically within the hospital's day to day lives to bend the spending curve or sustain the spending curve and I agree with exactly with what Robin said that this is a start and with what Kevin said that that's not way too heavily on it in the first year but let's build the infrastructure. As we have with our staff, we now have a staff that is up and running fully loaded in terms of managing the V-Cures database and let's try to leverage that in a way to find helpful ways to help hospitals meet the goals that we all share. Any other discussion? If not, would somebody like to make a motion? I believe the motion would be to approve the fiscal year 2020 guidance as presented to us by staff and as earlier amended today. I move we approve the fiscal year 2020 hospital budget guidance as provided to us by staff and amended earlier today. Is there a second? Second. Been moved and seconded. Is there a discussion by the board? Seeing none, I'll open it up to public comment. Is there a comment from the public? Yes, Dale. On the total cost of care, this is a question. I've noticed when I've looked at hospital budgets and when I've looked at trends in general that whenever you try to hold something to a certain percentage of growth when you try to put it within a range, it always jumps out sooner or later and that has puzzled me. Then again, it also makes sense to me. You take 20 people and you line them up and you say, take a shallow breath. You're gonna see every once in a while somebody take a deep breath and that's what I'm getting at. When we try to control the cost, when we try to calculate total cost of care, how often does that deep breath occur? It might be this hospital, it might be that hospital. If I'm looking at diva, maybe it's so diverse that you don't see the deep breath because it gets swallowed by the average. Does somebody know the answer to that question of, do I need to allow for a deep breath? Does that create enough of an analogy to, I can't hold this every single year. I don't think without something happening where a deep breath will be required. That's the analogy I'm using. I think it's gonna take a lot of deep breaths. Yeah. And I would just say that the discussion though was helpful because when you look back historically, there was nobody that said, this must change and you're required to make changes but I'm gonna cite the research that was done by Jack Winberg in his variation analysis and when you look at two relatively close communities geographically where if you lived in one community you had your tonsils all routinely, not so in the other and then look at the work that was done on hysterectomies and it was really, it was just the research getting out to the providers that spurred that internal conversation and they changed on their own. And sometimes it just requires the discussion to occur so that people have the data and they start asking themselves the questions. So I think only positive can occur. Robin? If you don't mind, I would just add, I think as Maury mentioned earlier, part of what we do in the guidance is we set this high level target but it shouldn't be a one size fits all. So what we try to do through the hearing process is then tailor that information based on what's actually going on in the hospital because to your point Dale, every hospital in Vermont is different. They may have some similar pressures but they will also have unique challenges specific to their region. And so to me that's what the hearing process is for is to take the guidance which necessarily has to be uniform but then tailor it based on individual community circumstances. So I know Dan that you're reaching the good word in so. Thanks. Thank you Madam Chair. So I just wanted to comment on the total cost of care. This is something that all of us who are involved in the all payer model that we're focused on and we have to be focused on that's going to determine whether we're successful in that model or not. So I just want to clarify there's no concern with working on that and whatnot. Concern is the fact that particularly for those of us who are new to the all payer model which if it is the first year we just started out we don't have this information now. Glad to hear that there are some resources out there that we can turn to to get access to that information and ultimately to understand where there are areas we need to work on. We will be working on those areas when we're able to better understand that. That is something everybody at our organization is going to be working on. And I know every other hospital and practice that is involved in this they're going to be working on that as well. So my ultimate comment or request is that if that is included in the guidance and in what we're asked to respond to this year in the budget process that if you understood that we're going to be talking about process more than we're going to be talking about specific results or a specific area where maybe we're an outlier or whatnot because we're only in the very beginning processes of even talking about that process and even getting that information. So I was glad to hear the comment that this is something that at least in the first year, first two years is you're going to understand that but I just want to state that unequivocally that we want you to understand that and to give us that opportunity to talk about the process because that's where we're going to be and that's where we're going to be in August when we come before you again. Is that that process level? Thank you. I think it's a common objective that we all have to manage the total cost of care and we're kind of feeling our way through this on all aspects from the hospital side to the regulatory side. But I want to continue to remind everyone that more than half the total cost of care is outside of the hospital budget review process. But the hospitals that are in this and the providers that are in it are assuming 100% of the risk for that total cost of care. So we're balancing this process. We're balancing the other process, the Green Mountain Care Board and you know, so you know, as we focus about this I happen to think and I could be wrong because this is a gut feel, but I think the percentages that have been managed within the oversight of the Green Mountain Care Board, that growth rate has been lower than the other growth rate and that growth rate has been lower than the increase or than the actual commercial ask. And this is where I get back to where actual to actual is important to truly understand the cost of care is in budget to budget. It's what actually comes through the door for those patients you take care of, for the payroll that you spend for those people to take care of. That's the cost of the care. It's not budget to budget, okay? So I just have to continue to remind everybody if we continue to put the whole burden on 50% of the system in, keep in mind that there's no clear path to figure this out right now. So we have to figure it out together. But that's gonna continue to put more and more burden on the 50% that has been managing a little bit lower than that cost curve of those other two pieces and put more and more financial pressure on them than there is today. So and keep in mind we have to figure this out. So and it's gonna take time to figure it out, but the hospitals are only 50% of that total cost. So that's what everyone needs to remember here. And that 50%, if you look at actual to actual cost curves when you look at our growth to those growth rates with Jeff just mentioned earlier is significantly less when you go actual to actual to almost every item that you compare it to. And then I think, I mean, and that's kudos to the Green Mountain Care Board and that's kudos to all of the hospitals, but I just worry that that trend can't continue just on one side. We need to figure out a way to transition it to the other side too and also create the accountability there. Point we'll take. Other public comment? Anyone? Okay. I guess call the question. All those in favor of the motion to approve the fiscal year 2020 guidance signified by saying aye. Aye. Any opposed? Thank you. Thank you, Lori. Thank you. We'll send that information out on Friday. Super. Our next topic is the enforcement and fiscal year 2018 budgets to the actual results. We will be showing you the requirements and the timeline, the enforcement policy, the fiscal year 18 budgets that you approved, the actual results of the fiscal year 18 and further analysis of enforcement and policy triggers. We'll be showing the budget and actual operating margins and trend margins and then your next steps. This is the timeline. The hospitals will be required to send in their actual results for fiscal year 2018 by January 31st, 2019. We received all the hospitals except for one is still preliminary in the North Country Hospital. So the numbers here still are preliminary. So take that into consideration, please. So a couple of weeks ago, we gave a review of the actual results of fiscal year 18. Today is the enforcement discussion. And then based on your recommendations, we will have further action next month to either ask for hospitals to come in or you have your votes. And then hopefully by the end of April, we'll have letters set out to the hospitals on your decisions. And then we will try and do a summary of the actions that were taken and the results we made. This is the enforcement policy currently and our guidance for fiscal year 18 with a lot of information here. Mainly what we wanted to point out is that the GMCB gave a, excuse me, the enforcement requirement was that the GMCB would review hospitals that were 0.5% above or below their approved MPR. This does not necessarily mean that the GMCB will take action. The budget reviews will compare each uplier to results from total system. The reporting requirements for the review will be determined by the room up here board. And the board will afford the hospital the opportunity for a hearing and may require a hearing if it deems one necessary. The board determines that a hospital's performance has different, different substantially from its budget. The board might take actions including but not limited to reduce or increase the hospital's rates, reduce or increase net revenue or expenditure levels in the hospital's current year budget. Use its finding as a consideration to adjust the hospital's budget in a subsequent year or years and establish full budget review of actual operations for that budget review. This slide is showing what was approved for the fiscal year 18 budgets. We had a 3% target and then a 0.4% increase for new healthcare reform investments. The board decided to rebase quarter medical center and the UVM medical center for their 19 budget decisions. The board approved Southwestern Medical Center's dental home COA for 581,360 for the budget was not just in our database. This changes previous slides on the budgets. So Southwestern's has changed to 160,078,864. We give you the look of the approved budget and then the rebase budgets for quarter and UVM around the bottom. This chart is showing you the budget to actual, the variances and then operating margins and total margin. This chart is showing you the trigger that's in the policy of plus or minus 0.5%. So you would have, you would probably review all the hospitals unless they were rebased and so UVM would not have to be reviewed based on this chart. The next chart giving you some options of looking at hospitals that are plus or minus 1%. And in this case, we would be, Southwestern would be fine and quarter and UVM would be fine in their rebase budgets. Another scenario is looking at the hospitals plus or minus 2%. And in this case, you would, Ratterborough, Central Vermont, Northeastern, Rutland, Southwestern would be fine and then quarter and UVM's rebase budget would be fine. We also wanted to show you what budgets or the hospitals that are just a positive 2% over their budgets. And that would be Montesquatney, quarter hospital and UVM. And we would review, we would not review quarter and UVM with their rebase budgets. The next slide for your review is to look at the hospitals that are negative 5% actual to budget. And that would be Gifford, Northeastern and Springfield. And this one is just showing you the rebase budgets. The top section, of course, would be what you originally approved. Can you just back up one and because I'm not sure the public that was at the last meeting was probably aware, what has changed in Northeastern in the reporting to put this here? Northeastern, we presented to you the actual results on March 13th. Northeastern had given us their NPR and FPP number. It was what we know. It was not submitted into our adaptive database. Since then, quarter, excuse me, Northeastern country called us last night and said that those numbers were wrong and gave us the correct numbers. So that's why you're seeing this variance of over 5%. Kevin, I had a discussion with Lori this morning about that as well. And what did change is what did not change with the operating margins. Those are as they were presented to us earlier. So the connectivity between NPR and operating margins was not affected in that these operating margins are the same that you saw on the original chart we had. We would have caught some of these issues if things changed within the database. So we were just going by emails of what these things were. How are they coming with their software change? I'm in contact with them a couple of times a week at this point, and they're still updating us on when she's completed various tasks. So they have a few more sheets to enter. I'm hopeful it'll be soon, but I don't have an estimated time. Okay, thank you. You're welcome. So the next slide is looking at hospitals that have rebased budgets. So you can see a comparison of what you approved for the fiscal year 18, and then what was rebased for those hospitals to jump off from for the fiscal year 19 budgets. And we wanted to give you also an idea of what's happening on the operating margins and total margins for all hospitals, what they budgeted and what the actual came in. So the next steps would be your direction, what you would want staff to do, any puzzles you would want to contact, and then possible voting on their enforcement later on in your life. So I guess it's really at a point where it's time for the board to decide what is the percentage that is going to trigger a new enforcement hearing, not necessarily an enforcement action. Does anyone on the board wish to start a conversation? Marie? Sure. I had worked with Stout earlier. One of the charts that I had put in was the plus 2% on the upside and the minus 5% on the downside for actually potentially looking at enforcement. And then the other chart that also, I think this needs to be discussed is the next page as well, which is the rebased budget. And the reason I say that is because I feel the hospitals own their budgets and they came in here last August and they presented the top part of the chart. And at that point, they had 10 months of data. Although their budget, they may not have been working off that, they actually, with what they submitted to us, they still had 10 months of data. We rebased their budgets based on actuals because there was no way, they were already gonna, UVM for instance, would have had to been down year over year. So that was the right thing to do. I'm just throwing out, I don't know what we wanna do, but I don't wanna rule out rebased budgets from any enforcement. Last year for Porter, we didn't do anything for enforcement, we rebased them, but we didn't do anything as far as any enforcement action. And they came in significantly higher. UVM came in $44 million over their budget. And that's again, what they presented to us, we threw out this rebased last year. So I don't have an answer to it, I'm just throwing it out as discussion that I wouldn't rule those hospitals out from being rebased. And I do wanna point out a couple of other things when you go to slide six. And I mean, this is also what Mark is getting out a little bit, which is when we look at the variance for right now because hospitals didn't rebase on the operating margin as well. So I just wanna look at the total. We had a $22 million overage on NPR. And if we go over to the operating margin, which came in at $28 million on the operating margin, not the total margin, the budget was $67 million. So we had a $22 million increase on the top line against budget and a $40 million miss on the operating margin. And then when you look at the particular hospitals, many of that is coming from hospitals that missed their top line numbers. And we're not able to correct expenses based on where their top line was trending. And that's one of the things we've been trying to really press that we can't have aspirational budgets we're calling them if you want to have stuff missing the top line, but we're not cutting the expenses. So the total margin corrected somewhat but a lot of that's because investment portfolios did well. And when you look at just the operating margin, which is expenses to revenue, the change was really significant. And to the point of when we go to when we looked before at our total system wide, we were up 3.1% on actuals for NPR, but we were up 5% on expenses. And the expense base is about $2.5 million so that 1.9% change between revenue and expenses increases is almost $50 million and that's what we're seeing here. So I know it's a lot of it is the challenges the hospitals are facing. I don't know how we solved that, but I just think it's really important when we look at, you know, there are eight hospitals there that missed their top line numbers. Some of them vary significantly and their operating margins are significantly in the red. And we know Springfield is one of them, Gifford, and when we're looking at North Country and that's why when we're talking about enforcement and last year we only rebased hospitals that were up on the higher end. We didn't do anything for hospitals that fell short and we said we'll kind of watch it. I think we need to rebase some of the hospitals that are falling short from their numbers. Otherwise we're gonna be in more trouble with getting significant losses. So based on that conversation, Maureen, do you wish to make a motion that would include those hospitals that you believe that enforcement hearings should be scheduled for? Not taking action, but basically giving them the opportunity to come before us and answer some questions? You know, I think we should, let's have a little bit more discussion of where people are. I think some of the other concerns are in some of the hospitals, even if they were higher, they'd be missing their operating margin as well. And some people may wanna, we may wanna look at whether the 5% down is enough and captures those hospitals that maybe fell in at 3% down but are losing a lot of money as well. So I think let's have discussion first and then I would raise that. Okay, other discussion? Go ahead. I'm just trying to catch up to the 5% column. I just would like to go to chart page six, which I think you're already there. And just make a couple of observations that, and this is consistent with what Maureen was saying. If you look at the operating margin column, you'll see that the total operating margin for all hospitals was 28.4, 28.5 million. And that the operating margin for UBM-MC was 46.1 million. What that means is that the total operating margin for all the rest of the 13 hospitals was a negative 17.7 million dollars. And so there's a concentration there. And you can also see that on the total margin column, a little less strident, but still you have UBM occupying 71 million dollars on the total margin, which is 74% of the total margin. Yet UBM comprises only 49.7% of all the hospital NPR. So, and I don't make this point to point at UBM. I do make the point to point at something which I don't think we can deal with here, but I think that we need to be aware of which is payer mix. Is some hospitals are in a position, given the service areas that they serve, that they can, for example, cost shift onto the commercial payers for what they don't get from Medicare or Medicaid. And so as we go through this process, I don't want to, and certainly there's gotta be some enforcement here, but some of it seems to me to be some unfairness in how payer mixes are distributed. That is the lay of the land today. It's not something we're gonna change here, but I think just looking at these numbers where, I think UBM has a payer mix close to 60% commercial, where you go to some of these other hospitals are down in the low 40s. That is a huge differential, and it's something that I think that we have to keep in mind and maybe use this process to expose better those issues, so those that can solve the problem might take some action. Okay, other discussion. I would just throw out one more. If we look at page 13, and I think this is just a discussion for the board as far as if we want to look at any other hospitals for potential enforcement. If you look at the far right column, which has the hospitals that actually came in, what their total margins were, and those that are in the red, and Gifford and Springfield would be picked up in the minus 5% that we talked about. Coffley had a minus 3% on their revenue side, but is losing a significant shift in the 2.2 million they lost at margin and a negative 1.6. So having them come before us doesn't mean we're gonna take any action, but I would probably throw that into the mix as well with the hospitals that are losing. And if anybody wants, we could even open it up more based on just the total operating margin and some of the changes there, where hospitals were able to make it up. And again, we'd have to dig into how they did it, but some of it is based on investment performance, which may or may not repeat. That can go the other way. So if we want to be looking at our hospitals able to stand alone on their operating margin in total, and that would put Northwestern in that mix as well as Central Vermont, although they kind of turned it around with their margins. So just want to throw out a couple ideas for people as far as what you want included, and that would be another thing rather than just focusing on the NPR, but then marrying that up with their operating margins as well to determine if there's a mix there where we at least want to have them come in. And again, a lot of this is just concerned for their sustainability, their financial liability, how are things going this year so that we're not surprised later? We already have seen Gifford come back and ask for a rate change. Springfield's come back and asked for rate changes. We don't want to run into similar situations next year. That's a really good point, Maureen, and regardless of whether we decide to have enforcement hearing for coupling, I believe that it would make sense for the board to invite the chair of their board and members of the coupling team to meet with us anyways to give us an update, because given the fact that they lost a key member due to a death, they're losing a key executive due to a change, and they're struggling because of the health of one of their key practitioners, I think that they've done some amazing work and are being applauded for what they've been done to still manage to what they had come before us within August, but I think it would be helpful if we just heard from them and got an update on where that process is, how they're gonna conduct their search, when the change might occur. So even outside of the enforcement, if we don't decide to have an enforcement hearing for coupling, I think it would be wise for us to invite the men just to update us and let us know what's going on. So all the thoughts from the board? I totally agree on coupling. Personally, I guess I'm having a process question. I feel like for enforcement, it needs to be consistent with our enforcement guidance statute and rule that was put out, which means that I think we need to have kind of a standardized approach. But I do think that we can do informational meeting separate from that because of other issues that are going on that could present future problems. So I think what I would do personally is the plus 2%. I don't know if the right number is minus three or minus 5% on the down, but I would pick a number and then if there were other hospitals that we have concerns unrelated to their budget performance, but based on other factors that we know are going on, then we invite them to come talk with us. I mean, I look to Mike in terms of thinking through sort of the legal process piece, but at least for me, I'm a little more comfortable having it be pretty structured and almost rule-bound because I think that is kind of necessary due to the legal nature of this. But that's, you know, everybody knows I'm a lawyer, so I tend to fall down. No, I think you do have to have consistency that you can't pick and choose. I would just say though that given what we put out for guidance last year, which is different than this coming year, it was that half a percent. And we made it very clear in the rebasing that it really wasn't impacting this year. So you could technically make an argument that every single possible could be called, but I think that would be a tremendous waste of our resources. We certainly realize that budgets are exactly that, that nobody has a crystal ball and is going to come in exactly correct. If we could do that, we probably wouldn't be sitting here. So I think that you made some very valid points, Robin, and that's kind of where I'm falling, similar to where we fell last year with the 2% figure. Again, I don't know either on the downside whether it should be three or 5%. And, you know, again, I would just keep pointing out that this is really just having the hearing on it and this is not making a decision one way or the other. Anybody else? I guess I would say in the hospitals that I'm most interested in hearing from with respect to the financial concerns are different countries from building Cobley. So it sounds like 3% under is the trigger on the downside. I'm concerned about financial sustainability of those hospitals and missing their mark by that much with expense growth that's higher than that. So to the extent that having them come in and tell us there's no reason what's happening, I think would be very informative. And again, it doesn't really lead to some enforcement mechanism, but hearing what's happening is really important to the board. On the top side, I guess I would say plus two. So that would include them down the side of hearing what's happening there. I'm sorry, what would you say? Mount of Scotney on the positive side either would be the plus two, which we sent over. Maureen? Did you have any position on the rebased budgets? I do not have a position on the rebased budgets. We rebased them and therefore they don't trigger that 2%. Well, they do trigger it because the rebased was very clear of what the effective period was for the rebasing. Okay, so. Okay. Yeah, I mean, I don't know that there'll be action taken, but I do feel strongly that they should come in if they exceeded the amounts. And that's again, because when they came in and presented in August, and their year end is in September and they were tracking to exceed a number, they owned the budgets that they came in with. We just did the rebase because they were very unrealistic at that time, so we did do a rebase. We may do nothing, but I do think we should at least have a discussion to make sure to help that when we go through the budget process this year, that people will be putting in, putting in a comparison against where they're actually trying to end it. Is anybody prepared to make a motion at this point in time? About the rebase before we do that. Sure. And I apologize, because I did not go back and review, I didn't quite understand what the rebase issue was in the slide, so I did not go back and review the decision around the rebase budget, but has Mike made a ruling that we can review it if the rebase is outside of the budget guidance, because you have to read those two things together. Okay, so I mean, I'd be more comfortable having our general counsel look at the rebase issue to make sure that we can do that, because I think it's not just a matter of what's said in the budget order, it has to be read together with the guidance. So perhaps we could, would people be willing to kind of come back to that issue next week? I think we definitely could come back to the issue. In my mind, I remember it as the motion being stated a certain way, but I think it doesn't hurt to do the research to make sure that I'm not wrong. So I think we could make a motion and at least get the ball rolling as far as getting hearing scheduled outside of the question on the two rebase hospitals. So if somebody could make a... Can I interrupt? I think that hospital budget team would like to do something. One thing before you guys do make a motion. We did, we do wanna note that for a negative number, for that negative threshold, you would wanna make that negative 2.5 because Coughly actually came in at a negative 2.64, which would also make Northwestern come in as they were in at a negative 2.65. I just wanted to make sure you were clear that if you did set it at a negative 3.0%, it would not include Coughly. Make a motion for discretion. I move that we request hospitals to come in if their budgets were 2% above NPR, FPP, year-end, or fiscal year 288, 2.5 below. Is there a second? Second. I've been moved and seconded. I'll open it up for discussion of the start by saying that I'm gonna support this motion because I think we have to start someplace. But if it doesn't address all the beers that I have about where some of the budgets are headed, and although I hate to do this because I know I'm gonna be hearing from some people, I'll use an example. The hospital in my hometown would not be subject to enforcement hearing under this. And yet if you look at their five-year growth trend on expense growth, it's very troubling. So, but I think that that'll be a good discussion for this upcoming budget process. And I can live with where we're headed on here because I think we do have to be consistent. You know, I'm not sure if 2% of the involvement, 2.5% below are the exact number, but it's a good discussion point. And again, these are just hearings and there may be no action that occurs coming out of that. Other discussion? Maureen? That's what to be based on, do we just gonna wait until it gets back on in the morning like that? Yes, I think we have to at this point. So again, this is not the final say on who those hospitals are in total, but it gives us a chance to really start to do the logistics so that we can bring people in and have the discussions. And so I look forward to having those discussions. I'm sure that our team will do a really thorough job trying to ask some good questions. And then we'll both be met. Other discussion from the board? I would just say that I think we're at a different climate right now and I think the meeting that we're having on Wednesday about the health of rural hospitals and the challenges they face go part and parcel to this entire conversation about the worries about those hospitals in particular that are not meeting their top line numbers and have intense growth that exceeds their revenue growth. And so I think the board is really taking on some interesting challenges and trying to figure out how to ensure the health of our rural hospitals. And so these are thinking to be multiple conversations that are gonna help us learn and the public learn what's really facing our rural hospitals that is not unique, especially Vermont, excuse me, Vermont, but also nationally and how do we address these challenges? So I'd like you, I'm excited about this process of learning. Okay, I'll open it up to the public for public comment. Yes, Dale. So as I was listening to the conversation, I decided to look up feedback loops. I didn't quite catch that, Dale. Feedback loops. Okay. Which, they're in biology, they're in electronics, they're in economics, they're in psychology. Everything has feedback loops. So my comment is, I'm wondering if that's something that we're missing? I mean, hospitals do have feedback loops. Healthcare does, population help does. But they don't have one-year cycles. They have much shorter cycles. So I'm wondering as the hospitals get into these kind of scenarios, is the issue that they need feedback on what their economics is, like every three months, it's gotta be, there's gotta be a feedback loop in there that you would design, somebody designs, and you check in with the feedback loop as much as you do the hospital, but the feedback loop is working for you in between when you actually do the hospital reviews. Would that help resolve some of these issues? It's a thought, it's an idea, it's not complete. So we are getting feedback on a monthly basis as they present their actual performance and there are a couple of hospitals that are now having a conversation with me monthly as we try to ask questions about what we see in those monthly reports. I don't think that for most hospitals, it's surprise what they're witnessing, but it also doesn't hurt to have the conversations. So I think there is a feedback loop whether or not it's sufficient or not deal. We've always walked that line, and we're trying to find out what's the right amount of requests that we have for any hospital and when do we exceed that and become excessive and become a cost to the system that's not creating better outcomes. So it's a tough one. Other public comment or questions? Yes, Mark? You know, speaking on behalf of the University of Vermont Medical Center in Porter, you know, we're happy to come in and have a conversation, but it's the same presentation that we did back when we talked about this before. So there's no new information about what's driving this. It's the exact same presentation that was done before. So we're very happy to come in and have that conversation if the board so chooses, but I think that information is already out there. I also want to put out there that I think it was in 2017 that we actually requested a rebasing at that time and we were turned down. So at least on the Medical Center, this is related to a population shift within the state. That presentation is no different than what was shared before. Porter's story is no different than what was shared before. So I mean, happy to come in, change the day on the presentation, have the conversations all over again, but what is driving the variance in 18 to 17 actual is the same explanation of why 18 needed to be rebased going into the 19 budget process. So I just wanted to share that with the board. Thank you, Mark. Other public comment questions? I don't see any. So I'll call the question. All those in favor of the motion to ask the staff to set up enforcement discussion hearings with possible budgets that were exceeded 2% above or were a negative 2.5% or more below. I think I have a motion correct. Do I wrap it up? Yes. Further discussion? Seeing none. All those in favor signify by saying aye. Aye. Any opposed? So Lori, you and your team will get these scheduled. Yes, we will. Thank you. Added the direction to make a connection with the actual results presentation. Great. Just a quick comment in the spirit of verging control. As you heard today, there were some, there's some updated data to FY18 actuals report, which is the basis of a lot of this conversation. North country's data was considered preliminary in that report and it has since been updated to us informally, but not in our adaptive software and also Southwestern's FY18 approved budget as a result of the dental home. So all that updated data is reflected in the Lori's presentation, but not in the FY18 actuals report that is posted to the Green Mountain Care Board website. So I wanted to say that for verging control, what's posted on the Green Mountain Care Board's website will be updated, but it will not be updated until North Country submits an adaptive. So just be cautious as you review that report because now some of the system-wide calculations are no longer accurate. Thank you for that. Now, one of the things that I always find fascinating is the Vermont Health Care Expenditure Analysis and take it away. My team is going to desert me and they're going to want to do these as long as there's any questions. So we're going backwards now. We're talking about 2020 guidance and we're talking about 19 amended budgets and 18 added. We're going to go up to 2017 Vermont Health Care Expenditure Analysis. The topics through this presentation will be, I'll give you an introduction. We're going to have a relationship to the total cost of care. Summary and then dive right into Vermont resident analysis and spending and growth. How Vermont compares to the National Health Expenditures of NHE from CMS. And then we also have another perspective called the provider analysis where we look at the revenues received and the growth trending for the providers. We also have a chart on hospital revenues and migration of hospital inpatient discharges. There's a slide where we compare the two perspectives and I'll explain to you why they're not going to be the same amount. And then we also have a projection of the birth analysis and the provider analysis for fiscal years 18 and 19. And then the appendix. The expenditure analysis has been in existence in the Vermont Health Care Expenditure Analysis since 1991 and it has been an annual report and it estimates the future health care spending and covering, excuse me, future health care spending covering a period of at least two years. The report examines the spending trends and sources of funds. It compares Vermont to the national data reflected in what's called national health accounts produced by Centers for Medicare and Medicaid Services, CMS. And it quantifies total spending for all health care services provided in Vermont for residents and non-residents and for services provided to Vermont just regardless of site of service. These two symbols on the side where you have an R is going to be presented on all the slides when it's a resident analysis. The P is going to be saying provider analysis. They're two different populations. And I wanted to show you or briefly mention to you the relationship of the VECHA to the total cost of care. The VECHA measures expenditures at a broader and more comprehensive level than the total cost of care measures that are in the all pair of health care organization model agreement between Vermont and CMS. The total cost of care... Can we just refer to it as the expenditure analysis? Yes. I believe VECHA. I can't so sick of these acronyms. Sure, sure. But the expenditure analysis is all the expenditures for Vermont residents. The total cost of care is certain populations and such as Vermont residents without excluding certain populations and Vermonters without insurance. And it does not take into consideration the FPP plan or it's called Federal Employee Health Benefits Plan. The Vermont expenditure analysis includes all people receiving care in Vermont and the outside of Vermont. The total cost of care only focuses on Vermont residents. The all pair model is limited to claims payments and for services covered by Medicare, types of services covered by Medicare or non-claims payments, related to direct medical care such as care management and cavitation. The all pair model of total cost of care does not include retail pharmacy, the expenditure analysis. This summary of the expenditure analysis is that Vermont residents' expenditures increased 1.7% from 2016. This was lower than the 3.7% increase in 2016 and it is an average increase of 3.2% for the period of 2012 through 2017. Commercial insurance spending increased 2.5% and this was mainly due to the admin and net cost of insurance, other professionals and other unclassified and deficits. Medicare spending increased 0.8% as a result of utilization in hospitals, other professionals and admin and net cost of insurance. Medicaid spending decreased 0.2% and mainly due to the decrease caused by the rebates realized because they had higher rebate percentages for specialty drugs, but this also was offset by the increases in mental health and other government activities. Vermont has seen a payor shift over time for healthcare services. From 2009 through 2017, percentage of total residents' costs paid by commercial insurers decreased from 38% to 34%. Out-of-pocket decreased from 15% to 14%. But in contrast, Medicaid grew from 25% to 27% and Medicare grew from 19% to 21%. When we compare ourselves to the US, again, we increased 1.7% from 16, but the United States increased 3.8% in their total spending. Vermont was lower than the 16 and increased by 3.7%. The US was lower by 5%. Per person spending or per capita, Vermont was 9,667 and increased by 1.8%. This was lower than the United States per capita amount of 10,229. Vermont healthcare share of gross domestic product is 18.5% in the United States is 17.1%. On the provider analysis, we were seeing healthcare service revenues received by Vermont providers for in and out of state patients increased 3.3% in 2017. This was a little higher than 2016 by 3.2%, but lower than the average annual increase of 3.8% for the period 2012 to 2017. There was growth reported in the hospitals 3.2% and this includes the employed physicians that the hospitals have acquired. The revenues increased 24.1% for vision and DME, 7.2% for home health, 5.5% for physicians, 3.9% for dentists, 3.8% for other professionals, 2.8% for nurse homes, but this was offset by drugs and supplies of 0.9%. A lot of numbers there. This chart is showing you through the years 2012 to 2017 the growth between the years, the growth between the payers and also the provider and the facilities. So when I was quoted a lot of those numbers this is the chart where I would get a lot of information. The total income spending growth, this is showing you that it was in 2012 with 3.1% and now at 1.7% the increase. We are at $6 billion for 2017. We have spent in these categories so hospitals were over $2 billion. Mental health and government activities is $7.96 million. These are in the, it says thousands on the bottom but the total expenditures is $6 billion, I emphasize that. So the increase in spending was $104 million or 1.7% over 2016. We saw increases in categories such as admin and net cost of insurance in the commercial payer. Vision and DME was seen increases in out of pocket. Other professionals increase were seen in commercial insurance. Medicare saw increases in hospitals and mental health and other government activities such as mental health clinics, home and community based services and reported increases in medical. This chart is trying to show you where it went. So again, this is in and out of state spending $6 billion. So the majority was the hospitals but then the other categories were drugs and supplies that drugs and supplies was 12% of toll spending positions are 50%. This is a chart showing you that commercial insurance is 34% of the spending but 51% of our enrollment. Can I get a comment on this chart? Sure. So I think one thing that might be helpful to a point that Mark Stanislaw made earlier for future versions would be to also show the percentage of commercial that's self-insured because when you look at the part of the commercial sector that we have in our rate review program, which is the fully insured market, it's actually a minority of this 51%. Most of the commercial sector are the self-insured market, federal employees, military, Medicare advantage. So maybe that someplace else in here but I just wanted to mention that that might be an additional helpful chart that will help people track the numbers more closely to our other regulatory processes. So if you were talking about this particular information. I can't actually see it, sorry. Probably. Yeah. But this is in for anybody's reference. This is on slide 12. Thank you, Laurie. So I basically wanted to show you because of the spending out. The population doesn't necessarily follow the spending. And this one is almost looking like Pac-Man but this is where it came from. This is the payers. So most of the spending came from health insurance and then the majority was for other governments and other public. For commercial insurance, we split it up so that you see what the payers are, the categories that are increasing those particular payers. And commercial spending was 50 million, increased 50 million to two billion and this increase was made from admin and net cost of insurance and other professions. The decreases were reported in hospitals, physicians, and jobs and supplies. A question had come up in previous expenditure analysis where our people have getting their services and it was noted that we had in-state spending of 75 to 76% so that's not too, too bad. And then the commercial insurance insured increased to 42% from 2016. Can I ask you a question on that? I think I asked you this before but just to be for edification. You, on the commercial insurance, you're looking at admin and net cost of health insurance and my understanding now is that that includes amounts put in reserves. Yes. Yes. So I don't have to go through all those other slides. Sorry. Are you all set for the commercial? So Medicaid, most every year they see increases in their mental health and other government health activities. Excuse me, Medicaid spending decreased 3.7 million to 1.7 billion. They also saw increases in, like I mentioned, mental health and other government activities and admin and net cost of insurance, hospitals, nursing homes, and physicians. But what I found was interesting is they saw decreases in drugs and supplies due to reduced spending on higher rebates for specialty drugs. When I was looking at this particular pair, they had a large increase in their spending but it was offset by these rebates which was pretty substantial. They have for in-state spending is between 85 and 86%. This is probably not surprising, it's for Medicaid. And their enrollment decreased 4.3% from the previous year. Medicare increased 10.2 million to 1.3 billion and this was mainly from hospital spending. There also was increases in other professionals and admin and net cost of insurance. Their in-state spending is between 73 and 68%. What I saw was that some of their spending was decreased in their drugs and prescriptions and that was from out of state. They were getting it mainly from out of state. Their Medicaid enrollment has expanded to 2% over 2016. And this chart is what Tom was talking about. This has come up the last few years as wide as there, such as swing sometimes for commercial insurance or even for expenditure analysis. The admin and net cost of health insurance leads this most of the time. And I thought I'd give you a look at why, especially commercial insurance, the pieces that causes their admin and net cost of insurance to drop or be increased. And as Tom brought up, the change in surplus or reserves is the one that causes the big swings. I also wanted to point out Medicare and Medicaid also have admin and net cost of insurance, but they don't have the change in surplus like commercial. This slide is trying to show you what categories of service are bought by government versus private payers, such as ourselves and other pocket. Pairing 2017 to 2009, government payers accounted 34% of the spending and 51% of the population, as I showed you in the previous slide. Medicare accounted for 21% of the spending and 21% of the insured. Medicaid accounted for 27% of Vermont spending and 24% of the population. The pocket as a percent of total spending has been about the same. This then is doing the similar of what's showing you by the different categories of service. In Vermont, when we compare ourselves to the natural health expenditures, Vermont is compared in the state health expenditures a lot and that is usually only published every five years. And the last one was for the data of 2014 and that was published in 2017. So when you compare Vermont or if you're questioned why Vermont is so high, a lot of it is we have better data, detailed data, specific data, and we also have a aging population and we are more generous in our Medicaid payer. So this brings us to the detail behind these numbers. This chart is showing you that CMS will show you the national health expenditures, the health consumption expenditures and personal health care and then you have the Vermont expenditure analysis. We compare ourselves mainly to the health consumption expenditures because the other category includes equipment, research and structures and awesome investments. Vermont does not track that. So the total spending as I mentioned in the summary the CMS data increased 3.8%. We increased 1.7% for spending. Our per capita is 1.8% increase. The United States is 3.2% and our share of the gross domestic product is 18.5% and the US is 17.1%. And then we show you the different charts for growth trends comparing ourselves to the US using the health care consumption expenditures. Total spending growth, per capita growth, per capita again, this is showing the dollars and this one is showing the share of the gross domestic product, Vermont versus the United States. Vermont's gross domestic product has increased but our population has been decreased. And now we move on to the provider analysis. This summarizes the revenue growth by the payers that provides funding to the providers. And we usually receive direct information from the hospitals, home health care and the nursing homes. The rest of the analysis is mainly information from the census, the CMS national health expenditures and other sources. Let's move back up to the slide that compares the gross product. And I just want to point out that people often say, why did health care reform have to occur? And the simple answer is that the growth in health care was greater than what was sustainable in the economy. And when you look at that chart there, it's a glimmer of hope and the glimmer that what we're doing is moving us in the right direction which you can see the spread between Vermont as a percentage of its economy and the variance to the rest of the country really is starting to come together. So I just throw it out there that hopefully this is a sign that we're doing things right. So the provider analysis is now 6.2 billion. It's a $197 million increase of 3.3% from 2017. We saw Medicare and commercial payers account for the increases in revenue in the hospitals. We also want to make note that the hospitals make up about 42% of the total revenues in the health provider analysis. This chart is showing the growth over time. Revenues increase from 5.2 billion in 2012 to 6.2 billion in 2017. Some of the shifts in these growths is also we are trying to improve our analysis so sometimes it depends on where we're getting our data. You might have a little bit of a jump or a drop in the growth. The community hospital revenues by payer. And then we also wanted to show you the physicians that are in position of revenue in the hospitals. The 14 community hospitals have approximately 16% of their revenue as physician revenue. And they have a little bit over 1,000 FTBs that are physicians, over 13,000 of non-MDFTEs. And for 2017, the hospital reported 231 travelers. And we're hearing that is increasing. This chart I think just used to look like this one is to kind of like, this is showing you the in and out of state patients for 2000, it's actually in 2016 Uniform Hospital Discharge Data Set that we're reporting this in 2017. But what I find was interesting is each hospital will have different shifts in their out of state patients but over all the state will see only about 13% between 2015 and the 17th. This is the chart where we compare the resident analysis and the provider analysis. I wanted to make note for you, the resident analysis does not have hospital physicians that's at zero, but the provider analysis will show that because we have that data. The hospital physicians are included in the physician category on the resident analysis. The resident analysis has admin and net cost of health insurance, the provider analysis does not. Take a look at drugs and supplies. The resident analysis will include the rebates. The provider analysis does not because we do not have that data. This year I provided you projections for the resident analysis and the provider analysis. And the resident analysis is based on information provided by payers if they're able to give me the data and also based on the trends we saw in the last few years for the payer and the provider facilities. The provider analysis projection is based on what I'm seeing for trends but also we receive or I collect data from the national health expenditures and they have inflation factors. So I have taken that into consideration for projections. And in this chart, because of our budget process, we're able to have hospitals projected 18 and improved 19 community hospital budgets are included in this chart. And then the rest of the appendix is if you wanted to go through them or not. This is the matrix with all the different cells where we get our data for the resident. And the coding of the color meaning where allocations are applied or the direct information and where we're getting estimates from the national health expenditures. This is showing you the commercial matrix because a commercial includes self-insured but we also include workers comp. There's long-term care in commercial. There's Medicaid stuff. There is other non-major Med categories in this commercial payment. And this is the provider matrix. This was the chart I showed earlier on enrollment and the sources we give enrollment in enrollment is from the ASSR, which is the annual statement supplementary report. We collect that from the insurers about the time that they send in the annual statements to the NAIC. We also receive information from the Vermont Health Insurance Survey, NICURES, DEVA, and also I've had reports from the Dartmouth Institute to help us with the Medicare before we were having Medicare and NICURES. This is showing you what the national health expenditures, how they record their data. Vermont, we use the personal health care and the health consumption expenditures. We do not account for the dark blue, which is the investments, research, and structures and equipment. And again, this is talking about the national health expenditure that I mentioned before and the links that people want them using my resources. And I'd like to definitely acknowledge my hospital budget team, my peers at the Bureau on Care Board, the Agency of Human Services. They've given Medicaid data and DFR for the workers' home. I could not do this report without other people. And Dave's got our link for the Tableau Interactive that will be ready tomorrow. Any questions? Any improvements? I just want to start off with a thank you. I know this is a lot of very hard work and a lot of hard work by a number of people. We probably could spend a half an hour on each one of the graphs or tables for a broader discussion. And I think that this is just the beginning of the discussion. I'm sure that you're gonna be feeling a lot of questions as people start to digest the information and try to more fully understand what they've just seen. So thank you in advance. Questions from the board? I don't have a question. I just like to echo your thanks because this is one of, I probably shouldn't say this out loud in a public meeting, but this is one of my favorite reports. Because I feel like it really provides us with information about our healthcare landscape in all the different components in enough detail that you can really start to see how things are changing over time. So thank you, thank you, thank you. You're welcome. This report will be on the website for this meeting, but it also is on the website on the expenditure now. And we also have a manual on how to use the expenditure analysis. Lori, can you just talk a little bit about the tabloid or activists, the new feature? That is a new feature. Can you just talk a little bit about the movement of the fact that they go online and use it? Yes, basically you should be able to see it for multiple years, but I also think I need to phone a friend because I haven't used it enough myself. And I think that it's going to be very helpful so people can see if you move different levers, what are your trends going to look like? If you want to see what is happening out of pocket, you should be able to see that in these interactive data. We are only going to be having for the resident analysis and it's not for providers. Because V-Cures is also our support and V-Cures is the residence. Stay tuned. I think it's going to be better. And we're going to be having other types of interactive tools. I believe we might be having hospital budget information and others and we're just talking about today. David wants to definitely experience. We should say who David is. He's in our data department at the moment. Part of the 18. Part of the 18. Yeah, I've played around with it a little bit online and I think it's kind of interesting because you really can tailor the graph to what information you yourself are looking for. So it basically allows for different looks than what we might provide in this report. So if folks have something specific they want to look to then the Tableau interactive may be open to them. The Tableau is, you can access it and if you go under a data analytics and then the analytic reports then you should be able to link to expenditure analysis. I should say that all the data that feeds the report are downloadable. If there's a look that we're not automatically providing you can kind of take a look for yourself. Also want to thank the things and all the hard work. And kind of a question because the video is listed in here. But when you go to slide 15 and a few slides after that where it talks about in-state spending for commercially insured was about 75% and then it did the same for Medicaid was, Medicare was 68% in 2017 and Medicaid was 86%. And do we have a slide that shows where all of the, you know what the total is for all of the out-of-state spending by remoders and by category? Because I just wonder, you know whether there's anything there we saw it was heavier skewed to a percentage of hospitals or even different drugs. Yes we did. Yeah, okay. I mean I don't have a slide but I have the document if you would not see. Well we're talking about one of the hospital charts that showed that 13% of the hospital spending was from out-of-state and what we don't have by category is how much was out-of-state for remoders and where are they spending? Are they spending more in different categories disproportionately? Just, you know, we're always worried about what's going on in the state but there are a lot of people going out-of-state and more people than elsewhere in the parts of the earth and things like that but just wondering if there are any trends there of where that's changing. Right, that's where I had made, I had noticed that a blip will call it for the drugs from down here. Yes. Thanks. You're welcome. Again this is a huge amount of work and it's the kind of thing that's like a library to go back to it when you need to know something because it's just a nice integrated report. I have, just I'm looking at slide 42 and I'm looking at the, so this is health insurance coverage. Some of your Medicaid numbers include nursing homes and other kind of non-insurance-based benefits that people can get from Medicaid. But I'm wondering, so I'm wondering here on the line that describes Medicaid caseload, you can see this very rapid increase from 2013 at 127,000 to 2014, 146,000, peaking in 2015 at 161,000. And that was the point in time where, you know, all the problems that folks have with my health connect were at their crescendo. And then you can see the drop in enrollment down to 2017 to 150. And, you know, I'm told and you can track this through the emergency board, which tracks caseload that a lot of this drop is just cleaning up the files. And I'm wondering, you know, because whether or not these Medicaid numbers have been scrubbed for the reconciliations of the Medicaid caseload in those years where they were off by quite a bit? I'd have to ask that question. And also, these particular enrollment numbers are supposed to be as of the end December 31st of 2000 from whatever year we're asking for. So you're asking if they were scrubbed? That's the story of that. I think that through the emergency board, if you read the emergency board minutes, you can see that they systematically up through, up to 2018, were going through their caseload and reconciling it for people. Some of them were eligible, but some weren't. Some of them were pulled into different categories of Medicaid assistance that weren't correct. And so by 2018, they were back on track with a Medicaid record of caseload that people felt they could rely upon. Okay, are there questions or comments from the board? Now I'll open it up to the public. Questions or comments? Yes, Eric. I just want to thank the board so much for putting this together and really, it's a huge effort to compile and generate and put this all together. But also, the movement of the board to thinking about how the information is consumed and put it in on how low. And I promise David and Sarah do not pay me to say this, but yes, it's absolutely wonderful. And I think it's, at least for our shock, it's causing us to think about how we share information differently or would like to. And it's a massive task and it's been very well-executed. So I really want to thank you for that comment, Eric, because it couldn't come at a better time because we were just bombarded with a very negative email that said that the board never tries to communicate to the public in a way that the public can understand. These are the type of innovative things by moving to the Tableau software that we're trying to do that to help make whatever product we come up with actually useful for the public and something that they can manipulate around for their own particular research purposes or what have you, and so thank you for that. I don't have to get compliments, thank you. Especially from the healthcare app. Yeah, especially for me. I couldn't let that go. Other public comments or questions? Yes, Mark. I just have a couple of thoughts for just the kind of sharing. I don't know if this is, you know, why would the upturn in Medicaid to be directly related to the ACA conversion that would be piqued in 2015? And as all of these chains were being set up, Vermont was early and this was, I think this was in Robin's prior role, but there was a lot more people that came up from other insurance claims and actually went on to Medicaid more than he thought was gonna go to commercial exchange. Well, so that's part of the uptick there, I bet. And then the other thing under the grugs on the Vermont Medicaid, and I forget which year this happened, but Vermont Medicaid took away the 340B discount, so that's probably why the drug cost went down in that year. I don't know if the drug cost went down. Yeah, well, I mean, the drug, well, I mean, you know, that difference in payments, you know, that was borne by the providers candidly. But still, so I was just speaking to specific events that I think spoke to, you know, what changed an out-of-trend number. And it may or may not be correct. Just on your point around the Medicaid enrollment, I think most of what we saw in terms of new Medicaid enrollment was out of the uninsured population, but there was, at the same time, just to make it more complicated, a change in the way that income was calculated for the purpose of Medicaid eligibility, and that did shift people from catamount into Medicaid. And that was the income change component that was hard to estimate. And I think what that trend was basically, what you saw for all of the states that expanded with our Medicare coverage or related to the ACA components. Well, if we had a 3% drop, we'd be in the car. Yeah. Any other public comment or questions? See none? Again, thank you, Lori. I think you're going to be a pester for a little while as we all take questions while we're driving or what have you, so. Also, if the board can think of other, we'll talk about sweet home spotlights or anything that you'd like to begin to, or me or my co-workers, ladies and gentlemen, we've already got a request from the Joint Fiscal Office for some questions before, is there any past presence? You'll be busy. Thank you. You're welcome. So at this point, is there any old business to come before the board? I guess I just wanted to update the board and the public that yesterday was an exciting day for me. I got to go to Washington to meet with the key people who work on innovation at AHHS, our partners in the all-fare model. And what is so refreshing, too often people think that government is broken. And I would say that you can always find an instance where you would think that government is broken, but here was a classic case of the fact that he had some truly incredible public servants with a huge knowledge base and to think that we were sitting around on the table, that the envoy from Vermont included the governor and the secretary of AHHS and the director of healthcare reform. And you sit there and you think that just because there's a change in the administrations that things aren't going to get followed through on. And here was a case where you had a different team in Vermont than what was in place when the all-fare model was signed and a different team in Washington that was in place when the all-fare model was signed. And yet everybody was still with their heads down working on the work because it doesn't matter what your political philosophy is at the end of the day, everybody knows that people need to have quality healthcare with good access and high quality at an affordable cost. And that's really what that group of individuals in Washington is working on. So a refreshing day for me, a long day, but one that I will always remember. Any new business to come before the board? Seeing none, is there a motion to adjourn? Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Any opposed? Thank you, everyone. Enjoy the rest of the day.