 And I think what I'm going to do is start with Russ, if you are on Russ McCracken. Perfect. Can you just share with us any of the insights you gathered over the thought about over the recess about how we might proceed with motions in answer to member lunges questions and any additional insights? Sure. Sure. Member Lundra is the question of whether the board should make it more formal and explicit that the board is considering NPRFPP growth from hospitals from projected to budget and not just budget to budget which is specified in FY23 guidance when we look at the 8.6 percent cap. I think that it makes sense to make that more formal and explicit. The board has some authority under its COVID flexibility act that was renewed this year to make changes to rules and guidance. I think we are more expanding this way the guidance is applied than actually changing the guidance in this case. I think it's worth noting also that when the board sets a budget to budget guidance, I think there's some assumption that the hospital's actual performance and its budget are going to be fairly similar so that we're looking at an actual growth rate. Given the challenges that we've heard from hospitals about budgeting in preparing budgets with the impact of COVID still being felt and what we've seen from projected to FY22 projected to budget variances, there's some pretty significant changes there. The rule is our hospital budget rule is also very explicit that the board shall consider the actual performance of hospitals relative to their prior budgets. Taking all that together, I did speak with Member Lunge during the break and worked on some suggested motion language that would be happy to turn over to Member Lunge if she were so inclined. Great. Member Lunge, do you want to make a motion? I do. To Russ's point, I think this is belts and suspenders, not absolutely necessary, but I think it makes sense to do. Noting that the board shall take hospitals performance with respect to prior budgets into consideration and budget review and as permitted by Act 85 to safeguard the stability of healthcare providers and allow for an orderly regulatory process that is responsive to the evolving needs of the COVID-19 pandemic, I move that we accept the staff's recommendation to allow hospital NPR-FPP growth to be reviewed on a projected to budget basis in addition to budget to budget for determining how the hospital aligns with the board's guidance. Great. Is there a second? Second. Thank you. Second by Tom Walsh. Is there any discussion on this motion from board members? No, hearing none. Okay, so all those in favor of the motion, please say aye. Aye. Okay, any opposed? Nope. Okay, so let's record show that it was unanimous in favor of that motion and we'll be using both projected and budget to budget in our decision making. Great. All right. Well, thank you for that, Russ, and thank you for that Board Member Lunge. At this point, I guess I would start with we can kick it back over to Sarah Lindbergh and we can begin with Southwestern if board members are comfortable with that. We can revisit those slides and see if there is an appetite for making a motion or if there's any further questions that anybody has about Southwestern for Sarah and her team. So I'll just kick it off. I'm comfortable with the staff analysis and I'm comfortable approving the budget as submitted for this particular hospital, but also happy to wait to do a motion if other people aren't quite ready for that. I agree. I'm fine with moving forward on this hospital. I'm good to go as well. Okay, great. So if somebody wants to make a motion, there's some suggested motion language on the slide that will make it easier. I will go ahead. And so I move we approve Southwestern Vermont Medical Center's budget as submitted with a 6.4 increase from fiscal year 22 to fiscal year 23 budgeted NPR slash FPP, a 9.5 increased overall charges and subject to the standard budget conditions as presented to the Board today. Great. Thank you. Is there a second to Robin's motion? Second. Great. Tom Palem seconds the motion. Is there any discussion on this motion at this time from the board? No. All right. At this point, I will open it up for public comment. If there's any public comment on the motion at the floor, which is to approve Southwestern's Medical Center's budget as submitted. Are there any public comment here at this time? Okay. Seeing none, hearing none. Nope. Steve Majetic, you have your hand raised. Yes, I just hi everybody. I just like to thank the board for their motion. And on behalf of the hospital, you know, we're working really hard to make sure that we can achieve this budget as most of the hospitals in the state are. And again, I like to thank the staff for their work and their transparency through this process. Thank you very much. Yeah. Thank you, Steve. All right. Is there any further board discussion on this at this time? All right. All those in favor of the motion, please say aye. Any opposed? No opposition. So let the record show that there was unanimous approval for the budget from Southwestern as submitted. Great. All right. Well, thank you. Let's move on perhaps to the next hospital. We have Northwestern up. Is there any questions? Anybody have any questions for Sarah and her team about Northwestern Medical Center? No. Okay. I'm not seeing any questions or comments. Is anybody ready to make a motion? There is some suggested motion language on the screen. I am ready to make a motion. I move we approve Northwestern Medical Center's budget as submitted with a 4.5 increase from fiscal year 22 to fiscal year 23 budget and PRFPP, a 9% increase to overall charges and subject to the standard budget conditions as presented to the board. I'll just note an explanation that I chose the 9%, which was the updated request from Northwestern as Sarah presented earlier this morning. Thank you for that clarification. Is there a second to this motion? Second. Second by Tom Walsh. Fantastic. Any further discussion on Northwestern's budget at this time from the board? Okay. Not seeing any. I will open it up for public comment. If anybody from the public would like to comment on this motion for us about Northwestern Medical Center's budget, please just use the raise your hand function. Okay. I am not seeing any public comments at this time about this particular budget or this motion. So all those in favor of Robin's motion, please say aye. Aye. Aye. Any opposed? Nope. No, none opposed. So again, let the record show that there was unanimous support for Northwestern Medical Center's budget with the slight revision to their overall change in charge to 9.0 instead of 9.4, which was what was submitted, but then updated, an updated submission. Okay. Let's move on to the third hospital then that we were going to discuss this afternoon, Copley Hospital. Anybody have any questions or comments for the staff on the Copley Hospital budget analysis? No. Okay. Is anybody ready? I move we approve Copley Hospital's budget as submitted with a 12.1% increase from fiscal year 22 to fiscal year 23 budget and NPR FPP, a 12% increase to overall charges and subject to the standard budget conditions as presented to the board. Great. I need a second. Second. Second. I got two seconds. I will take, I think Tom Walsh was first in the seconding there, so Tom Walsh will count for that one. Is there any discussion by the board at this time about the motion? Not seeing any discussion from the board. At this time, is there any public comment? Anybody like to make a public comment about the Copley motion at hand? Joe, is that you? It just reads as Copley one guest, but if it is you, feel free. You have the floor, but you're on mute, so you can't have the floor on mute. Okay. Yeah. Thank you. They give me a generic label, so I apologize. Also want to express my appreciation for everybody. It's a lot of work. These have been very tough couple of years, and I know that the board and all the staff work diligently to try to help us all to run hospitals. So I appreciate that. I just want to express that. So that's all. Thank you. Thank you for the comment. Appreciate it. Any further board discussion about the motion? And Copley one, which I think is still Joe, if you have your hand, can you get lower so I know that you don't have another additional comment. Thank you. Okay. All those in favor of approving the Copley hospital budget as submitted in Robin's motion, please say aye. Aye. Any opposed? No. So let the record show again that there's a unanimous approval for Copley's budget as submitted. Okay. At this point, I'm going to turn it back over to Sarah. I think there's some more hospitals that we will like to hear the analysis of, and I think I will leave it up to the board if you want to you know, there will be some motion language here that's been presented. If somebody feels like making a motion on any of these hospitals, certainly feel free to. We could go through another set of hospitals and then circle back. I will leave it up to the board to decide as Sarah is going through these slides. Okay. So we're going to be looking at Gifford Medical Center. And so they're one of the trickier ones to try to keep apples to apples over time. They're doing a lot of really neat reorganization in terms of shared services and whatnot, but that's made some of kind of the longitudinal analysis a little trickier, but they certainly came in with the lowest projected to budget increase in NPR and FPP at 1.8%. They are tracking very closely with that all pair model growth rate from 2019. And then they also had one of the lowest requests for a change in charge with that sugaring out to just over looks like $675,000. So $678,887 dollars that they're expecting in net revenue from that charge increase. You can see their historical charges, which we'll see on the graph compared to inflation in a few slides. So yeah, they again were the very lowest projected to budget increase. Their compensation growth actually was a decline. Part of that is that those moving pieces like we talked about, but we didn't see any red flags in terms of their compensation efforts. The other inflationary growth was a bit above our test value, which is from those projections from Moody's and CMS. I'm sorry, from the Bureau of Labor Statistics and the Economic Analysis. Utilization assumptions are expected to take a decline. There was very good evidence in their record that had to do with staffing constraints, changes in utilization and an EMR implementation. So those all were pretty well documented. We always remember with percent change is going to be a lot goofier on small numbers. So part of that negative 2.7 percent is just a function of small numbers. And so for the rate, that effective rate is a 2.9 increase, which is again the lowest that we're seeing. And I was just notified my labeling isn't ideal here, but so the kind of organization-wide operating margin that they're asking for is 1.5 percent, knowing that they've got the FQHC and other entities underneath it. But at the hospital level, it's 11.4. But kind of the effectual system margin is 1.5. So I'll correct those labels and repost this after we wrap today. So apologies for that labeling. It wasn't meant to be confusing. So you can see here that charge increases have typically been above inflation for this facility. But we also know that, like a lot of other cause, you know, that effective rate is less than the charge increase. So that headroom is probably not as big as it looks in terms of inflationary growth comparison. But that also may be part of why we're seeing a relatively lower asking that the current budget would want to do a lot more analysis before we looked into that. Susan, your camera's on. And then we want to take a look at that test that came above the threshold. It's actually a pretty straightforward thing to get to. So if you look at, this is again very much about the small numbers issue, but that fuel oil increase of 47 percent is just a relatively larger portion of their total operating expense budget. And so that hits at 4 percent. So 47 percent increase is actually pretty modest compared to some of the other fuel increases we were seeing. So staff thinks that this is really kind of not a concern at all and does not recommend any resulting change to approve their budget. So essentially, we recommend that after just double checking that evidence that you approve it as submitted. So at this point, I don't know if you want to think about whether to vote or to keep it moving. Well, let me just ask if anybody from the board has questions for you about what you've just presented for Gifford. Allow the board to just digest what you've just shared. And let me just ask, maybe I'll start to give everybody else a moment to figure out if they have any questions for you. Can you just clarify what you said? So there was a slide that had the operating margin for the entire, for the hospital as 11, well, it should be the operating margin for the hospital is 11.4, but recognizing that it cross subsidizes a lot of their other institutions under that umbrella. And so the 1.5 percent is really what the hospital's net operating margin is after it's subsidized the other parts. Is that accurate to say? That's correct. It's kind of the inverse of Southwestern, where Southwestern is a lot of it's at their parent, but here Gifford's the parent. Gifford Hospital is the medical center is the parent. And so there's subsidization that happens underneath that parent corporation. And at the end of the day, the margin that's left for Gifford is the 1.5. Gifford Medical Center that's left is 1.5 after those subsidies for childcare and for other entities under there. Well, it's, yeah, it's like, and yeah, it's like the operating margin for that full consolidated system is 1.5 percent, but the hospitals who gets to hold it for them. Hold it. Yeah, I understand. Okay, thank you so much. Any board questions at this time for Sarah on Gifford Medical Center? I don't have a question. I would just say that I very much appreciated Gifford being modest in their charge and effective commercial rate request. I think in the past we've had some concerns about it, the hospital having relatively high prices, but it looks to me like, you know, there's some possibility that that will get more towards the median, especially as with this sort of request. So I'm comfortable with approving Gifford as submitted and with the staff recommendation. I am as well. Is there any other word comments about about whether you're comfortable voting, I guess is a question. So I guess we could try it. If somebody wants to make a motion, we'll see if there's comfort in voting at this time. Does anybody want to make a motion about Gifford Medical Center's budget? I'd like Robin to make a motion. I would, but Robin does it far better than I did it, Ken. This is my official job, the motion maker. Did I motion to have Robin make the motion? It's a line item on your resume that just says motion maker. There you go. I move to approve Gifford Medical Center's budget as submitted with a 7% increase from fiscal year 22 to fiscal year 23, budgeted NPR and FPP, a 3.7% increase to overall charges and subject to the standard budget conditions as presented to the board today. Do we have a second? Well, I saw Tom Pelham muted himself and seconded, but I could read lips. Tom, could you just unmute yourself and second for the record? Second for the record. Thank you, Tom Pelham. Is there any further discussion at this point from the board on the motion on deck? Nope, not seeing any. So at this point, I will open it up for public comment. If anybody from the public wishes to comment on the Gifford Medical Center budget and the motion on deck, which is to approve it as submitted. I see Dan Bennett. I see your hand raised. Yes, thank you. I just want to thank the board and the staff for their work on this. It's been truly a difficult year for everyone and very much appreciate the work that you put into it. So thank you. Thank you for the comment. Is there any other public comment at this time? Okay. At this point, then, I guess I will say anybody in favor, all those in favor of the motion to approve the Gifford Medical Center budget as submitted. Please say aye. Any opposed? No opposed. So again, let the record show that the board has unanimously approved the Gifford Medical Center budget as submitted. All right, Sarah Lindberg, you are up next. All right. So next, we turn our attention to Mount Ascotney Hospital and Health Center. So their budget to budget increase would be 10.4 percent. But if we look at that consideration of projection to budget, it is 5 percent. We do see some growth above the all-pair model. However, that is, again, we have to remember these are relatively small numbers. So those proportional increases may not be as dramatic as they seem in the system. So that's not in any red flags, as far as staff were concerned. I'm sorry that I don't consistently treat staff as plural or singular. It's an opportunity for growth. And so their overall change in charge was 4.7 percent, which they were expecting to apply five and a half to inpatient for 0.92 outpatient and three to professional. And you can see that they also show that, and it's a good reminder that these charging increases are not just tied to commercial and for some of our critical access hospitals, there are substantial amounts of funds, particularly from Medicare that are tied to these charging increases. So just a really important factor, particularly for those reimbursed by Medicare through the critical access hospital mechanism. So that sugars out to a total amount of money of $2.9 million in the charge increase overall. Relatively modest increases historically, which will compare to inflation in a few slides. Or right away, it looks like I accidentally transposed the order there. So we can see here that similar to seeing that the longitudinal above inflation was a little bit longer than for some of the other hospital statewide, but right in line with what's been happening statewide for 19, 20 and 21. Notably, their approved charge last year is much different than the trend we've seen in the state where that number climbs substantially. So that's just an important factor here. And so now we'll review the test. And so their MPR growth is below that 8.6%. Their compensation growth at 6.5% is right at the median. Here again, it was that other inflationary growth that caused us to just double check and for utilization, 4.9%, which is a little bit above the median, but that largely had to do with changes in some of their service mix. 3.2% was the rate increase, which is that commercial effective rate, which is very near the minimum. So quite modest, relatively speaking. And that is designed to support a 1.7% operating margin. So that is the kind of summary of how our analysis worked for Mount Ascutany. And in their case, it's also pretty clear that not so we tried our best to make this as apples to apples as possible. But people were able to add their own factors and not everyone identified insurance as an inflationary cost growth. So it's hard to put that into context with other hospitals. So the fact that they included it and they have a relatively lower operating expense budget compared to some of the other hospitals, I think that may have artificially inflated this number. So I don't see and the insurance based increases are right in line with what we're seeing for most of the other hospitals. So didn't think that that warranted any recommended changes to their budget. So after that assumption check, we would recommend that this is also submitted as approved as submitted. Great. Thank you, Sarah. And I just want to say, I really do appreciate the staff digging into these areas where they're falling out of what these reasonable assumption margins that the staff has established. So I appreciate the additional context that we're getting on all of these. Is there, are there any board questions for Sarah and team on the Mount of Scutney analysis? Nope. I'm seeing shaking of heads. Okay. Does there anybody that would like to make a motion about the Mount of Scutney budget? Robin? I move. We approve Mount of Scutney Hospital Hill Center's budget as submitted with a 10.4% increase from fiscal year 22 to fiscal year 23 budgeted MPR FPP of 4.7% increased overall charges and subject to the standard budget conditions as presented to the board. Great. Thank you, Robin. I just need a second. Second. Second from board member Walsh. Appreciate that. So any discussion on the motion on the floor? Okay. Seeing none from the board, I will open it up to a public comment at this point. Does anybody have a public comment about the motion which is to approve the Mount of Scutney budget as submitted? Okay. I'm not hearing any or seeing any hands raised. So I'll go back to the board then. All of those in favor of approving the Mount of Scutney Hospital and Health Center budget as submitted, please say aye. Aye. Aye. Aye. Aye. Aye. Aye. Any opposed? Hearing no opposition, let the record show that we have unanimous support for approving the Mount of Scutney Hospital and Health Center budget as submitted. Okay. Sarah Lindberg, back to you. Great. So the final hospital that we had kind of expected to tackle here in this area is Grace Cottage Hospital. There, this is another case where the budget to budget increase looks a lot different than the projected to budget. So that 15 percent budget to budget increase actually ends up being 6.1 percent. And again, here that growth rate is more a function of small numbers than anything else. But again, not raising any red flags in terms of jeopardizing total cost of care targets for the all pair model. You can see that this probably these numbers look pretty familiar probably for this organization. They're requesting a 5 percent overall change in charge and which would be applied equally in the charges for inpatient, outpatient and professional services. Again, another critical access hospital, we see that that charge does have effects on more than just commercial and ends up being 1.2 million dollars. So again, those small numbers, high proportions or relatively higher proportions are less dollars when we look at that stuff. So when we look at the tests, so the 6.1 is right near the median of the NPR growth from the 22 projections to the 23 budget. They were the highest we saw for the compensation growth. Also, so if you review the Economist reports, you'll see that wage inflation is even greater in nursing homes and other assisted living facilities. That's not great cottage as a hospital, but given the types of services that they're providing, that might be part of what's going on here in addition to market factors to compete. I also think that I haven't quite isolated the travelers component of that, which I think is also inflating that number a bit. So I think it's reasonable. It's below the 13.8 percent. So I don't see a lot of reason to push back on that per se. And their other inflationary growth is 0.7 percent, which is another kind of indicator that they're probably putting the contracted labor in a different spot than some other places. So taking together, I'm good with it. Our staff recommend being good with it. The utilization tab was not completed in the appendices. So we'll try to look at that through a little bit different lens, which is why we're taking a closer look at this. But the effective commercial rate of 4.7 percent is in that kind of 25th percentile range. And then I think there's kind of a larger pattern here where the operating margin is booked to be negative. So negative 3.7 is the lowest one. And so we can say that that's in terms of putting pressure on our commercial payers. That's a very low operating margin to be budgeting with. There are charge requests. This is what I think of more like the CAW pattern. So we see these charge requests being kind of above inflation, generally speaking. But they do see a similar bump in 22. But again, we're very close to exact inflationary increases in 1920 and 21. Again, particularly it seems the pattern with CAW is that the actual net revenue for commercial plans is about 60 percent of the charges with some variation in there. But again, that approved value is probably an actual net increase of less for their prices. And so we looked at the utilization numbers that they provided in Adaptive. And they also address this in their narrative. But essentially, they're projecting continued utilization rates for everything, but physician office visits. So they're projecting a 13 percent increase. And that's just a simply a function of additional staff. So they've got some more staff coming on board. So therefore they're able to increase that value seemed in line with similar FTE to utilization increases that we saw this year. So don't recommend a change based on that. So with all that context, staff would also recommend that this one be approved as submitted. Great. Thank you, Sarah. Does anybody from the board have questions for Sarah about the analysis on Grace Cottage? Okay, I'm not seeing any from or maybe Tom Walsh. Yes, go ahead. Yep. Sorry, just a little slow on you. Sarah, could you walk me through a little bit more the expected change in utilization with an FTE? Yeah, so it's not perfect, but we are seeing kind of four outpatient kind of office visits around a 10 percent increase. It's so relative to the amount of utilization, though. So like this hospital again, you know, relatively low on the the raw utilization. So, but yeah, so they they I can pull up the narrative as well, if that helps in terms of that. But yeah, I was hoping to get a more formal look at that for the board, but I've been running out of time to do everything I hope to. But if from the work you've done so far, the expected increase in utilization they've proposed seems in line with what you've seen elsewhere, given on on the new FTEs coming on. It seemed in line, yes. And if we want to kind of put a pin in that and have us kind of show that I can be prepared to do that on Friday. I'd appreciate that if you could, please. That sounds good. Is there anybody else have other questions about Grace or Tom, do you have additional questions about Grace that you would know to Tom Walsh? Okay, anybody else from the board have additional questions or for Sarah? I just have an observation that this is always a little bit of a difficult hospital. But keep in mind that they're not operating money whenever they need it, they seem to get it. And so, you know, they have a capacity within their community to raise money and they have done so in the past when needed. So, you know, given that deep community support, I feel comfortable even though they're at the higher end, you know, of some of our metrics. Thank you, Tom. Okay, so I think it sounds like there's a little bit of follow up work that Sarah is going to do and we'll come back to this on Friday and potentially have a vote on Grace Cottage on Friday with some additional information. Sarah, how are you feeling with going through any additional hospitals or does this feel like a good stopping place for you? If it's acceptable to the board, there's some homework that I need to tackle here and if it's possible to take that time to make sure I get you material by noon tomorrow so that we are ready to get literaler sleaze up Friday, that would be welcome. I don't want to waste folks time, but. No, I think that's great. I mean, I think there's been a lot of progress today. I'm very appreciative of all of the progress that you were able to make in the analyses that we did. And so, you know, giving you more time to do the hospitals that frankly are a little bit more complicated and have a little bit more analysis that needs to be done based on the tests that you've run, I think is really a good use of all of our time. So with that, is that acceptable to other board members as well? Yes. Okay, I'm seeing lots of nodding of heads. So I think at this point in time, I will see if there's a motion to adjourn. So moved. From Tom, a motion to adjourn and then I need a second. Second. Second from Tom, Walsh, wonderful. All those in favor? Please say aye. Aye. Wonderful. Any opposed? No. Great. All right, then the motion passes. We are officially adjourned and we will be back on Friday morning at 8 30 with we'll go through another slate of hospitals and thank you, Sarah and team for all your wonderful analysis that allowed us to get through the hospitals we did today. All right. Thank you. Thank you all.