all call to order the Green Mountain Care Board's meeting of August 21st. Today we have one agenda item and that is reviewing Copley Hospital's budget submission and so I'll ask Mr. McCracken to swear the witnesses and then Mr. Wooden we can proceed with your opening statement on behalf Copley. Thank you Chair Foster and thank you Copley team. Since we just went through names I won't ask you to reintroduce yourselves unless you'd like to. We're happy I'm happy to go ahead and swear you all in now. If you would raise your right hands. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth so help you God. Well thanks very much and I will turn the floor over to you. Okay Sarah if you could just tell us if on you can see our screen share when it comes up.  Well it'll come in handy perhaps thanks everybody really appreciate it. Thanks a lot of work and effort to get to this point I really appreciate the folks around the table and Chip is our Chief Financial Officer Nancy Banks our board chair really appreciate her volunteer efforts in helping manage this facility as well as all of our volunteers. Kathy DeMars is an Ex Board Chair but she's also the CEO of the Home Health and Hospice Agency and so she's been very helpful and has been through these meetings before so she might be able to add color I appreciate that. Dr. DePuy next to me is the Chief Medical Officer gentle surgeon very flexible in his duties to help us all stay focused and Karen Cavender is in charge of perioperative emergency services. Karen this past year has been very flexible and I appreciate her taking on new roles and responsibilities as we all try to keep trains moving on time and forward and Liz Couto also has taken on some new responsibility I appreciate that Liz she's in charge of our emergency department and all of those related services so I think they're going to be very helpful in this discussion. So I want to go over a few things I just went over our participants thank you very much we're going to quickly do an overview strategic plan finances and then quality and access the overview is just to get to know us a little bit although you've been through a lot of these so our mission is we're trying to tighten it up but basically exceptional quality care close to home that does relate to our strategic plan but a happy appreciative faces of those that work here I being one of them you'll move on to that this is a comply our history we've been around actually 90 years and going back some of the old photos the community involvement of the hospital is really touching it continues we have great relationships with everybody last year we celebrated 90 years we did find because only in Vermont looking through the oldest of records we found the name of the first baby 90 years ago I asked somebody go on Facebook because you can answer most things out of Facebook or social media they found the gentleman in the Northeast Kingdom and he attended our ceremony so that was pretty fun he's was exactly 90 brought his family and that was kind of fun side story this is our old hospital I love this I actually have a collection of antique Vermont hospital postcards that's an usual collection to have this is for a copy and it's now owned by the oil county mental health services so it's right near us really close to the hospital just sort of down the street but they the designated agency manages the ones that love the list to the right that was in the old days they would do drives some hospitals would do a linen drive some hospitals would do food drives this was a food drive we got the exact materials and I'm not going to read up and some of them are funny like you know a can of rabbit meat or ends of unknown substance so the overview of the hospital were independent non-profit CAH one of eight in the state which is a lot service area population I give this to new employees every time we have new employees once a month we do orientation service area is interesting because I've been around long enough I think I've presented budgets since year 2000 hospital service area definition it becomes a concern because every time you see a numerator and denominator when you're doing the math sometimes we draw conclusions about the calculation with hospital service area my estimate for comply is it's between 30 and 50 thousand patients the old fashioned definition used to be where is the majority of the inpatient admissions for a hospital they can share their service area has to be at least 51 percent anybody not making that the entire yard was considered contested but when we do some of these math exercises I think we lose track of something so for us maybe 30 000 is for our building center and parts we take care of for example and maybe also our VR but I'm not sure about that that might be fuzzy because some people do like to make an effort to come here probably 50 000 more applicable to maybe orthopedics so it's hard to look at just a hospital service area we're a cah emergency department visits they've gone up quite a bit I think was going to test to that we budgeted that around 12 000 paychecks medical staff members the volunteers and donors on the bottom are really quite important to us and bring a lot of meeting to the meeting for the work that we do overview of services a lot of hospitals give you this so we have a variety of services from neurology neurology you know a lot of its orthopedics general surgery gynecology cardiology just figured I'd give you that list I think every hospital probably has a list similar to that here's a discussion about our hospital type so this is an agenda where I said say what's hospital type mean well there's three types of hospitals in the state for the most part critical access hospitals which receive 99 percent of allowed charges sometimes people get that wrong thing that it's more than that allowed costs and then critical access hospitals that's that category pps is sort of going back to 83 with dr g's and then tertiary care centers or academic medical centers get some additional benefits in reimbursement also expenses to this is our size relative to the other hospitals so we are just three percent of the budget so for the entire budget of give or take 2.8 billion dollars that was 2001 so that's just kind of helpful I know a lot of the budgeting stuff we go through the same amount of questions which just makes it a lot difficult for a small critical access hospital as opposed to a much larger organization just sharing that perspective a strategic plan we've done that it's a three-year plan a little over the halfway point in that plan in 2023 three major themes coming out of that which are most important are financial sustainability exceptional quality and workforce culture and keeping care local somebody had asked me when we went through the process and a lot of involvement with the staff or some community members on committees why isn't quality first you know why isn't your quality first and it's like well I wish it was we're hopeful to get to that point it is certainly most important however we've got some financial issues and pressures that are really taking center stage I think our quality is excellent and dr pequi is going to borrow some of that but finances sort of need to be there because we're sort of struggled with a lot of things going into the finances operating margin discussions so this is our history over the past since I get seven years then a negative operating margin we're only working hard to try to turn things around we did get significant relief in 2021 I'll just show you that without the covid funding we would add another negative 1.2 percent operating margin so we're very thankful for that it did make it look like we've got a great operating margin in 2021 I'm not sure how the staff and the finance team sort of cleans that out you know a bunch of money one year doesn't mean that you're super happy in all things are well for me I sort of did an average of those three years sort of said if we averaged out everything that happened for 2021 and 22 we probably had a positive operating margin of about a little bit one million dollars so just to share that with you operating margin now there's four themes here operating margin our rates price is charges kind of the same thing days cash on hand and capital needs so the first discussion outside of operating margin it's just sort of our prices and charges this was a request we had a couple of years ago we updated it in 22 the issue was that you know how our prices compared to quest for a profit uh lab out of Canada New Jersey unfortunately uh just because it's out of state that's why I said unfortunately it's helpful to keep business local and state so we did this um somebody gave us the list of the most common CPT descriptors and in all cases 10 out of 10 charges we were less than the Vermont average and on many of those we were actually the lowest by far I did have asked for some notes but on on many of those if you did see we are by far the lowest the hospital comparison where the hospitals around us where somebody might consider driving so that's one study that we did uh here's another study this is with 2021 data where emergency department and diagnostic imaging old-fashioned inpatient charges in all of these cases we were below the average and every single one of those and on the starred ones we were the lowest in the state but these are these are pretty dramatic differences if you sort of look at some of those I know it's a lot to look at here's an update that our CFO did Jeff did this because the state had asked so what if you get the charge increase what would you look like compared to the other hospitals well Jeff actually took every hospital listed up top a through m and took their prices and gave them the increase that is being requested so if you if everybody got what they wanted for 2024 putting us what would we look like and again on the uh starred items with the lowest state we are lower hundred percent every single one of these on state average and on the red ones um we're a little bit higher some of those is uh there we're a little bit you're higher than them sometimes it's $10 sometimes like a little bit more this issue of us addressing prices I'm going to sort of unfold this with more discussion that our prices are are so low our prices charges same sort of thing our rates not the rate of increase but just sort of what is your charges has been a problem um and it's been around for well over 10 15 years so if you look at some of these examples I'll just grab a few we were extremely low here's just four bumps so this is a lab culture where $44 the highest in the state is 440 a year in bacteria culture we're 27 compared to 222 700 percent the next one is $1,500 versus close to 6,000 so that is almost 300 percent it's sort of these are big numbers now we're not talking you know a $10 band aid versus a $2 band aid these are really expensive and an assay thyroid is 195 percent I'm only bringing this up because I think that of all the things we do and there's so much data that we look at so many ways that we look at data cut data new methodologies of looking at it over time or in a pie chart format at the end of the day this is what the patient sees on their bill this is why they might have an HSA and go to the hospital we are in my mind just all over the map it's not like we're give or take 10 percent for 20 swing we're talking to give or take a thousand percent and some of this stuff it to me it's hard to understand but it's one of our problems because our rates are so low and I'm not sure how I'm gonna play catch up to even get to average but we'll be having that discussion give a rate request maybe you have some ideas because I don't know how to get them but been around way too long I think I started this chart in the year 2000 so I don't have the first three years but this shows every year oh I can use mine thank you very much every year what was submitted versus what was approved and anytime you see a red circle that means somebody was clipped for lack of a better word the budget got clipped and the red dot means that's the highest increase in the state there's the lowest and this is complete and if you look over time we went for 12 years the only hospital in the state for 12 years would never be clipped or concerns about their budget I might be proud of that but I think we weren't asking for price increases I think that was historically not a good idea because we were asking for zero or close to zero and then if you look at the period after that we got the most sort of adjustments of any hospital where we had eight years where we were downgraded sort of six times and a few of these black ones are where we're in the negative and we continued in the negative so I want to share that with you this is when the Green Mountain Care Board taking over from the public of second good place right here in 2012 just for perspective kind of interesting what happened in 2012 Mr. Wooden can you can you stay on that side just for a second sure and have you provided these I assume you have is that right yes I think I've given a paper copy to some folks but yeah yeah this is a great chart and I'd love to I'll be happy to give you the Excel spreadsheet if you want to look at that some years we've had dramatic adjustments these two years when the Green Mountain Care Board started amazingly just stopped doing it just kind of interesting and we picked it up I'm not sure what happened in 2015 maybe somebody has an hypothesis happened there so it's just it's just interesting but we've we've not fared well in this process but let's just be sharing with you and I think in the past we didn't ask for enough money I think there are many years we did not ask for enough of a rate increase and that's why our prices are systemically just stuck right thank you sure this is that same data just sort of summarized in three formats it looked for the past 15 years we were the lowest approved budget increase of 15 years versus the highest which was about 2.25 percent more every year for 15 years I could have gotten 2.25 compounded over 15 years would be a different place past 10 years we were also the lowest off by two and a half percent and I'm thankful so this is my fourth year presentation of budgets this goes back five years so I have presented gotten three years approved and I'm happy to say I'm not the lowest and I'm really working hard to figure that out but we've always been extraordinarily low given any questions anybody just sort of jump in past ch five year operating margins is right here back a couple of other years so I think if you look at the history of this data Springfield as we know which one bankrupt has lost the most money we're the second biggest concerning hospital regards to losses on average so that's again why I'm concerned about what we're doing forward and here's that perspective about how much we got cut so these are the rate requests going back to 16 and then this is what got approved I accepted the 20 budget but I have been here since I created the 2020 budget I got here at 19 so we asked for negative three we got negative four we asked for zero we got negative three this is performing we asked for zero again we got negative 3.4 so we've had a lot of history and happy to say I'm trying to correct things but this history goes way back it does show that for operating margins you know we're at 619,000 just one step better than Springfield which is concerned for all of us and when you look at the outcome of the comparison we continue to be this is one of there's many ways to look at what we do but I think the all-payer cost of care model is helpful you know how much do we cost relative to other counties and it's another piece I'm not saying I hang my hand on any of this stuff you have to look at a bunch of them but with the lowest of 22 that's the latest data and going back to 2013 which I think it first came out sorry about that we are the lowest so there's something about this county and community and all the work that we do whether it's home health primary care we're extremely cost attractive last couple points I want to mention day's cash on hand we've had problems with that we are at 83 Springfield it's above us we're down there with Springfield Grace and Copley it's a concerned cash becomes a concerned for a variety of reasons as you can imagine here's a chart on debt low capacity our long-term debt to capitalization we're here about 3rd from the bottom we're actually much lower but we did pick up a medical office building it's a orthopedics and pumped it up but it becomes a problem we have issues and significantly when it comes to operating margin cash debt and one of the problems with our debt and challenges it's hard to actually take on debt it did get some debt for the USDA but it's hard to get debt when you've got cash problem and you've got an operating margin problem so the USDA is very gracious and helpful to us listen to our detailed story and we got through that screening process but they were very generous because operating margin and cash alone would dictate that we are extremely high-risk not that I'm happy to report that here's a chart that I had to come up with to figure out why our capital is so underfunded and why some of the items around here are in dire need of repair but look at IT alone IT infrastructure and closets are horrible shape our operating plan boiler room we've got a number of issues so this is a chart that I did sort of say okay each year what did we budget going through our staff analysis process a lot of detailed discussion with every manager the need age of equipment all sorts of things that going through our finance committee that our board then going to the green mount care board and getting approved so this is our budget and this is what we spent I put a red circle when we under spent so every time we under spent I put a red circle and when you total this up for this 11 years going to 2020 because that's changed a bit since I got here which we we had budgeted $55 million of need and we spent 42 so I don't know how to describe that is that a deficit did we save money did we under fund still making I mean I've got I got a roof on the Mansfield orthopedics building that looks like it's a I don't know potato chips because it's so dry and just waiting for that to sort of lake so we didn't really save this but we really have to address this in any capital way back that you probably double the triple the price of it particularly if it's building so I wanted to just go over that the orthopedics discussion and then I'm going to give it to Don who is one part excellent overview of quality here's a quick orthopedics discussion so remember the hospital service area definition this is the towns where our patients come from some of them are out of country we have one out of state with 49 folks which is great and this is the county so the loyal county we take care of about 62 percent of our business is one county so when you and and this it's funny I'm not that in there that doesn't match by a couple percent but that's our pie chart for where our service area comes from hospital but here's a pie chart for Mansfield orthopedics just the waterberry office so if you look at the waterberry office it's amazing how many people so the graph on the right shows that literally 72 percent of the people in that redish area who come home to our office 72 percent of the people that come to our waterberry office are from south 14 percent of sort of the kingdom of franklin and only 14 percent of from here so it's amazing how many people come to our waterberry office to the point where we did they are in the process of trying to build a more comprehensive office to keep people getting here sooner but I thought that was interesting even when it comes to issues of quality and access in our strategic plan there's two items that we're working on one of them is how do we work with our local primary care offices we have two of them our nursing home designated agency for mental health home health all these folks to say how do we manage care make it more efficient tighter how do we consider sharing staff and regionally we're with a group a new upstart group from on to the community health network community hospital network that we're trying to put together to help us locally within the state of a lot elsewhere to drive down cross being more efficient to find ways to help each other whether it's travelers or sharing staff other staff john's going to talk about a couple things i'm going to turn it over uh thanks uh yeah that looks good you know oh this yeah and then this one's this one's good um so i think this is my eighth year uh at a budget presentation and i think probably Dr. Holmes has been there for most of them so she must be getting pretty pretty tired of me but i also get to see a different part of the green mountain care board in the last couple years i've had the privilege of participating in two initiatives of trying to get a handle on how to really look at both access and quality of our hospitals in a way that's actually you can you can reliably and repletively measure and that's somewhat robust i think it's probably fair to say that the access part of that is still a work in progress but i think the quality part at least from someone like myself who's been thinking and doing this for a while is pretty well understood at least at a first pass attempt and so this would be the quick summary of a set of metrics for hospital quality i think it would probably start by acknowledging there are really two kinds of data to work with one is basically the hard clinical data that's what you're actually measuring something that actually happened and then there are data that's somewhat softer more experiential that basically asking people kind of what they think so in that ladder group we have the hospital report card reported to us through the bdh particularly the the hcaps which are surveys sent to patients who have recently been in the hospital and through both 23 and 22 cobbly has had all five stars that can possibly be given as a hospital in 23 there was one other bramont hospital that had five stars on the skutney and in 22 it was just cobbly and through both of those years for the two things that i think are probably most important when asked do you recommend the hospital to a friend or how do you rate this hospital and and what they really pay attention to is if you rate it basically at nine or a 10 at a 10 cobbly's cobbly's always in the top three through both of those so i think that's uh that along with the slide that joe showed that so many of our patients come from outside of our what might be thought of as our natural service area really says two things about us that people really like coming up cobbly and even though we know we don't advertise this or aggressively get the word out people do know and they keep showing up so moving on to some harder data the readmission data get this through vaas and fiscal year 21 and 22 cobbly's average readmission rate is 7.7 percent compared to the critical access hospital average of 8.7 percent and the all comers vermont hospital average of 9.7 percent which also suggests that the cobbly's doing quite a good job really in two separate areas one is that we're actually doing a good job of caring for our patients and preparing them through discharge but also now we're working well with the rest of our community the local primary care offices and home health care and basically you need all those folks working together to really make a successful discharge and workout and last but by no means least there's the national surgical quality improvement program which is the gold standard in measuring surgical quality if you ever want I can talk about this for probably the better part of a day but just to give you the 30 000 foot view on it I presented in this slide two kinds of data and this data is basically all surgical service data measuring our all complication rate over six years 2017 to 2022 on the graph on the left that's raw data another way of thinking about that is that actually happens when you come to cobbly or you go to the average nisquip hospital and as you can see the chance of a complication when you come to cobbly is very much lower than an average nisquip hospital if you're wondering like what's an average nisquip hospital they for the most part they have names like uvm and dartmouth and mgh and cedar sinai and hospitals of of those ilk so it's a pretty fast crowd that we seem to do quite well in comparison of if we had folks from uvm or dartmouth or mgh sinai at the table they would have they would have some yeah but about that is they they would tell you their patients are sicker and they do lots more cases and that that's really not a fair comparison to them I would say two things I would say one is well yeah your those are good points but this is what actually happens when an actual person goes to our two hospitals but also nisquip has accounted for all those things on the on the graph on the right they have a rather complicated statistical model that takes into account patient factors and case numbers and case mix and have presented the six years data for this along with the average of the six year which is sort of the harlequin thing all the way on the right and if your value is one that means your your average and if it's below one that means you're better than average and as you can see our six year average is about point nine and that's with everything considered and I would also know that their statistical model also has a very hard regression to the mean component to it they don't actually believe at least statistically that hospitals really are a lot better or a lot worse and that it's all sample error I I disagree strongly with that but even considering all that copies kill looks really good and I would say that we look good and it's consistent over many years and somehow we seem to do all that having basically the lowest prices in the state and as you know because you pay a lot of attention to the money our ability to be sustainable and to sustainably deliver this good care is at significant risk really because our prices are so low so I'm sure Karen and Liz are going to add to some of the questions when we get them and probably field a lot of that discussion but we're open for conversation or what you'd like to talk about thank you for sharing that we'll turn to director Sarah Lindberg and she'll walk us through some of the data that she's pulled from the benchmarking tool and then you know your team Mr. Wooden can jump in with any comments that you'd like as she goes and then we'll turn to board questions great thank you are you able to see the screen I'm in a little bit different environment okay great yeah all right fantastic all right so we see for npr growth that Copley among the critical access hospitals has the second lowest growth in net patient revenue and we also see a pretty impressive amount of operating expense growth at five percent so managing those expenses I do know that some of the provider transfers may be making some of this a little bit hard to compare so I just wanted to make sure I followed one so the one of the transfer said it was from Mansfield orthopedics to Mansfield orthopedics so I was trying to figure out how that works from a provider transfer standpoint vis-a-vis the hospital yeah so I can no I can jump in it's doctor doctor arrows and I think folks comment about this but he made a decision of significance of leading the organization we were certainly surprised and heartbroken and he is by far the most productive orthopedic surgeon that we have well loved a lot of tears a lot of sadness but he loves doctor arrows and so we had to immediately figure out and make a commitment to get additional provider we've always had a backlog we've always had greater demand and supply that news was pretty much jaw dropping and so we went down that road made that commitment I will say in the process of hand transitioning and managing that it was always an outpouring of affection for good people and you know wanting them to think about staying and so forth but it was pretty intense it was extremely sincere so in this family much later made a decision and asked to come back to the hospital and he's a very wonderfully kind person he's one of the nicest folks I know the surgery department no offense dr. de Crete so we were sort of in a tough situation we were thinking about that we we've had demand that is far exceeded our supply so that was the unexpected sort of transfer request that jumped around but thankfully he's staying we have a new our first female orthopedic surgeon starting next couple of months finishing up a residency down at Boston so we're very happy to welcome dr. Aaron Picciotino so that's kind of the discussion there it was a gut wrenching transition that the community wrapped their arms around him and his family and he decided to stay so we're really thankful so that's kind of that I don't know if you guys want to add to that yeah I guess I would just add right off that even with dr. Aro Stain and dr. Picciotino coming uh waiting list for particularly joint services at Copley is still going to be three to six months out so I mean if we really did have a handle on on access it would still look like we're struggling to keep up okay um this was the the other two transfers so I did more like what I traditionally think like that's a community service at the hospital kind of helped fill I just don't quite follow the orthopedic so is this a new hire or is it like a new service I'm sorry I don't need to be done so I just yeah it was a it was a it was a replacement it was intended to be a replacement for dr. Aro so Aaron Picciotino the commitments were made and so that's how we got her and she's going to be joining us but maybe Jeff can answer that yeah so Sarah after we had hired um which was really I think a testament to Copley we were able to hire dr. Picciotino very quickly um and what then happened is then thereafter dr. Aro came back and said he would really like to stay um and so that wasn't represented in our budgets only dr. Picciotino was represented in our budgets okay got it yeah okay added unexpected added provider okay it was hard to say no to her though she's uh she's going to be a great addition to the team yeah yeah no I understood okay uh thank you uh and so uh looking at the finances over time uh you have a very uh unusual uh relationship between your operating expenses and npr so for most people we see a bigger gap here and a heavier reliance on other operating revenues so um this is probably a testament to the lean and mean mentality um but however I do see this is very unusual unfortunately to see the orange line above the blue line I don't know what that weird feedback is is it better now um and so my my main question is uh related to operating margins so a jump from negative one where you're um forecasted or predicted projected to end in 23 up to 3 percent in uh 24 budget is a pretty big jump in one year so I was just wondering you know kind of your approach to that in building your budget so building our budget uh on the jump in one is you know getting our rates to at least be average that's one big thing for us that we need to do the other thing is working the uh the traveler expenses getting those unnecessary expenses down below uh where they need to be um you know our travelers uh they were at a high two years ago of $109 an hour we're now averaging about 120 um our travelers were at a high of um just actually this fiscal year um in the month of March of being between 32 and 35 we've got them down to 27 and we need to continue to keep bringing them down and so it's the relationship of managing our expenses either be it through you know cost containment measures working um all the different avenues that we can't to get the expenses down but get the revenue to be average yeah and oh go ahead I'm sorry travelers have been our biggest challenge unexpected uh the price differences went up as high as $200 an hour at the height of uh COVID and I know nationally there are some hospitals spending over $10,000 a week for a nurse so if you do the maps on that that's a half a million dollar job for a single first so I know the country's been reeling on this I know a lot of states have tried to put forward legislation to manage both the traveling companies how much profit they make as well as limiting staff from jumping I know Missouri this year actually made a go with that and I hope that's something maybe the state of Vermont could look at because we went from zero to a hundred in terms of expense and it's not desirable for us because we just keep having new people join we've got to train them acclimate them you know operationally it's been very challenging but I don't care what's that I would say that uh we've really tried to take a different route on that um when we get travelers in we there we're very particular about who we bring in we're looking for a good match for the facility and then once staff get here we try to treat them exceptionally well so they'll stay and we don't have that additional cost of breaks in between contracts where you're running under as well as the cost of counting on someone coming and then canceling their contract at the last minute we've also converted quite a few travelers who are now permanent staff here uh so we continue to try to go down that route recruit and retain everywhere we can yeah we've we've heard that one through twice um always easy to a lot easier to say I think than than execute um so and here we see um this is unusual to see a jump in salaried folks between 21 and 22 I'm guessing that might have something to do with some provider transfer but uh might be off the mark there and uh again seeing that in terms of compensation if we trend forward where you were on a prefty basis uh to date um you're basically right in line with what the cost inflation is so maybe even a little low so um any kind of thoughts about uh this or related information yes Sarah um my apologies when we did see this when your data tool came out we did look into it and so what we discovered is in 2021 there was a traveler fte's reported in that number in 2022 there was and that goes back to that 30 got it okay and another testament to our data model uh needing a little tune up so thank you okay um so despite having the travelers in there you still see the perft ego down so despite those challenges that's that's uh that's I'm surprised to see that trajectory um what was up with the utilization in 21 you guys like blew off the doors that according to what we've got here is that also maybe some restructuring or you had any ideas what might be going on there yeah um you know having this organization shut down due to covid um was insane and there's a lot of pent up demand and um our providers um our staff really stepped up to it and the patients did return in regards to the surgical volumes we it was pretty amazing right at the end we were the first hospital back up and running with inpatient cases the very first day the governor lifted the ban we're ready to roll yeah we were ready to roll yes and yeah last we were the last hospital to follow the governor's recommendation also we just had people that really wanted to work and we were extremely busy once things lifted yeah just just been very busy surgeon yeah oh i'm sorry i know that um you know as more and more services shifting to outpatient which tends to be a little trickier to try to um plan for um how you kind of handle that uncertainty i i know with the flood you guys were pretty seamless in your response and able to not really skip any beats so um just curious kind of how you hand you know prepare for those kind of ebbs and flows in case flow like that well um just been that on the outpatient stuff will see in future data our orthopedic team on their own they're they're really self-driving they got their own attitude about quality and operations and it's great they really want to do the best next thing and they've been talking about doing outpatient joints and um they sort of pressed us before COVID hit like we really want to get on this and we wanted to study it we were trying to understand the finances but once uh COVID started to unfold people didn't want to be inpatient people didn't want to be at the hospital so our outpatient orthopedic business and i'm sure you can attest to this really has taken off we it's amazing how much we do outpatient yeah i think prior even to COVID um in response to patient desire um we were hearing from patients asking if we did outpatient surgery at that point we did a very small number of our patients outpatient um we really did not have a robust program which needs to be multidisciplinary it's not just surgeons deciding they want to send patients home it starts at the time of their initial visit we have to include PCPs in that physical therapy our pharmacy department anesthesia it's very uh complex and so as a group we pulled our steering committee together and we started working on that before COVID even hit again in response to patient requests but also seeing an increase in our inpatient volume we were starting to see borders in the ED and we were starting to look at what are we going to do with the house is full with medical patients and we have no place to admit our surgical patients the vast majority of our inpatient surgical patients were total joints so those two things dug tail together very nicely and so we really were well underway in that program we were probably through our second iteration of um what our protocols look like and then COVID hit and I had surgeons in anesthesia available for big long meetings because they weren't operating anymore and we got that program up and running so that when we opened our doors we completely flipped our inpatient outpatient model and uh from the time we open till now we're at 97 percent of all of our total joints hips knees and shoulders and ankles go home same day it's pretty remarkable that's amazing yeah yeah yeah without this is the first time I've seen this data so I don't know exactly what's being measured with the word utilization but for sure several things happened at the same time one was when was the outpatient joints which we lead the state in anyway so other you wouldn't see that in other hospitals data and I think that's just added on to as you may recall from the from the COVID years even important things like mammograms and colonoscopies they stopped being done entirely so as soon as we started it again there was a huge basically backlog of of things that really needed to be attended so I think what you're probably seeing with that spike I mean would be our best guess since we don't know exactly what it is is the combination of those two things and if and if our spikes are a little higher than most people's I think that's why yeah yeah and just here to understand so I appreciate your perspective yeah the final thing is is we also you know as an organization I think you hear that a lot of organizations are choosing new EMRs you know and converting over to new ENRs properly was in a similar situation we needed to understand what we needed to do but instead of going out and changing over from our current system to a brand new system we actually did what we call the refresh around that time frame too and that is where we took CPSI we created a new version of CPSI and some of our stats did change and could also be contributing to those numbers kind of striking out okay and then I think you kind of covered a lot of this you know as far as events go a lot of immigration I think our HSA is going to be a lot different than how you think of your catchment area but also notably just seeing a very high proportion compared to some other HSAs of Medicaid spending in that HSA so just kind of a you know that's a the whole HSA so not just Copley Hospital but just seeing that that's kind of an unusual distribution of the dollar share for Medicaid so you know part of that might be those low prices that's keeping the commercial bars low and so you assume the 6.6 percent inflationary growth from 23 to 24 and I meant to ask ahead of time but hoping to get a sense of what the realized expense growth is estimated to be from 22 to 23 and I can follow up Jeff if you don't have that at your fingertips yeah I mean the expense growth we actually use busy and through NIA they communicated 6.6 or it was slightly lower than that but yeah we can definitely follow up and give you the exact number but that was supplied by our group purchasing agent yeah yeah and I think you know we'll be reaching out I think to all the hospitals just get a little bit more granular on some of the variation in other cost inflation so again looks like you use the group purchasing organization we just didn't see too much detail about what you were budgeting in some of the other buckets okay and then when we go to the cost report we see as a fiscal year 22 this adjusted discharges measure which is certainly imperfect as a lot of us in the biz know that it's hard to count outpatient events so we use this adjusted discharge and we see that you're kind of at the top of the whisker so on the middle here would be the 50 percent 50th percentile half the data in the peer group is above that half the data is below it here we've got the 25th percentile with 75th percentile and this upper whisker is Copley we also see that you have a higher acuity I presume that has to do with the orthopedic share of your services having a higher CMI but now that you're moving to the outpatient setting I want to make sure that I've got that right you've got that right yeah well I'm not so I'm not so sure is that inpatient yes so it's it's going to be DRG payments so DRG weights so even though you're in the outpatient setting are we still going to get it on a CMS UBO 4 I'm sorry if it counts outpatient then yeah that probably is right historically we had a very high CMI because we admitted all the joints we did but since we haven't been doing that we would have thought our CMI would be going down quite a bit and although I think it's gone down a bit it hasn't gone down as much as we thought I think just because sicker patients are coming into the hospital now yeah yeah and that you know that acuity is above the 75th percentile so that would you know include assume some more intensive services and yet we see that you I believe are 16 there you go that's right 16 percent so uh yeah what do you think that's about just going to say it's accurate I think it's great I love that chart I mean I mean nobody you know I'm not on some of these charts I'm not sure how to manage that I'm not sure you know what I mean like we don't think about how to perform best with the ratio of administrative and general salaries to clinic salaries you get what I'm saying so I can appreciate it of course I like it because it makes us look good but I don't I'm not sure what to say about it I do want to go back to the case mix index one just an interesting subject and maybe Karen or Liz has thoughts but when we went to so much outpatient on one of our biggest services and the volume in the mount you would think that our inpatient hospital would just be empty and the hospital be like wow so your census must plummet and yet for an ER the types and volumes of patients that we're seeing in our ER and the volume in the types acuity it's interesting that we don't feel any less busy certainly I don't think Liz feels less busy in the ER nor does the floor right I gotta get that right yeah I mean you you said it exactly I think those of us that are on the floor and appreciating that are really realizing that there's just more patients and there's a higher acuity you know by 2030 all boomers will be 65 or older and that is a huge population that you know also tags on to what resources are available um you know we when we budgeted for the amount of visits that we were going to have you know we if you look at you pulled up you had a graph earlier about you know the number of ad visits being a 12 000 and a little higher and then a little higher and then it dropped off which was COVID because people stayed home they didn't want to see us and that you know and the ones that were coming to see us were really sick and really high acuity and I think had we you know projected through 20 and 21 to right now we would have continued to go up and potentially budgeted for the numbers that we're actually seeing now which is you know like I said at this point we're at 14 000 um but we budgeted under that so we're really just seeing so many more patients that we um have to keep for longer which it was amazing to switch over to an outpatient um process for a lot of these joints they do a lot better but it also decompressed upstairs and it really just worked timing wise to help us out because I don't you know three years ago we were you know playing a one for one game leaving the ER with no admissions which isn't realistic because the ER is the only place that we can't turn people away or stop treating them um or let them go somewhere else so we really just continue to see that increase um the millennials is the next biggest group and they are the ones that are having these compounded stays and related to mental health and substance issues as we run out of access to help them get out of the ER but again the ER is the only place that we have to keep them and we have to treat them and they have extended stays continuing to the patients in the hallway um foreign rooms without technically staffed beds so I think just when we talk about what do we want to budget for we realistically should be budgeting for and that's you know essentially what we've done an email for is how do we kind of jump from 2019 to where we should be right now to make sure that our census and our acuity matches essentially the quality that we want to give you're right it should be number one on our list of things but realistically as we're all sitting here we really have to be financially stable to do that and right now it's hard yeah that feels like an understatement um yeah uh so as far as uh cash we've already kind of talked about your challenges to rebuild some of the cash that you have on hand uh seeing you you know pretty close to 25 percentile it not probably not congruent with that uh financial stability uh that you're talking about uh and then for you know I almost hate to call it profitability in 22 but um you know seeing you near the median as as low as that is uh is uh wondering if that has to do with uh this outcome which uh is just a bit below the median uh oh I'm sorry that was Gifford uh you are right there with Gifford though um at 11 000 per discharge so again this is claims data uh for each average cost uh allowable by medicare adjusted for your cmi we get about 11 000 per discharge which uh you know is uh one of the most impressive among the critical access hospitals in vermont and is between the 25th and 50th percentile in this distribution um so cost coverage this one um I think I definitely well here why don't we look so if we look overall we see um that inpatient uh just decreasing um given what you said about your service mix I wonder if part of that um might be the shift to the outpatient setting and that we're seeing it kind of move there see how this line goes down about the same even more dramatically but this is rising so that might be if I had to guess what was going on here but uh also seeing a pretty uh steady downward trajectory on the inpatient rates from medicaid uh vermont medicaid and we see here um that at 57 percent that is the lowest cost coverage in fiscal year 22 for inpatient um and seeing also very low cost coverage uh on commercial and so then when we look over to the outpatient side uh we see you know more uh a little bit higher cost but not not you know pretty close to peers um and pretty close to peers payment uh but covering 189 percent of that allowable cost for commercial versus the 76 percent for medicaid which was one of the um you know higher cost coverage is on that side so um this one looks real funky to me when it averages out um we see that overall the commercial being 160 percent of the cost but still seeing a very low cost coverage uh for medicaid um in a low payment so um so you know when I look at the the typical payment for commercial the the height of that bar is pretty similar among these few hospitals um so I'm just I know it seems like at least from a charge perspective that um you're making up for lost time or feel like you're behind but I guess here it looks like it might be getting better for at least from an allowed amount which we know that the patient share isn't always collected um but just you know curious if uh this perspective uh how that jives with kind of this uh low price over time uh that you've given us lots of data about yes yeah so does that surprise you or you think there might be something funky going on I'm just curious your kind of perspective on this there when I looked at the on this and I went down to the bottom three graphs exactly what you said it's um it's basically a shifting out of the um inpatient orthopedic procedures into outpatient orthopedic procedures in regards to the cost report that had a pretty dramatic effect on our cost report we're working through that that's what you're seeing there okay uh and then uh so here we have again a standardized price per inpatient stay and we see for inpatient coply again this is 18 through 20 so um especially given the changes in your the setting of the most of your service this might not be very informative at all but at that time anyway you were right at the median uh so again what we do here sum up all the pay uh commercial payments we have in the the all payer claims database divide by a standardized unit of service to try to get to an apples to apples um and then we see you actually quite uh below the 25th percentile in that time period on the outpatient side so I would imagine probably this is now if not at the median uh you know closer to the median and this is probably dropped down uh given that but again we won't see that updated analysis for a while uh can I ask a question sure so how does this relate to just the prices that are published or not jefted most all of this data of course into the staff like how do how do these charts relate to the fact that somebody is selling this service for a hundred dollars and other people are selling it on average for 300 and some of them are selling it for a thousand dollars like how does the basic you know we've got this disclosure of prices in America the public understands that we understand that but then we go through these machinations and it doesn't seem like it's that big of a deal and it's like oh my gosh but what we're seeing and I don't know if we collect people's bills I mean I don't know how do you have any suggestions on how we can better understand our prices because they seem dramatically low yeah and I think that's one of the the tricky things about um how we look at charges versus the allowed amount right and like we're pretty weak on understanding the allowed amount in an apples to apples fashion so that that is why I think you know there's can be some value to these machinations but uh still imperfect yes I know when I first got here I've been here for four years um I found that in the charge master and you know what charge masters are it's important you look at them but in our charge master we had a number of cases where we would bill less than the allowed amount and hopefully a few people are gasping but uh you know it's it's not possible for insurance companies they will pay you the lesser of your charges or the allowed amount we were actually charging less than the fee schedule and just leaving money on the table so folks like Blue Cross and MVP would just kind of giggle and say oh my gosh company's really funny um so I just think the prices and what's allowed you know the fixed fee schedules I think we really all need to understand that because at the end of the day that's what a patient gets for a bill like oh my gosh your MRI you know is so inexpensive or it's so expensive you know you would hope that we would give the community or the public a sense that we've controlled these give or take 10% so a 20% swing or give or take 20% so a 40% swing but we give a system where the public can literally get charged as you saw in just one you know 900% more from going from one place to another and these are thousands of dollars I mean that one example was like four thousand dollars more I'm just throwing it out because I don't understand it and I wish we would understand how that works yeah yeah yeah it's almost um it were obfuscated by design for some reason but yeah I think that that's exactly right uh is that um yeah it's it's a very uh bizarre market no one I don't think would uh draw this up on purpose and uh look forward to working together to try to get that right sized and uh screwdable screwdable to a consumer yeah that that was all I had I don't know if there's anything else you want to comment on from the data portion before we turn it over to the board for their questions nope I think we're good all right um thank you director Lynn Burke uh I'll open it up there's no set order so any board member that has any question or comment please go ahead I can go ahead and go first um hi all I hope you're doing well um I was wondering how you thought about uh Medicaid redeterminations and whether you included some assumptions related to that in your budget yeah um with the uh redeterminations we did you know through our contractuals have um you know some assumptions that are built in um this is a wait and see for us um you know we're expecting hopefully um that we do a spectacular job of uh getting those individuals onto a commercial plan through the exchange but we're also understanding that we'll probably see them come into our charity care and even as well as our bad debt so could you explain what those assumptions that you included are so what we did is you know working with like you know specifically one care um you know we did reach out ask them what they thought that on you know on the changeover was going to be they did communicate to us that it was um it's coming on a little bit quicker than they expected but we kind of used them as a guide to get to where we needed to get to so basically you took the change in the Medicaid fixed price amount that one care will be providing passing through to you and then use that as your assumption for your other Medicaid related business am I understanding that right yes but uh and you know but the thing is is where it actually ends up it's going to be the question that's going to be a wait and see sure yeah sure so you um did you also apply that same assumption to your bad debt free care right now you will see that the bad debt free care we use the historical trends for those we have it built into our Medicaid number okay got it thank you for explaining that um in the answers to some of the staff questions you outlined several expense reduction efforts that you've been pursuing is it possible to quantify sort of your expected savings so we can get a just a a sense of those dollar amounts either if it's in the past what you are able to save and if it's in the future what you're expecting and obviously if you can't do that now that can be a follow-up I think that if we could take that as a follow-up but it would be tricky a lot of them are more of processes that we put in place you know looking at our contracts making sure that everybody's touching the appropriate contracts we do that with our capital as well you know it's not just um I always love it um you know if your budgets go through um people kind of think that okay great now I can get FTEs or now I can buy my capital that is not the case we always make sure that we're diligent and we look at where our volumes are and you know where the the organization is before we approve that so we put a lot of processes in place I'll just I'll just sort of jump in Robin thanks so um the travelers uh in our efforts to retain staff prove staff and a big part of that relates to our salaries our benefits and making sure that we are competitively attractive the variety of things that we need to do to do that our straight salaries part of that we're looking at trying to reduce our travelers by about 33 percent from our current number but I can't I can't predict that and when this and the eds has got holes over schedule you know this point where it's like you can't run an emergency department with significantly understand you just can't do it I mean there's a line in the sand that he would come to me as we care in and say listen we just can't do this so we've got our goal of a 33 production in our travelers try to meet that if we're a bit slow in the beginning we're gonna have to maybe work us about the end we'd like to get to no travelers but it is by far the biggest expense supply chain efforts we're looking at other options even that group that I talked about then the state to see if we couldn't save money on supply chain efforts contract review process capital review revenue capturing revenue and improving our charge capture process we don't we don't have dollar amounts on many of these because it's just hard to sort of say we're going to do that we are trying though like a traveler side but I know I mean there are people that come to us and say yeah I'm gonna I get a job as you know hard working people that have been here for many years and say yeah I'm going to go traveling in Vermont I get to come home at night I get to see my kids you know it's just too much money not to leave you and when it happens it is really painful you know and that problem continues with us and some people come to us from other hospitals too so I can't complain it's a one-way door some people will say well you guys need travelers so I'm gonna quit working at hospital X and I'm gonna come work for you and it just doesn't feel good for any of us it feels horrible you know on either side so I don't know the traveling I don't have any ideas without to add anything to that I mean I think for all of us really you know living here and working here really working on the recruitment and retention which like you said we're all kind of hammering in travelers is not a problem that just we're facing and you know to Joe's point we do have a lot of travelers that come here and live locally and just you know they can get more as a traveler which I think for health care when we're trying to say what's realistic as a budget and we as a nation have to figure out what to do together to really help health care continue moving forward it really is making your area some place that people want to stay and tip the scale from what you can make as a traveler hourly to I really enjoy working here and will make a reasonable wage so having the right resources and I feel like I've been a little bit of a challenge coming into this team was you know looking at what we've done for the last couple years and what we really need to do in the next couple years to make the workflow change we've done some great changes in the ER to realign back to some standards set by our national organizations for standards of care but we are still very much far behind it and that's not gonna come without increases and what we need we need the department from the hospital and if it's not there it's really hard to keep up and it's really hard to say we give this great quality of care that people want to we have 10 hours of the day where there's only two nurses staffed in that ER that's our staffing pattern currently you know with that comes a request in FTEs um it was again two nurses that have a lot of productivity throughout the rest of the hospital and quote unquote take care of the sick of the sickest includes a charge nurse or a team lead as we call it here so there's not a nurse sitting around the corner that you know can pop in so realistically to um to kind of for me at least rebuild where someone like me who's been doing this for 14 years and I want to be here and I live here and I want to give good care to my um my colleagues and my community um we have to realign that so that is it's a good place to work where we all feel safe and I think that ER we talk about all of the issues in the ER that we can't avoid there are some things that we can do to make it better and it's just an investment I think the scales will tip when we start making changes for a little bit higher wages for what we're doing um you know Kathy brought up in the first meeting that you can go down in the street and make um more money working at Dems Place making babels or I took a little break after COVID and I made more money bartending two days a week than I do nursing with three degrees for three days a week so you know the big picture why but that's that's really hard to figure out how do you scale back on travelers but make it a good place to work where we can all survive thanks um I know a lot of the other hospitals have been focused on grow your own programs I don't know if that's something that you have currently implemented or have thought about so yeah we've done a couple uh significant things we are now a uh clinical site for BTC their nurse that we are you know bringing in nursing students here uh hopefully is now uh one of the hospitals that where they sent their students for clinical um and then on top of that we've started a nurse residency program to try to compete with some of the larger hospitals that do the same thing um so you can take a new fresh new grad and put them through a residency program um which is you know an extended orientation uh really and then we have year-long extensions to residency programs for our specialty areas like the operating room and the emergency room um our nurses and ED nurses do not grow on trees they're very hard to find um you know you can hire a brand new grad onto med surge pretty easily um and uh you know routinely you find um travelers high in those specialty areas and up until uh two years ago we have a standard of five OR nurses uh in our operating room here to run our three ORs we have five nurses and three of those nurses were travelers for almost a full year and we hired three young nurses out of the VTC program put them through a year-long residency paid for them to go through the association of operating room nurses program as well that was an added expense for us but these are local women who want to stay close uh and who are flying on their own and doing a great job but you know that was a year-long commitment of paying both them the cost of their program and a traveler to backfill them because they were learning on the on the job and you had to have you know we're working nurse beside them um which goes back to why we're one of the reasons why we have to be so particular about our travelers is we are so tightly staffed that travelers sometimes are helping us orient and train new nurses here thank you um i have a couple questions related to the commercial contracts but i think those are likely uh necessary to go into executive sessions so i was thinking i would hold those for others to ask their questions chair foster yeah i think that makes sense um i have just a couple myself just jump in here um well first i wanted to comment that you know i know you have felt that it's difficult given the rate increases that you have not received but i will say the positive of that is i think it looks really great for the state and for coply that you have kept your costs down your operating expenses have been kept low your your your data looks good so there there is a benefit and i know it's been maybe not as easy as one would hope but we appreciate how well you've controlled those expenses so thank you for doing that um the one question i had was on the budget cuts that were in um your opening statements were were any of those enforcement based or were they all just in the budget hearing process are you talking about the budget cuts to rate increase or to capital that we chose specifically what which what are you looking for to rate increases those were green mountain care board us going in asking for x-ray and then um after deliberations that was the rate that we received okay they weren't a performance year than a cut because of the knock okay no it was i mean do it's it's not your history a lot of people on the board it's not mine but if you go back it's surprising like if coply came i think they had years if not asking for enough but even some of the recent years coming back they asked for zero they got negative 3.4 they asked for zero they got negative you know i mean they're it was pretty dramatic in terms of how little you know and when you cut that much i mean that our our biggest problem is we're running a negative operating margin for seven years if you don't count the covid money so maybe six years if a lot it's it's not sustainable i mean we're we're not a going concerned to even give us loans so that we can improve our cash because people look at operating margin and cash if you're late on both sides we don't look attractive it's kind of a downward spiral so i i appreciate the accolades i wish i could afford them uh you know and maybe there's stuff we can learn or you know i i'm always thinking strategy like what are we doing wrong is there something wrong with our it system is there something wrong you know i mean i'm trying to look around like what is it that would make such an orthopedic hospital specialty hospital to just be performing below lackluster like that i i don't know that answer oh i'm still looking for that right yeah in terms of the grow your own programs in the nurse residency program what when did those start we've now graduated two classes so two years ago we started um our entire nurse education department is two people um and one of those people works primarily for btc they're their clinical instructor um so we started i think the first year we only had four students uh four nurses in the program and we've expanded it uh this this past year to seven i think made it all the way through just a couple things and then don't jump in so we we now use emt's in the er yeah right which we never did to keep the cost down so listen to the trialing that we pilot these things to see if they work to keep cost down our nurse managers many of them are taking shifts and actually pitch in i know this sometimes comes in on weekends if not nights to fill holes so we are asking a lot of leadership and they're doing that the house supervisors actually will pitch in i think we're really asking people and they've been very gracious to sort of see what they can do to help out so our um some other examples is dr cunan adam cunan our cardiologist is being contracted as a 0.5 fte to northwest medical center that's part of the v can process so we have uh you know we've contracted out our one of our cardiologists part time there our cno is actually the cno at coo at springfield hospital so we've contracted her to help out it helps me on the cost side people become very flexible they learn a lot they they get perspective so those are a few i can think of i have to think of others but we really try to it's not one answer but everybody pitch in what can we do we know labor's our biggest expense but how do we make sure that we're you know asking everybody without just hiring but at the end of the day we still have to hire we still need people but you've got to comment yeah as far as the uh the the grow your own um it sort of it there's a lot of different phases to grow your own copies been a clinical site for norwish and DTC for both RN and lpn nurses for for a long time i'm i def i remember when they all get sent home during covid in retrospect that's kind of hard to understand but uh seem like the thing to do at the time and uh these programs are they're these programs are tough for a small hospital that does generally try to run as lean as we can while keeping our quality where we think it's acceptable but we've had a long commitment toward that and we've really done nothing but make uh our commitment involvement kind of more robust and more rich and we have a lot of lots maybe four or five nurses now uh that are integral to our operations that started out as medical assistants or basically runners you know years ago and we i'm just remembering some things so we've shared chaplaincy services with the home health and hospice caffeine can invest we have we do so much of this we don't really think about it and also some quality work we've sort of shared to sort of help you out with quality we've shared staff with the manner the nursing home across the street i mean we do try to pitch in just like hiring somebody as much as possible um probably also did a nurses aid program too and they allowed my staff from home health to come and be part of that class so they trained them so not only did they gain nurses aids i also did so it was a good collaborative yeah approach to and that program's run two or three times i know yes we are on the program three times now we've sent a couple local kids off to scrub tech school happily paid for them to go with the commitment that they would come back and work with us two of them one of them we sent out of our kitchen another one i plucked out of the community per se they got into the excellent program over in concord and we committed to paying for that program for them and now they're working with us here um we're actively looking at someone in our lab who would like to expand her horizons that we're also going to do the same things send them to scrub tech school so um you know we're constantly looking for ways to keep people motivated to stay here as well we are unionized uh environment for nurses and so we have to stay within the confines of our contract but we've done all kinds of things like create things called flex positions where if you're somebody that used to work in the emergency department but now you work over in the recovery room uh we'll give you a flex position which pays you a dollar more an hour if you're going to be if you would be willing to flow back over to the emergency department and work if they were um you know tightly more tightly staffed over there so we're constantly trying to work with union leadership to come up with ways to keep people motivated um and to stay here and to grow professionally um you know we're a small place but there's lots of we're trying to make lots of opportunity here for people so that they don't feel like they have to leave yeah i i think like we don't keep a running list we just try to do this because we have to but i know that we uh not only do the birthing center nurses sometimes flat out float out to med surge but we actually place on expecting moms in the birthing center when they're not busy so we bring them up to relieve lisa's area because she's like you got to help me out and so we put people in our birthing center all the time and have the nurses float back and forth so i will say that the union leadership the staff we all get along we actually figure this stuff out there's not a dire you know tension between the union and us we're all trying to figure it out to make sure the hospital stays vibrant we can take care of patients so i just want to put that plug in because everybody really being flexible in a lot of places they don't float between disciplines like that most hospitals do not it seems like you're really innovating and doing a lot with what you got and that's where it does pull through in your numbers i mean it does so that's great um shifting gears a little bit one of the statutory factors the board um in our statute for review is is marketing costs i don't think we've requested it necessarily but could you as a follow-up could you send me um any data you have on the marketing spend absolutely the marketing is not an allowable is it an allowable cost in the chemistry course some of it is but development is not right yeah raising advertising yeah average so some stuff is some stuff isn't i will bring up a age old suggestion i've always had that um because i care about your job and what you do because i'm a i'm new to the state i've only been here 40 years but i consider myself you know committed to vermont 40 years is maybe enough i care about my tax money and then the somewhat thankless work that you guys have so i do want you to be successful all of us but i think the idea of having a single auditor because i've listened to a lot of hearings and i've seen stuff over the years where you always end up saying well what did you do with this expense or what did you do with this revenue where did you put your 403b revenue and there was a hospital for years that put the 403b revenue 340b sorry they're so close 340b they put it below the line right yeah so for years the hospital is putting 340b revenue below the line now i don't know if anybody knows what that means maybe sarah does but it's like wow you put all that below the line but nobody bought it and so i'm a real proponent to say you ought to have an outside audit firm and maybe we should all pay for it but you you're asking great questions but so much so often you're like oh you guys interpret it differently so oh and your question's great but the definition of what it's considered you know what marketing or advertising again it would be nice if that was really clean for all of us yeah no i think it's a fair suggestion it seems like there's a fair amount of variation between how people account for things and i think it's a fair suggestion okay well yeah i'd appreciate that if you guys can follow up on it if you have it after this i don't have anything else and thank you guys very much maybe i'll jump in i have a couple quick questions how are you all good thanks good i'm wondering if you this is i suspect this is a follow-up question as well and sarah alluded to it already in her conversation but if you could unpack so your your delta on your expense operating expense is about 14 percent from from fiscal year 23 budget and i'm wondering if you can break out what that could like do a little anatomy of it what is from utilization and then what is cost inflation so you know what are your assumptions about wage growth for your existing employees you know medical and non-medical what are what are your supply inflation assumptions about both medical and non-medical supplies utilities purchase services pharmacy all of that so we can really understand the cost inflation the price component of it separately from the utilization component i think it would be really helpful for us to understand the 14 increase and also if you've got a way to think about it from actual you know projected fiscal year 23 to fiscal year 24 that would be helpful as well yeah jessica can i ask kind of like that old schedule that used to you know here's where you are go through make all the changes yes yeah that was really helpful to me that was that i could you know follow the numbers there so that would be really helpful thank you what happened to that old schedule it wasn't asked really sure oh okay yeah i know i know because i've got some numbers in front of me but i know on the you know the staff salary increases they're significant because we had a three-year contract review for nursing right as covid just started and then another hospital close by with a lot of staff and there we do and uh they were 300 higher per year than us so the pressure on us from some hospitals really throwing a lot of money is going to come do it's coming to uh we we have no choice it's on the market it's pressure on all of us yeah on all of us right it's bills thank you happy it's all the partners yes so cdmc just unionized i'm sure you're aware of less than a week ago so we are just entering a negotiation year here our contract is up at the end of the year and we'll be in negotiations so it'll be very interesting to see what happens you know they're pretty close to us and you know see what happens with their salaries for nurses there and how that'll affect our negotiations here with our union yeah and if some of this information you need to because it's you're about to embark on negotiations with your union have to be submitted in confidence i think there's our legal team can evaluate that but it would be really helpful for us to understand where is this expense growth coming from yeah that's a big part of it that's one of them that that pressure is pretty destabilizing yeah yeah it's dramatic the differences much like the charges and prices sometimes a pretty dramatic yes uh is it possible for you to just put up there was a slide that went by so fast i think you had listed all of your areas of specialty is it possible to just re-project that for a quick second yeah um if you guys i'll share the screen sis the slide that you were looking for it is yeah okay i'm just actually wondering because i was just this went by so quickly for me but um i noticed that there were a lot more areas of services here than in the visit lag uh data that was submitted and so i'm wondering it and some of it i realize is impatient related but to the degree that some of these are outpatient services we have cardiology general surgery infusion ortho neuro and the women's center are the only services that um there was data provided about the visit lag so i'm wondering if you might be able to as a follow-up submit that for some of these other services you know particularly areas where we know there are pain points and neurology being obviously one you know pain management has been won around the rest of the state so trying to get a sense of access to some of these services more broadly than what was submitted in the narrative yeah that's helpful i didn't know we were reporting pain management was not our service that was an independent provider that we rented clinic space to but we listed it up there because they come to sort of copy neurology we can give you that that used to be across the street it was one of those provider transfers a couple years ago but we'd be happy to provide those okay so some of these are not no longer cobbly provided services on this list well neurology came over to us so we absorbed that one so we have that data pain management is kind of a little bit languishing because there's a void and we have we've put our toe in the pool we haven't fully committed pain management clinic but we're trying to figure that out because it was a service for a long time gastroenterology we've folded that into general surgery so there's a few new odds is there but i know a couple of hospitals put up a slide like this i think it's interesting maybe every hospital ought to have a maybe you guys ought to have a spreadsheet to say every hospital at least critical access hospital so let us know what you guys are doing yeah and h-rap is you know another process by which we're trying to gather that information and take an inventory of the types of services that each hospital offers but it would even be helpful to understand wait times for urology and gastroenterology separately from just general surgery so if as a follow-up that would be really helpful and the other i guess request that i have is referral time what referral lag wasn't submitted and that's you know the difference between one referral is submitted and when the appointment is scheduled and i know you're redoing your emr so if it's an emr issue i would my request would be as you're redoing your emr to start capturing that data and i say that as a patient who is now waiting over three weeks for an appointment to be scheduled so i'm three weeks into my referral lag for a particular specialty service so sometimes the referral legs can be just as long as the visit legs so we're trying to begin to track that data and understand where the pain points are so if it's not possible now would you be willing to make it possible as you're restructuring your emr or if it is possible could you submit it i mean with all these you know we'd love to make sure that we're all on the same page you know like with definitions as well so maybe you know what you're expecting if you could you know get that to us as well sure i think yeah we can yeah so yeah yeah dr homes like there's one of those things that and this came up a lot in in your work group the greek mountain care force work group about it so it's a very hard thing to look at apples to apples because it definitely depends on what the acuity of the referral is is like we can almost see you the next day if you really need to be seen the next day and it's so there's all this well it's multi-factor yeah that's how that works out so good luck and i understand that there's some you know there's some triage that happens when there's scheduling right absolutely i understand that and that's why it makes it's helpful to make a comparison across specialties or within a specialty across hospitals right to some degree yes the acuity could be different at each hospital but it just gives us a starting point to see where some of the pain points and access access is one of our you know areas that we have to focus on so we need to understand it better so recognizing that no data point is perfect and that there are you know needs to be nuanced in the interpretation so if it's defined as non-urgent when's the next available appointment if there's not an urgency to it might be a good way to start yeah that's a great you're going to be super discouraged when you see the data though because you're going to say that's crazy a lot of a lot of people do have to present with much more urgent need you probably all know this i think everybody knows this but i know in society if you can't see a doctor about an issue some people just show up to the e-art so you probably know that that's uh that's a that's some doctors will even say just go to the e-art they'll start this was raised in a hearing just the other day right so absolutely there are primary care providers that know about the wait times for imaging and the prior authorizations associated with imaging and they're sending patients to the er to have that imaging done or to see a specialist because they know that the wait times are excruciatingly long so we need to start understanding this and understanding if some of the ed utilization that's growing could be related to you know wait times elsewhere so trying to start tracking the data so it would be really helpful however you might be able to help us with some of that data we'd appreciate it um you know something in the narrative found really interesting so it was related to some of the transferring of patients out of the ed the borders and there was mention in there that medicaid started reimbursing $200 a day for ed borders that have you know mental health conditions and could not cannot be placed in inpatient psych but coply chose not to participate because of the administrative burden in getting that revenue so i wanted to just understand that a little bit better what was the administrative burden associated with getting those dollars in for patients that are boarding it was basically you know when we took a look at the uh the requirements all the paperwork that would have to be filed and all the criteria that have to be adhered to it was that type of uh it was additional expenses on coply that you know we just basically at that time could take on we didn't have the staff to be able to do that appropriately so if you i mean per patient how long what was what would you estimate the time it would take per patient to fill in the paperwork i'd have to get back to you know what the individuals that did that study okay i'm just curious because they were the you only the you were the only hospital that mentioned the administrative burden at least as far as i can remember um so understanding that and and maybe there's a way that we can send a message over to diva that says like hey this is you know maybe there's a better way those were i think um yep those were my questions thank you yeah good afternoon this is tom walsh um i don't have so much of um so many questions but i do have um some comments i really want to thank you for the the data that you brought in the quality data uh that you presented is um the type that we'd like to incorporate more of in future years um high quality low prices are something that um i think we want to be able to um not just acknowledge but celebrate and encourage um your operating expense growth was less than or around less than or equal to half of your revenue growth that's outstanding your the ratio of admin to clinical uh salaries was below the median also outstanding you know the new numbers that we brought in uh this year through the cost report um you you joked about it but you look really good and yes there will be variability in how people fill the fill those forms out but unless that variability is systematically biased among some of the hospitals that'll average out when we look at big groups and where you are will stay relatively the same compared to other groups that's how averages work and so you're you're doing some really good things and at least from the number perspective um and um i just wanted to acknowledge that i think that that's that's excellent and the struggles with the with the uh traveling staff i think finding ways to um you know there's an there's an old saying that i've sometimes been annoyed by so i'm surprised that it pops to my head but um you know continuing to do the best you can to train and retain the staff that's available to you um i hope you keep trying to figure that out um because you you're doing so many good things and that the turnover that comes from traveling people in and out is not only expensive but it has cost as far as quality safety and reliability and so just some kudos i know that may not come often from a regulatory body um but you presented a lot of compelling information today so thank you thanks very much appreciate that so i think i'm last up here for questions um i've got a few for you all uh i guess the first one when you put up your slides initially with the change of your prices with the 15 percent would you be able to put those back up again in the before and after they went by quick so i i just thought i saw something i i just wanted to make sure yeah i saw it right oh sorry yes that one there's your this one that's the post that says this is the one that if we applied our 15 percent and leave every hospital yep some some hospitals don't have their data even available that's when the blanks are okay so uh your semi-private med search room there is $1,300 a night and then go back to your pre 15 percent it's it's just $1,300 a night that kind of stuck out to me that there was no no no change so i think i apologize i'm probably missed okay i was just well it may be wonder when you're looking at applying the the commercial rate if you are going to apply it to both inpatient and outpatient i i don't think i saw a breakdown of your intent on how that commercial rate was going to be applied so breaking down our rate increase between inpatient and outpatient unless you're going and targeting the the room and bed rate is kind of a difficult um difficult task when we look at our charges we look at it more as hospital versus clinic and due to the clinics actually you know adhering to fixed fee schedules we don't usually and i believe we did put this in our narrative i put the rate increase to the clinics but we'll put them to the hospital charges so a good example is when you take a look at those diagnostic imaging you don't know which of those are going to be inpatient and outpatient so you just raise as an individual okay um so you would seek for additional revenue for an inpatient stay that would just sort of be part of the yes the charge okay thank you um one of the other questions if we this slide is is fine to go on too one of the big um areas of revenue for your hospital is orthopedic procedures and i was wondering if you had orthopedic procedure data compared to peers in a similar fashion to this so you're just looking at the cost for an orthopedic type of yeah or that yeah that i guess um is it your prices or is it your cost or is it your revenue i would say it's the the price the amount of money paid to the hospital i guess is my my interest in that well every this is where things get really complicated i mean the price is what we put out there on the bill which goes to the commercial carriers goes to medicaid medicare we don't charge you less the bill is the bill and it's going to be applied to everybody from there you go to the commercial machinations to figure out what percentage of charges they're going to pay you know the other machinations so well how about in a in a similar way that this is presented has that to to to not confuse things oh you mean in terms of actual prices for the whole for yeah for orthopedics we'd have to look at uh professional fees and then the technical fees some of the technical fees could be part of existing prices so jeff would have to sort of do that construct it'd be nice if you we asked a few people to do that you know we'd find out the accounting errors but it'd be nice to sort of say hey i wonder how much it costs a few of the hospitals what is it to do a total shoulder or a total hip or a total d i can appreciate it it's a big it's an expensive process and procedure and you're actually dipping into something called medicare price transparency um and it's something that i think medicare's finding is not as easy as they thought it would be um because it comes down to it um how people classify code charge is so different it makes it extremely complicated for patients that are trying to look at this data to get meaningful understandings one simple thing is like what joe was just saying does that cost includes professional charge well if that professional charge is you know a private practice doing the procedure you're going to get another bill um from another organization not from properly um in addition what makes this data very difficult to look at is our critical access that it's and if you're a medicare patient it gets into different billing guidelines we are a critical access hospital that bills method two so it's really just an incredibly challenging number to get at but the price is still the price and if you look at cpt codes i think you're making it like we should we should spend the time to understand this both the cpt code professional fees and maybe taking a dozen people that got total hips you know asking to audit like can we get i don't know i've often thought about putting in the paper would you mind sharing your bill like somebody ought to put the paper hey you know we'll give you ten dollars if you share your your total hip chris bell to sort of look at it it's good it's a great question i think we could maybe i'll take a peek at our we have a price transparency calculator available to us and also the insurance companies do so it might be just an interesting place to start um one of the other things that i'm trying to sort of just understand is on um sit on the utilization slide that sarah had put up is it's a kind of a complicated slide because it shows um change in utilization and so in one year it was 40 something percent and then followed by something in 30 percent you know again this is sort of a complicated data source with your model of business um but i'm trying to understand when you when i see those high utilization rates with some provider transfers in the budget that your utilization projection for next year of 3.2 percent it seems awfully low to me compared to your recent historical performance your ed utilization you set us up with these new ortho people well with a new ortho provider i know eros is kind of he came and he went and came back but uh if you could sort of try to help me understand how 3.2 came about when we have these these higher numbers kind of kicking around yeah so again i think there's a lot of um data going into uh you know um sarah's numbers and sarah if you could those volume numbers are coming from adaptive okay and so again when you see um you know the uh that spike um from i believe it's 20 to 21 go up um i think a large part of that is due to our EMR conversion but then when you see that number come down from 21 to 22 that specifically right there is a representation of um us starting to ramp down on that provider that we're talking about it was due to our orthopedic provider um basically um you know running to patients through the OR let me just sort of interrupt from a sec because this this where the where this gets to be a complicated figure is that's actually changed from the prior year so that well at 21 you're 50 above 20 this is saying in 22 you were 36 above 21 so utilization is still increasing this is where i i had the same look because you have on your face and you're very small to me that those are incredibly high utilization increases so this is basically you know if you're up 50% one year and you're up 36% the year after you're up over two years some very large number yeah we would have to unpack that i see what you're saying uh yep i don't understand what's it so this is both operating expenses net patient revenue and utilization right right what's but what's behind those utilization numbers utilization of what exactly yeah so as you might be aware it's awfully difficult to count things outpatient um and so what we do is we get an uh adjusted discharge uh value by taking the reported uh inpatient discharges uh getting an average charge using that charge uh and then applying that proportionately to your outpatient revenue and when appropriate sniff and swing beds you know so so so for outpatient revenue goes up dramatically because we're doing joints as an outpatient then when you normalize it that's going to look huge when it might not have at all yeah yes yeah and if you figure out a better way to count outpatient services please let me know so yeah that would be the medicare then change going from inpatient to outpatient for our joints which could be cause i'm not a great deal of that but yeah and i appreciate it okay i appreciate you bringing this up dave like anytime we see aberrant data points we'll study them and then sometimes like i don't have time to study it but that's a really good question and it could be how we come up with adjusted discharges so historically hospitals had high inpatient high inpatient revenue outpatients was a small percentage of it when you sort of how do we count these you do this adjustment on the inpatient side but don's right if you look at numerator denominator i think we're probably whack a doodle that's his term uh because of the outpatient but we should look at that i don't i don't we should really understand that because that's the only thing i could think of is that calculation methodology doesn't work when you're going that far that quickly to the outpatient basis so that the third side to this square and maybe the fourth side is what i'm trying to figure out or just make it make it work maybe it's a triangle is the exhibit 10 when i look at the change in net npr fvp 23 24 it's broken down by rate and utilization and the vast majority of your increased revenue on this appears to be rate versus utilization but i think we've been talking about a lot of utilization changes and so i'm just trying to understand why the utilization projections seem so modest compared to you know that the the rate projections because i you know you're doing a lot of outpatient procedures that should generate i would think would generate a good amount of revenue like if you look at the outpatient part you've got 6.5 million due to from 22 to 24 due to rate of commercial revenue and 720,000 due to utilization it just doesn't i guess that just it doesn't make sense to me from what you're saying about your increased utilization i i agree i know sarah's chart that she just showed us was not just utilization there were three descriptors right in the top sarah it had to do with net patient revenue expenses and utilization so if you look at her chart read the top of it it has three factors we call it utilization and we're boring into that but there's three appears to be three factors in that calculation so i don't know sarah help me out lifeline anybody um yeah i'm sorry maybe i misheard but i thought dav was talking about exhibit 10 yeah yeah which one is exhibit we don't have exhibit 10 that's what we submitted yep yeah uh i can pull it up i don't we have exhibit 10 is that ours it's through it that um just the right here yeah it takes dr berman's points well take it that yeah yeah it's a good point thank you yeah that's great because we're gonna have increased utilization yeah so this is trying to kind of dissect how much of your change in npr and gpr is due to rate versus utilization versus pair mix and so what we see here is according to this exhibit most of it being driven by rate yeah and that coincides to what we communicated you know our utilization is only going up three percent and so this schedule reflects that but again it comes back to you know that utilization indicator what will totally take that and put it on its ear is if your patients don't really change i.e. you're not getting you know um you're getting the same patients but they're shifting from an inpatient environment to an outpatient environment that is going to greatly change your adjusted discharge number just because of that that the way it's being calculated okay maybe would you take a look at this with sarah and make sure because i know that there were some issues with the exhibit nine with the commercial insurance medicare advantage component that you fixed and yeah we'll get that this is yeah this is the older one yeah um would you just take a look at it with sarah and and see if it it seems accurate thanks um uh i guess i just have just one more question which is um which is really something you mentioned in the in the hearing today and in the the narrative about the decision to stay with your current EHR instead of switching to sarah and i believe this is 2019 and i was just wondering if you could um sort of comment a little bit on what drove that decision and what the with the financial impact of that decision is either in in cost avoidance or in predicted uh you know a lot of people switch EHRs to try to increase their their billing and coding and and financial performance if if you could sort of comment on the financial calculation of not switching um thanks dave i'll take that so worked in six hospitals i used to be president of the wingland healthcare information management system society for the six days my background is industrial engineering i studied for trans 77 and no human factors engineering i was an industrial engineer in manufacturing um people don't fully appreciate that much like in any relationship that starts to go south you're half the problem perhaps in the relationship maybe you're more than half the problem maybe you're 70 of the problem but when you look at an it system oftentimes we just are very um dismissive and say that it doesn't work what's wrong with this printer oftentimes we'll call it people who say well you need to turn the button on because it's not on or did you read you know what I mean so there's a lifetime of a culture in america where we are very unwilling to read the manuals figure things out and get the most out of the system and we just change systems so i've been in hospitals that do that i've seen a lot of hospitals and do a lot do it through the green mountain care board public oversight committee process they have spent millions and millions of dollars i've never seen a hospital change an it system and be on budget they're never under budget they're always over budget dramatically every years ago quarter i think had a three to four million dollar estimate theirs came in at seven million dollars and porter sentences moved to epic i have a lot of friends and acquaintances and people that have changed information systems and they're not learning that they are part of the problem with the current system because they're not understanding it changing their behavior understanding the features and getting the most out of the system it's very rare for somebody to say we're going to get the most out of the system before we just jump when they do jump Dave more often than not a year or two goes by they're very frustrated very angry it's expensive and they blame the system and they sound like they were the complaining partner reconversion so i'm not a big fan of jumping out of an it system unless we really understand the value because um learning the features reading the manuals working on understanding if you're going to make any changes or how to do interfaces or how to manage updates looking at my it fellow here who's shaking his head so so Dave we decided not to do that because the expense of going to a cerner would have been staggering and we did not have the discipline of using an it system sufficiently so we're working on flexing those muscles i will tell you maybe maybe two to five years from now we might start and say okay we're going to look for a new it system maybe two to five years from now we're going to have that drive interest in learning and we'll say okay it's time for a new system and i think we're going to participate but you know these hospitals well you just you'll you'll find it out or you've seen it through hospitals that change information systems it's wildly expensive when i worked as part of the mass general system as part of partners on martha's vineyard hospital which is listed as the largest days cash on hand set right in your charts which is really hustling but martha's vineyard hospital was getting epic and the price tag that we had to pay at one point the estimate was this was 500 million dollars to convert the hospitals over that went to 750 i was there for a short period of time it eclipsed one billion dollars and it got up to 1.5 billion dollars for the conversion price estimate that started at 500 billion this happens everywhere so i wish i don't think we could afford it day we couldn't afford it money wise we couldn't afford it emotionally we couldn't afford it intellectually but i'm hopeful three to five years from now we might be at a place where we're strong understand what we're doing and say listen we really should buy something i don't know what the buy is though i wish epic would give an epic light software installed to small hospitals there's only 1400 critical access hospitals in the country i would think epic or some others might come up with a more abbreviated version because we don't need the complexity of epics so i when i got here i said we're not doing it we can't afford it but we we definitely couldn't afford it sorry for that long-winded answer doctor hey i thought it might be do you have a do you have a numerical analysis of it oh for us personally yeah no i could send you some articles from hymns that's thank you that is that is all i have thank you so much any other board member questions i'll just say i think i think i will skip the executive session given the time since we're towards the end of our time unless anyone else is dying to to and has some questions otherwise i can i can forego mine i think i think i'm okay um you might be able to get the information another way potentially if we need it um but okay um i'll turn to the health care advocate for any questions or comments yeah good afternoon um sandpiche the health care advocates office um i don't think this is an executive session question i hope it's not because i do want to keep to time um but i'm just wondering if copley has made a decision about participating with one care yet i know in your narrative you'd said in the summer you'd make a decision so i wasn't sure if you had so i wanted to ask so at this time um we you know for our budgets um the budgets have been built with the assumption that one care um you know we would be um you know uh in one care but at this time we have gotten a uh a delay from one care to make that decision so we're going to make it at the end of september really looking at the pros and cons the price the issues of revenue fees value in one care and i think a lot of the world has been turned upside down with one care and um we're we're having we're having those serious conversations about whether or not to continue but i don't have any answer yet okay thank you so now i wish i had great um any public comment all right uh seeing none um mr wooden i'll turn it back to you and your team if you have any closing remarks you want to leave us with no i i appreciate listening to our challenges i'm glad that we're cost effective i really stress about trying to understand if we can afford that and how we move forward just because we've got some dire capital needs we did replace our mr i we had probably the oldest mobile mr i in wingland it was so old uh we've we're trying to invest in the back infrastructure i think the clinical care we deliver is amazing i think the staff and the competency around true clinical care and even our experiential care with patients is amazing there is a lot of other stuff related to equipment buildings um where we work it infrastructure there's a whole bunch of stuff that it's just really is screaming for some attention so we've been trying to address that i wanted to ask nancy as our board chair or kathy also if they wanted to add any other comments uh just to really appreciate them being here so you want to yeah i mean i just would like to say copley is really important to this community and not only to the whole community but as the health care community we depend on copley for a lot and i know running home health i can call over here anytime and get the help i need for anything um i can call dr dupley because one of my nurses has a question and he gets right on the phone um we share expertise back and forth um i have a nurse that comes to discharge planning so we make sure there's a smooth transition of care back and forth um we get to use their tent outside for our own staff things i mean so they share everything with us that we could possibly need um and it's just so vitally important to this community that whatever we have to do to keep it whole and keep it functioning the way it is is what we need to do so thank you for listening to all this and how important everything is here for all of us yeah and i guess that i would just say that the community connections first of all you know i would share that copley enjoys this very special place in this community um which i think even the medical staff would agree is very unusual that hospital is so beloved in the community but the board understands that we're not a standalone organization and at our retreat in october we're really going to be thinking about how we can really do even more engagement with all the other um health related organizations within the community i think we have a lot of pride about how we do interact but i think that we realize that this is something that we need to continue to work on and it's a continuing challenge and so it's going to be one of the focus areas of our retreat um to look at community connections and how we continue to deepen them to avoid duplication of services and ensure that we are actually providing the services that are needed by the community thanks i know dr decree wanted to make a comment yeah one of the things that i think is pretty easy to overlook um and i know i often do when when joe talks about capital needs and crummy looking pipes i know some of y'all have been here and seen some of them um is i go yeah that's that's i'm sure that's very important joe but really what does that have to do with patient care um and i know i felt exactly that way when some months ago uh joe uh when uh delivered a project that gave us an alternative way of getting potable water into the hospital and i thought okay that's nice but what does that have to do with patient care except when we had the floods and the morrisville municipal pumps got flooded and therefore our water was sort of thought to be until we know otherwise contaminated and we couldn't use it the only way we were going to stay functional as a hospital was getting gigantic tanker trucks with fresh potable water hooked up to this brand spanky new system of getting potable water into the hospital with the with the booster pumps that allowed the hospital to still be a hospital during that time so you know even things that just hard to see the utility end up becoming completely useful because we would not have been on hospital at all for a week if we didn't have that and it's and we couldn't have sat here and told you last year how important spending money on one thing would have been anyway so thanks a lot yeah thank you everybody appreciate it thanks for your time thank you thank you for your time um i think that's all we had in the agenda so is there any uh new business or old business to come before the board and is there a motion to adjourn second second all those in favor please say aye aye aye aye and um we are adjourned