and Jill, whenever you're ready, you can just proceed. Great, thank you very much. So it's great to be here again, and I want to introduce the team that is here. Robin Elvis, I don't know if you've all met her yet, but she is our financial officer on week three. She'll certainly get a great orientation today. And with me is Stephanie Brawl, and I know you know Stephanie as our director of finance, and she'll be co-presenting, and we have lots of folks here that can actually answer the questions. Jonathan Billings is also here in the audience. He's the vice president of community relations and Rice Ramont. Dina Orfanitas is a new face to us as well. Dina is our chief nursing officer and joined us in January. Amy Putnam is here. She is our vice president of physician services. Devin Batchelor, who's behind me, is decision support and budget manager. Dr. Gregory Grophy is also here. He's the executive medical director for our physician services. Joanne Manahan is in the audience. She is our manager of our emergency department along with Paula Swartz. She is the director of our primary care and pediatrics practice, and just recently joined us. And also with us taking a great time and effort to get here is our board chair, Leigh Ann Berthume. So grateful to have Bob Leigh Ann here. Oh, Nick Haddon. Hi. I was looking for you. No, Nick Haddon was also on our board as well. So thank you all for joining us. So I wanna start off by really talking about the pride that I have in sitting here, the pride, the determination. And I must admit, last year when I presented, if you remember the Claude Van Damme picture, it was really my picture split between two of these big trucks. You know what? And now I sit here before you and wanted to know that that split is actually really painful. And we're feeling it in our organization and we'll talk about that, but the hope that I have with this amazing team to continue forward, to pave to lead our commitment is endless on this journey. So with that, we are nationally recognized. We're proud of the things that we're accomplishing. We also know inside the organization that we're working extremely hard to be lean, to be ready for this future and we're proud of those moves as well, but it's hard and it's challenging as we move forward. We're courageous in so many ways. We're balancing the care that you've heard a lot about in the previous groups. We're taking on risk at the same time. We have the same story of trying to ensure access, that recruitment and retention. Investing in the future of population health, which is really where we all need to be going and we can't do it without partnering in this transformation. Inside our organization, no more silos across our community, all for one and for the care of our community and regionally and across the state. With all of that, we're suffering. Our bottom line is challenging us. This is the third year that we're here talking about our bottom line. The environment is complex and really it's about aligning our priorities and our incentives across our system, in our community and also across the state. And I hope that we can do those things even in differently as well. So hospital issues, you wanted us to talk about those and the wage, pressures and the medical inflation is certainly going above the cap. Five and a half to six percent on the medical inflation so it's certainly hard to manage those expenses under their revenue cap. Recruitment and retention, as you've heard from many, keeping top talent in this time of shortage and uncertainty, people are questioning us differently about what we're gonna look like going forward in the future and how we're going to actually even pay physicians in the future and as we move towards capitation. So certainly you wanna make sure that we're hiring the top talent but folks that are leaning in to help us try to figure out this future because it's clearly not the same. When we think about recruitment and retention of top talent, it's so powerful to over communicate what's going on. So folks understand how the care or the service that they're providing is being so impactful in keeping the care local in our community. As I had a CEO round table just earlier this week to describe the changes that we've just done over the past couple of weeks, we've reduced some staff, one is too many. We did this in March, numbers aren't high but again, one is too many. To be a CEO that can say that you're not going to have any layoffs is a powerful statement and it's disappointing I have not been able to live by that statement. It's coming too fast at us and the challenges are great. At the same time as I described to staff and try to answer their fears with clarity and heart, I've been talking about why are we investing in something like Congress and Maine, building on Main Street of St. Albans. It is about recruiting and retaining. It's about education. It's about having 27 more graduates of nursing in St. Albans that can fill our fast turnover. I know Joanne Mannion's in this audience and she's been here 44 years as a registered nurse. The nurses that are going to school now are staying about 18 months to two years because it's other things they can do. How do we get them engaged and continuing on with us? The pace of change is exhausting our staff. Not only how we think through innovatively going forward but as I sit here for very complex behaviorally challenged patients in our emergency department waiting placement. And the patient on the progressive care unit on our inpatient that we almost can't get close enough to four assaults on our staff to try to manage the pressure ulcer on his heel. This is really what's going on. And then the medical record, you would think it would be so cool to integrate the medical record and it is people talking to each other across the system. Our ED saying isn't it fantastic that they now can talk to primary care and understand as a patient comes into the emergency department what their care has been in the community. They're saying thank you. On the other side, our primary care and pediatricians in particular are so exhausted and strained by this electronic health record that we're needing to plow in additional resources. We're losing revenues, decreasing access and the dissatisfaction of our providers is undescribable. Aging facilities, I know you're going to be reviewing the CON for us with our emergency department that tells that story. Our aging population, it's bulging as certainly as they come through with chronic condition. We're managing that. We're also in that Congress and Maine building besides a sim lab and nursing students having lifestyle changes, a demonstration kitchen, working with the food shelf in Martha's kitchen, helping people to use fresh produce and understand how to cook in their homes. Reducing and preventing chronic condition. The community case management that's going on. I know Laurel talked about the quadrants and how many people are in the quadrants of quadrant four. We happen to have more percent wise than anyone else and we are wrapping around it as a community. And prevention, the 46 year old that just last week was in our health coaching setting who weighed 350 pounds. In tears. Thank you for helping get my life back in my job. So ensuring access through employment of physicians. You know, it is building expense and it looks like our costs are rising but it's really about investing in the right access for our community. So everything goes around our community health needs assessment, mental health, addiction, obesity, suicide. You will see the list there. It used to be about primary care access and specialty care access. Now it's a list of behavioral issues and through our unified community collaborative and our accountable community health for our entire community coming together to solve this, the social determinants of health. Learning collaboratives that bring our community together and surgical optimization. As we think about lifestyle medicine and changing outcomes for folks and thinking about if someone is going into surgery now our surgeons are referring them to lifestyle medicine if it's obviously an elective and we're able to improve their health outcomes before surgery so when they go home maybe home is now a reality because they used to go to skill care and we're avoiding that cost now because we're doing prehabilitation so they're more ready and they're stronger when they go home. And Dr. Royer talking to Dr. Fontaine in a medical staff meeting and said I sent a patient to you who needed surgery and Dr. Fontaine knew that patient and Dr. Royer said that patient no longer needed surgery because of your intervention, reducing cost. The For All Profit Ambulatory Surgery Bob's Center. We have experienced a loss of a surgeon with that center. In fact, most all of our surgeries are outpatient because of the way we're managing and preparing patients and staying with best practice. What will that mean for us and our surgical program? The 30% capitation to 70% we're now going two years of the second 30% to 70% the 30% what is the path forward to get to 70% is certainly something that worries us. And then the revenue cap and then making sure we have the necessary future capital collaborating across our organization across the state collaborating with healthcare advocate. And we're glad that we have a meeting with you later this fall to really understand and to be better at how we handle our free care. Partnerships within our community thinking about this umbrella organization as we work with our board and leaders of other organizations such as home health and mental health and our FQAC what ways can we partner together align as we get prepared for a capitated environment that alignment is important as we care for the attributed lives together and understand where is the right care the right place for that patient. And I'm happy to tell you that we're partnering with the Howard Center as well with our addiction program and how we can actually co-locate those programs even with NCSS our designated agency so the door that folks walk in that need this care are going in the right door with wraparound services working in partnership together in the same space. Partnering with One Care Vermont partnering with UVM Medical Center on care with telehealth with enterprinology and other services that need to be provided locally for that wellness and prevention and the working bridges program with United Way our newly formed partnership. So we are redefining our future. We can no longer just cut our way through this. We're working with our board our medical staff leaders and our management teams with input from our staff and our community on what is the direction forward. This is going to take us answering questions of what do we invest in? What do we maintain? What do we change? If we've only had two ICU patients in the past week and a week before, do we continue with an ICU that we've always known? We're grappling with that. Should we have telehealth or are there patients that should be caused there in our hospital to provide that right care? Can we have intensivists through telehealth help our patients stay local? Because we know if they had their families around them then their health and their recovery will be improved. We have to grapple with that in the very short weeks ahead. Advancing technology, we've tried telehealth with occupational health, with endocrinology and others were on a path forward with that. And note that we have a violation of our bond covenant related to our debt service coverage ratio. Yes, a lot due to our Meditech circumstance I'll describe in a moment but also the use of locums and providers to keep our services available. You, as a result, have received a revised budget that was submitted. We had submitted a 1% modest operating margin as we have definitely had been our losing margins and with this revised budget it is a minus 0.2% margin. You'll hear more about that. So it's alignment. It's alignment across our organization and across our community, across the Green Mountain Care Board, our legislators, our payers, and the healthcare providers for all of Ramon, there's this collective impact that we're all shooting for and having the budgetary latitude because we are fueling and funding the future with hospitals and we need to be able to do that to continue this journey. And then there's Rise Ramon in balancing the chaos with the hope of the future and what we want for every community as you think about primary care and being the blueprint, the center of the healthcare delivery system, we think of Rise Ramon and lifestyle medicine and health coaching as the means. As they go out and do their work, their school, living in their communities, what is that community like? Is it embracing these changes that they need to make as individuals? We will be doing our second round of measurement studies in our schools this fall. In the Maple Run School, transformational policy development in their school that is moving their well-sat score from 33% to 82%, it really revolutionized a wellness policy in the school system and I wish that for every school system across the state. I watched them grapple personally as parents and board members about where we go with wellness. In the bottom one, this is a busy slide for you to review but the bottom one was Blue Cross Blue Shield, we're self-insured as you know, showing up and telling us as our administrator, there's something different going on with your employees. Yes, we do have some high-cost outliers but what they found is that those that are using our health coaching, we allow health coaching for all of our employees and their spouse but those that are using health coaching, there is a lower cost per person in the medical care of throw the $3,200 but you know what, they don't give pay for it. As we expand that out into our community and what's right for the gentleman who's 49 and 350 pounds, how does it pay for that? We're becoming frightened with our investment in population health. Okay, now I think the person's really fun. You know the person, thanks, thank you Jill and thank you all for having us here today. You asked us to speak about our net patient revenue and fixed perspective payment budget and I've heard some board dialogue and questions really trying to understand how organizations go about putting their budget together and how we come up with the rate increased request that we have for you all. So I wanna just walk you through this simple table that we have here. Where we always start is with our current year budget so for us you can see that number of almost 113 million and from there we needed to address a dermatology practice that was a physician transfer out of our system so this is a physician transfer that's really going in the opposite direction of what you're used to seeing. That practice was hospital owned and has become independent and is still in our community but we needed to take that out and so that really gives us our base or our starting point when we work towards putting a budget together for FY20. And the first thing that we do every year is we sit with our managers and our directors, our leadership team and our providers and of all of our revenue generating departments and we look at trends. We talk to them about volume and utilization to see what their thoughts are. We talk about providers that we know are coming and going and then we take a look at reimbursement from our payers and what we know is happening in that space. So we read the proposed rule for Medicare. We look at Medicaid and our dish payments. We also talk to one care and figure out what our assumptions are going to be related to the number of attributed lives and the percent of our population that will be under a capitated payment program. And then we say where are we in relationship to the cap that you have all established and provided your guidance with and that helps shape our rating increase request. So what we have is a 5.9% rating increase request and we'll talk about that a little bit more because we are putting together and submitting a budget even with our revised budget that has us at that cap we are not exceeding it. And then you have here listed of primary care transfer into our system. So that is separate and outside of the cap and again we can talk about that a little bit more later on in this presentation that that's the number of second from bottom. And that gets us to our total FY20 net patient revenue. So to talk a little bit more about the 5.9% because I've also heard discussion and questions around how do we implement that. And for NMC we really have two components to our rating increase request. So the first component is a 7.63% increase on our hospital based services. And the second piece to that is a 0% increase in our physician professional services. And we're doing that very intentionally. We feel it is important for a visit to a primary care physician or a visit to our addiction services clinic for example to remain the same. We want those to remain flat because we feel those are really the services that Vermonters need the most. And we feel it aligns with healthcare reform and really providing the right care in the right setting. The last thing I wanna mention is that we will not be applying our rate increase differently across payers. So you all know that we won't see the benefit of that rate increase from our government payers but we have not established one rate increase for Medicare and Medicaid and then a separate rate increase for Blue Cross or MVP for example. So it is the same across all payers. We wanna get into some key metrics with you all. And so this slide has a couple key metrics on it. It talks about again that patient revenue as we just covered. And that is the blue bar. And we also talk about operating margin on this same graph as well. And so that is the yellow line. So what you can see is that historically NMC's net patient revenue has met or exceeded our budget in most years right up until about 2018 actually. In 2019, we are not projecting that we will hit our net patient revenue budget but it is very important. I can't stress it enough how nearly all of that variance is related to the time period after May 1st which is when we implemented our Meditech ambulatory system and we've seen some challenges and certainly some revenue impact as a result of that. So this is an issue that we know is temporary and we also are working, I would say it's our top priority in our organization, we're working closely with Meditech, with our providers and with our staff to get those system issues sorted out so that we can get volumes and therefore revenues back on track and really back to a normal state for NMC. If you were to look at our net patient revenue through the first seven months of our fiscal year, so the information we would have submitted to you all that went through April 30th, you would have seen our net patient revenue be very, very close to what we had budgeted in current year. The operating margin on this graph is very concerning. It's concerning for us and I know it's concerning for you all as well. You can see the trend and you can see what has happened to our operating margin since the rate over correction in 2016. We are going to talk a lot about expenses because we understand that expenses are driver of our overall financial performance and of our operating margins and so we're going to get into that in great detail. But this trend is concerning and what we know is that hospitals cannot survive in the long term with negative operating margins. We all know it's really a two to 3% positive operating margin that is needed to be financially stable and to continue to invest in the organization. The next metric we have here is days cash on hand. So for several years, NMC would come and have the conversation with you all about days cash on hand and how it was increasing. And the conversation back at that time was that NMC was intentionally building up cash reserves in order to do some very large but very strategic and appropriate capital investment. So every organization in Vermont, it's on a different place when it comes to its capital needs and what is its age of plant and how long has it been since it has been a major renovation. And so we had positioned ourselves for that and committed to you that we would execute on a master facility plan that was largely paid for by our cash reserves as well as some other large capital projects as well. And that's exactly what we have done and it's exactly what we plan to continue to do in fiscal year 20. And so we're gonna talk about that some more when we talk about capital towards the end of the presentation. You can see that for fiscal year 20 and we provided a projection for fiscal year 21 as well that we will drop below the S&P benchmark for days cash on hand for an A rated hospital. Our strong balance sheet and our strong amount of cash has not only allowed us to invest in capital, we talk a lot about capital when we talk about cash but really it is also what has allowed us to weather the storm for these last three years and with our revised budget that we have would be a fourth consecutive year of having a negative margin. It has allowed us to sustain those losses and still keep the momentum of investing in access and in this transformation of the healthcare delivery system. And I just wanna know at the bottom here that these figures do include our ED modernization project certificate of need. So they may vary from what you have because as we prepare our budget we don't include CLNs that are not yet approved. But I wanted to show for illustration purposes here today with that included in the project which is 7.6 million. Okay, so here's where we're really gonna talk about expenses in our organization and the drivers behind our expense growth because we realize that we have expense growth. There is no denying that at NMC. And so here's a breakdown to help us better understand what's happening in our organization from an expense standpoint. So we've broken it down between kind of the base hospital operations and all of our outpatient physician practices. So when we talk about physician transfers we often talk about that as a revenue item, right? It's a revenue item that is excluded from the cap but what we don't often talk about is the expense component of those physician transfers. So if you're acquiring a practice do not only get to acquire their revenues but also their expenses. And so when we look at our expense growth it is fully loaded with all of those physician transfers and that's been really significant for NMC. So over the past five to seven years you all have seen us request and have approved physician transfers related to primary care on multiple occasions. Chronic pain and addiction services. Also pediatrics was a big one for us a few years ago. Urgent care and then other things that are considered you know staples, smaller services but still staples and important points of access for our community like dermatology, ENT, general surgery and the list goes on. So again, many of these things needed to be stabilized in order to address the top priorities in our community health needs assessments. And these are services that we truly feel are appropriate to be done at a community hospital. And so when we look at our growth and expenses we truly feel like it's not a story of expense mismanagement but really a story about investment. Meanwhile, our hospital expenses as the dark blue area are growing at an average rate of 4.3%. We've talked to you about the challenges with inflation and wage pressures and I know you've heard that story from our peers as well. And I also want to point out that that 4.3% includes the over $1 million of you know I'll call it budget reconsideration funds that you approved for us back in 2016. And we use that money to fund Rise Vermont into address social determinants and those are things that we continue to fund today. We know that every organization has an opportunity to reduce expenses and so we're gonna talk about that as well because expense reduction and our operational improvement plan is something that we are taking very seriously at Northwestern and I know Jill's gonna cover that shortly. So I wanna show you this graph as well which kind of speaks to cost but looks at it in terms of cost to the system. So this isn't just NMC expenses, this is cost to the health care system and I know that you all have seen this graph before and when you look at the health service area for St. Alden's UCS and not lower left quadrant. So this means that cost to the system is low and utilization is low. So we are not providing expensive services and we are not providing services in excess. To me, this slide really tells the story. We certainly have costs growing but they're growing in the right areas and we're resulting in financial losses. So with this lower utilization when you think about capitation and so we're at 30% capitated right now but when you think when you lower utilization that 30% of their savings in there, their savings then how is that offsetting the fee for service world and right now that is still 70%. It worries us, worries me about the 70% and getting to that over the next two to three years of capitation because again, we're all kind of doing the right thing and moving our attributed lives and making that much larger than what is the right amount of capitation to allow the savings to offset the remaining fee for service in our calculations closer to 80%. So this 30% that we're held to now for two years, we almost wanna celebrate because we're on this journey of capitation but right now it is really quite painful because we need much more of that in order to get where we want to go with this transformation and to make the finances work. So we're working hard to balance that and you can see that we're investing in the right things because it puts us in this lower quadrant but that doesn't translate in our financial sustainability and so that's what worries us at the same time we're committed to it. So this whole painful thing that I talked about at the very beginning we're leaping and we want to lead and continue to lead but it's painful and it's leading us to make some more challenging decisions that as we talk about expense reduction momentarily we need to look at bigger things like program services. And before we leave this line I just wanna speak to a total cost of care because that was something you wanna ask us to speak to as well and I know you have kind of a separate page document from us on that. So this thing all then to have a service area has a spending level that is below the state average and it is actually below the three and a half percent goal of you all. So if you look at it over the past five years it is at 3.4 percent and it is actually slowing. So if you look at it over the past three years it's actually at 2.5 percent. So how does all of that shape up and translate into a P&L and a balance sheet for NFC for FY20? So I wanted, I want you to please know that these are the revised budget figures what you see in front of you. So we have the challenging issue of our benetech ambulatory system and we have not changed our revenue budget at this time. Again we know that is probably the biggest area of risk in this budget for FY20. If you were asking me the thing that keeps me up at night it would be that. We know October one is quickly approaching and we have however added $1.5 million in expenses related to the benetech ambulatory project to this budget because we just, we know that they're not avoidable and that they needed to be added at this time and Jill's gonna get into some detail about what that 1.5 million dollars is. And so that results in a negative margin for FY20 for NFC of negative 0.2 percent. And I have not separately listed out on this slide the revenue deductions piece of our P&L but I do wanna spend a minute talking about it and specifically talking about that debt and free care. As Jill mentioned we're very excited to work with the healthcare advocate because we do not have a favorable ratio of free care write offs to that debt write offs and we wanna do everything we can to improve that. It's not intentional and so there are things that we can learn from our peers. I know now we need to talk to Northeastern. So if there are things we can be doing we absolutely wanna be doing them. I think every organization would agree that we would rather write off a dollar to free care than write off a dollar to that debt. So we absolutely wanna work on that. The balance sheet side I just wanna spend a minute talking about risk reserves because again it has been a topic of conversation. So what I'm showing here for FY20 is a risk reserve on our balance sheet related to our participation in one care of nearly three million dollars. That is actually the same amount that I anticipate having on my balance sheet for the end of this fiscal year, what I sit with today. And so I do not anticipate a Q and L impact related to risk reserve between FY19 and FY20. If one care is successful in increasing the number of attributed lives and the overall amount of our population that falls under the capitated program we will have to take a look at that. But there just wasn't anything imminent in our conversations at one care at this point for us to move that amount. And we like everyone have to work with our auditors to make sure that they're comfortable and feel that our reserves are appropriate. And NMC's strategy is to reserve risk at 75% of the maximum allowable risk. So we are not reserving at 100% and we do not have multiple years of risk reserve on our books either. 2018 is not quite settled but I do not have multiple years of risk. This is our cash flow statement for fiscal year 20. And the thing to really talk about and to note on this is the amount of cash reserves we talked about it before when we talked about a base cash on hand that we will continue to use to fund capital investment. So we do plan on spending more on capital than cash that we will generate in FY20. And this is one of those areas where I know you just heard the same thing this morning they look at it on a monthly basis and re-prioritize it because capital spend and capital investment is an area where organizations have some higher discretion or flexibility. So if we were to find ourselves not meeting our budget for FY20, this is an area where we can look, this is a lever that we can pull if needed. Now we're gonna talk a little bit about our costs, drivers and cost containment. Stephanie had just mentioned about the Meditech and the implications. We are on Meditech for our inpatient, also our emergency department and we recently on May 1st transitioned to have a fully integrated system for our ambulatory practices on May 1st. There was a lot of work. It was two years almost in the build and working with Meditech and testing with providers and staff. That being said, it has been a very challenging go live with the system for moving from a best of brain system to an integrated system. It certainly has some functionality that is missing from the previous. So we have a product functionality. We have scope and we have workflow. There's like three different buckets. So with that, and I'm just speaking with the CEO of Meditech yesterday and will be weekly in regards to what are the absolute deliverables because we need them leaning all in and this is one of the places of exhaustion of our staff and our providers. Our providers want to see patients and they don't want a barrier in between seeing a patient and communicating with a patient but making sure the documentation is complete. We all believe in integration but it is a little bit more challenging than we might think. So we've talked about our staff needing more resources. Also coding staff, it takes more time to do this work, information technology support and also interfaces and licenses and others. About 1.5 million. We're hoping we don't have to realize all of that but right now it is our best projection because of the complications we've experienced and the challenges to get a system like this to new code so to speak and new functionality. I'm really worried about the risk of losing providers as I sit here today but I will tell you as we put a path to go back to the previous system and the path forward they're equally complex around the quality and safety of patient care which we all stand for. And this is a difficult, I think it's been the most difficult situation for me to really work through as a CEO and making sure the care is safe and the practitioners have the tools in which to do their job in a safe and fulfilling manner. So cost. We've experienced certainly some changes in our financial situation. Here is an overview of the cost reductions, agreed to add it up to about 6 million. We have more work to do on the program and service lines. This has impacted people mostly through attrition is how we try to do our work and try to do it proactively. We've offered voluntary exit programs so we've tried to encourage and reward people for their service. We've certainly looked at maximizing our captures, our charge captures, our revenue as appropriate with our 340B. We've looked at every contract and we have through our implants certainly negotiated a change that has resulted in over $350,000. You can see the lists there, we look at overtime, we look at different costs, we look at policies, how we're paying our staff, how we're recruiting, our overtime and ultimately there's still more work to be done. Incredibly easy for me to reconcile the current year for you, right? We are trying to be as transparent as possible with you all and we really appreciate you and your staff being flexible with us and working with us because this is the first for us that we have such a significant issue going on that is negatively impacting our financials and it's happening at the same time as this process. So with that said, it has been very challenging and very difficult but we know that we will have at least a $9.5 million variance from what we budgeted for a net operating margin and where we will actually end the current year. And so we've tried to break down that variance for you into a few buckets and then I can discuss whether we have or have not addressed that in our budget for fiscal year 20. So the first of which is again the Meditech annual joint issue. So this is a net patient revenue issue and we estimated to be worth at least $3.3 million of revenue variance in the current year. And once again, we have added additional expenses to our budget for next year but have not changed our net patient revenue. For self-insured health claims, that's an expense item and we estimate the variance in that area of our expenses in the current year to be 1.7 million. So Jill mentioned that we have recognized savings for our healthier individuals who are working with health coaching or any individual who's working with health coaching. What we have also seen unfortunately is a few high cost claims. It often doesn't take many of them and we have a handful in the current year. So we do have stock loss insurance as everybody does but until it reaches that level, Northwestern has to pay for those claims. And so we have increased our health insurance planes budget from the current year to FY20 based on what we're seeing. We were seeing this early in the year and so when it came time to put our budget together, we have increased it in that area. We also had a surgeon, an orthopedic surgeon who was out on an unexpected FMLA earlier in our fiscal year. And I think you've heard people speak to how in a small community hospital, even when one or two providers leads, it can have a really significant impact. So we all know that these surgeons are generating ancillary services as well, whether it's imaging or the surgeries that they're doing in the OR. And so this particular surgeon generates the most patient revenue for Northwestern and was out unexpectedly and we have estimated that to be 1.2 million and have not built anything into next year's budget for that as he has returned. And then Jill mentioned earlier as well, we have some welcome physician cost in order to preserve access and to keep our services available to the community, some interim management and consulting expenses. So that's a little bit of a mix. Some of those things that we know are overdone with have not been built into the budget for next year but some of them have. Now we're gonna talk a little bit about capital. So I'll start with our CON projects. So NMC recently closed the CON for our medical office building and we anticipate closing the CON for our private inpatient rooms and our medical clinic space in November of this year. We have been granted expedited review for an emergency department modernization project. So that one is listed here as well for the cost of 7.6 million. Our non-CON capital plans include routine replacements of equipment for nearly 5 million and then we listed out for you what we call the strategic investment section of our capital budget. So we do break into two categories, routine replacements and strategic investments and these are the strategic investments that we are pursuing in FY20. So again, the emergency department renovation, it will actually cross two years. So the amount you see here is the amount that we expect to spend in fiscal year 20 related to that project. And that will update a space that has not been renovated in nearly 30 years and has several benefits, but arguably the biggest benefit is allowing us to more safely care for these really challenging behavioral health patients that Jill mentioned before, we currently have four of them. Co-locating addiction services with our community partners to create a center of hope and recovery. Like Jill said, when somebody can walk through any door and receive the services that they need, that's absolutely our goal. And then leasing space in the new building in downtown St. Albans to do that nursing program that we spoke about earlier as well and to have the longest classes in the demonstration kitchen. We've asked for a long range financial outlook and so we have put a five year projection together here but really the most important part of this is the statement that we have made at the bottom. This is what it looks like for NMC if we were to do nothing. And we are not a do nothing organization. So we know that we have to look at programs and services. We need to work with our board. We need to work with our community partners and our medical leaders and figure out what we are going to do to really be financially sustainable and to be relevant in the future. Okay, historical compliance with budget orders. Before we get into the slide, I would like to just speak directly to the last five years of compliance. In 2015, NMC was over the NAP patient revenue cap and that was resolved with our 8% rate reduction in 2016. In 2016, we were also over the cap and that was resolved by a reduction in our rate increase request for 2017. In 2017, we were compliant just slightly under NAP patient revenue pretty much right on budget. In 2018, we were under our NAP patient revenue by 2.6% but we're not rebased, so we're thankful for that. And in 2018, we were very much on track to meet our NAP patient revenue budget until May 1st. And so at this point, we do not anticipate that we will meet our NAP patient revenue budget. So we feel it's really important when we talk about budget compliance to talk about the history of rate increases. So what we have here is a graph that shows the median rate increase for all of Vermont hospitals. That's in the blue line on this graph. And Northwestern Medical Center's rate increases are in the black line. And the gray, it's tough to see here, but there is a gray shaded area that shows the lowest and the highest approved rate increase in any of those years as well. And you can see by looking at this that for eight out of the last 10 years, NMC has been at or below the median and oftentimes the lowest rate increase. And you must be curious about the red dots. Oh, yeah. So the red dot, which is closer to the top but not the top of the gray shaded area. So with that 5.9% rate increase, it gets us to a minus 0.2% margin. Our original submission had us at a 1% margin. And what we would need to have the modest 1% margin again is that red dot, which is 8.55%. The red dot, that's the top red dot. The one in the middle that's right above the black dot, which is us in two places. One is with the 5.9%, what is our average over 10 years of our increase? It's 2.39% if we had the 8.55 that would put us at 2.64% with the average over the 10 years for the rate request. On the next slide, you can actually see it a little bit differently. And it shows you where we sit with the compounded average annual increase over the past 10 years, with Copley clearly being the lowest and Northwestern in the second spot with our original submission of our budget. And there's that 2.64 that's sitting in there if there was an 8.55 to get us to a 1% margin. I think what's, it needs to be said about this particular graph and why we did this is because it's important to know that rate reductions are compounded year over year. They're sort of forever rate reductions, so to speak, multi-year. And so we're so far behind the rest of the group. If you take the next line, which is 4.19% of Brattaburl, as that being the average, our NPR would be higher by 19 million in this year. So we're continuing to lag behind and our bottom line is really suffering with the impact of that compounding effect, the forever rate reduction. Honestly, for me, I wanna discuss how historical rate increases or rate decreases have affected prices. So as of today, NMC's prices are less than what they were in 2015. A procedure at NMC with a price of $1 in 2015, today is priced at 97 cents. And you can compare that with the average of our peers at $1.15. If approved for the 5.9% rate increase that we have requested, our price will be $1.03. And we can compare that to the average of our peers at $1.18. So not being approved for rate increases that we have requested or having a rate decrease on our organization has really meant that Northwestern has had to fund raises for our staff, inflation and the investment in healthcare reform completely on its own and completely from its reserves. And we believe that we have been over corrected. We have to stop drawing on our reserves. They are appropriate and it's really time for NMC to transition back to making a sustainable margin. So we've reached our tipping point. There's no doubt you've held us accountable for our work and our financial status. Our rates have been reduced and over corrected. Our days cash on hand have been drawn down because of our plans for investment but also now for operations. We're cutting our expenses, you can see that and hopefully you can feel that in our work. We're going to be doing that with programs and services with our board leading us in the weeks ahead. We have been all in from day one with the all-pair waiver working with OneCare and actually for a bit we were the only one outside of the UVM Health Network that was partnering in that. We took the risk. We joined in early to learn, to grow and to pave the way. There's complexity and cost in managing a population. We still have chronic conditions as we work greatly to prevent them from ever starting. But we have a bubble of chronic conditions to manage through in order for our efforts to keep people well to really begin to make a difference. Our pressures are jeopardizing our access to care as we think about the things we're no longer going to do, things that we're doing now that belong in a community setting. We employ almost 900 people. We know we're an engine in the economics of our community. We're committed to investment prevention because it's the right thing to do. The traditional hospital of treating disease and incident must be transitioned to a system that's out in the community keeping people well. High quality of life, reducing the cost of healthcare. We're committed to the transformation of healthcare. But our bottom line suggests we need to back away. We believe this budget is appropriate. It's transparent. You know everything about us and we'll answer anything that you might have. But this budget does require approval for us to continue forward. This has been a tough year for us. And you might say a tough three years, but particularly tough in the challenges that you're aware of when we reported on a few months ago. And we've not wavered from our commitment to lead. We want the latitude to continue to do that and to continue to be a leader in the state of Vermont because our community, Franklin and Randall, are entrusting their care to us. And as I drove down here this morning as many of you did, we passed a very tragic accident on 89. And I know as we sit here and we talk about this budget, our hearts are with those individuals and the families in that devastating incident. When I arrived here and sat in my vehicle to collect my thoughts, I checked my text and this popped up from the early morning lab staff that knew we were here and they're rooting for us. And that's the reason. Our staff, our commitment to our staff, our commitment to our community, our medical staff, our volunteers that are there to provide exceptional care for our community. That gives us reason to be here and to have a conversation about our budget. Thank you for the opportunity. Thank you. Before I turn it over to member Holmes to start the question, I just want to say that very good presentation and Stephanie, you really nailed all the key points that we were looking at. Thank you.  She totally is. Thank you. So, Jill and team, I definitely want to start with an applause for your leadership. Obviously in a lot of the work that you do in wellness initiatives and population health, I know you're a leader, you've always been a leader. Now you're a leader in cost savings and trying to find initiatives. I know it's really hard and I've known you now for five years sitting here like this. And I can hear in your voice, these are challenging times, but I can hear in your voice the sense of urgency. So, and the concerns you have in the passion for your community and the passion for trying to find a way forward to secure you. I want to talk a little bit about, you've talked about trying to invest in the right access in our community. And redefining programs and services for financial sustainability. And I want to ask a bit more about that because I think it's an interesting times. And I think we've heard that from some other hospitals, Northern Country is doing service line, you know, reevaluation and so I want to hear a little bit about how you go about doing that. What are the factors? I mean, access is an important issue, probably the most important issue. We want to have access to services in your community. How do you decide what are the types of services that should be in your community? What should be outsourced to larger centers? How much does contribution to margin play in the next decision and how much does quality in terms of volume, can you get enough volume to support the quality that you want? How does that all work as you're rethinking this? Sure, let me tell you our process of getting to those decisions. So every three years, not unlike others, but we have a strategic planning process that allows a quorum or consultants to come in and actually look at our demographics. So we have someone actually come in, look at our demographics, also look at it on a national perspective and what trends are and what's happening in the market even with innovative opportunities in which to provide care. And we also interview stakeholders. So they will go out and interview in groups different and we also have our medical staff of course and our staff and our board leaders, but also subsets, varying subsets of our community. And then we marry that up with a community health needs assessment which really does drive so much of our conversations. So in that study for the demographics and looking at our population, they actually do predictive analytics in what type of services we're going to need and how many providers that we're going to need in those particular categories. And actually, even with those predictions, we are conservative because we will start something and then we will allow it to grow to see how it's actually going to fare. For example, with our medical clinics, by the way, Amy Petton's here, she leads the medical clinic, she works so closely with UVM Medical Center and others to figure out what are the right services because some of the services we can't provide full time.  Do we do it? Does the FQHC, whatever our private, so bringing up, we don't have to own it all. We just want to make sure that is accessible. So now it's somewhat about medical clinics and so neurology and negotiating, you know, what is it we need for a neurologist available? So we start off like with one day and because of the contract with UVM Medical Center and the flexibility, we can now work to like a day and a half and might we go to two. So it's a lot about prediction and looking at our population and then it's about starting it and not putting so much in, it's harder to back away but knowing the population and doing it and eating it, especially to go to partner. You mentioned partnerships earlier, I think that's really important. At the same time, we look at how care is being delivered differently. In these past several months, we made a decision to eliminate a service of interventional pain and how might we do that differently? How might we have chronic pain management actually back into primary care? There was a time when you pulled it out and you made it special and now how are you moving it back into primary care? So it's really important to be having these conversations with providers, seeing what's going on and making sure we understand what is best practice but ultimately we look at a lot of things. We'll get data, we look at our reality, we look at the community health needs assessment and we bank a lot on what our community is telling us. Thank you. Tough times with the Meditech. Oh boy, that's when I will also extend my sympathy on that. I was on the Porter board when they implemented the Meditech and I remember the growing pains and the suffering that they got through it. There's another side to it. But I'm trying to understand that the margin was obviously compromised by the Meditech. Was it productivity losses and revenue losses or was it unexpected expenses that drove more of it? What was it on which side of that? It was certainly a little bit of both but out of the gate we had budgeted for a transition. We knew the volumes would be lighter and that first four to six weeks is what we had predicted. And so we had booked our visits at about 50%. And what's happened is we haven't been able to bounce back. Somehow our specialists are coming back to a higher volume but our primary care and pediatrics are remaining soft. Now even the ones that have gone back to their volumes we're finding that they're having to do charting after hours so there's still complexity even in the ones to simply say, oh yeah, they're back to their volumes. It's not without a concern for the hours that they're putting in to get back there. And there is some, clearly some expenses going on in this budget for consultation and resources to be elbow to elbow with the providers so we can still see patients. I remember the provider burnout at the time. We're really totally worried about that and we are having conversations daily with our providers to be right there but it is very tenuous. Yeah, I mean I think as Jill said the only thing I would add is it has a revenue component and it has an expense component. So why are you not backing off of those revenues for FY20 because can you really get back up to your current visits per day by actual refers? And I think it would be too conservative for me to build in both the expense additions and the revenue reductions because the reason to bring on the additional FTEs is so that they can help get through some of that chart prep and some of that documentation that is slowing people down. So if we put these extra resources in place that will allow those visits per day for those who are still struggling to get back up to their normal levels. So that was our thought process there. This is a question I've been asking some of the other hospitals and it actually relates to an HCA question around the ratio of commercial to Medicare reimbursements and your answer in there was 1.3 to 1.46. So can I assume then, can I take that and say if on average Medicare pays $100 for a service your commercial payers would reimburse you on average about $130 to $145? Yeah, you have to take commercials as a bucket so there's multiple of them at the most. It is close to double, which is close to what you heard in the presentation before us and so once you average it all out that's the number that we provided to you. And I would also agree with the Medicaid number that was out there earlier somewhere around $70 to that $100 are just close to that as well. Okay. And I just wanted to, we've asked all the hospitals that total cost of care and resource use and I just wanted to say certainly when I looked at your numbers you were exactly as you've shown on the graph and low total cost of care and low resource use so I wanted to applaud you for that. Thank you. Okay, Robin, do you want to go next? Either way, do you want me to go next? Sure. Thank you and thank you very much for answering our questions before we ask them. And as a result I don't have a lot of questions actually. Clearly she's been spying. I encourage spying. Just to follow up to Jess's questions around the service line evaluation as I think you know I'm chairing the rural health services task force which is a legislatively created group looking at the sustainability of hospitals. And one of the questions that I've been asking to mostly the critical access hospitals who have been struggling is to expand on what kind of creativity or other operational changes you think we're gonna need to be envisioning for the future as we move into a more resource constrained environment even than today while maintaining access. And we've spoken to that a little bit in response to Jess's question but I just wanted to ask it in that context to see if you had anything else to add. You know I think the biggest strategy and unlike others is telehealth for rural communities because it's very hard to recruit to the rural setting especially if you're the only provider providing that service because they like that connectivity and that cross coverage. So I would say telehealth is probably our largest strategy that we're expanding on. Getting into I mentioned the ICU that's a real issue for us. Can we solve that by telehealth, tele ICU so that would definitely be a piece. We're having other conversations about what parts of care can be provided maybe at UVM Medical Center. We do pre and post things and they kind of do kind of the bigger stuff in the middle. So we're having those types of conversations as well. So you know we started with a theme of partnerships and I know that our strategic planning is coming up and our board chair being here is really about how do we leverage those partnerships locally because when you think about I mentioned the Howard Center and the addiction our addiction program coming together. You know in time once we do that and I don't need to get out in front of my own team but does that become something that the Howard Center does? Are they better at it and we support them versus joint? I mean these are things I think we have to have conversations about jointly and even primary care is the best place for that. The most important thing is that the access is there but it's going to be partnerships locally. We're thinking about how do we monitor patients in the home and we have home health. How do we partner with home health? So if we need to monitor and they're monitoring how do we do that together? So it's local partnerships, integration of overhead, you know even locally. And when I talked about the umbrella organization again we haven't done this only around benefits a little bit or even group purchasing. We're all purchasing things and is there a way for our community to have benefit about really integrating overhead services of IT and human resources and those are conversations that we need to have and I think just like with small community hospitals, the small community organizations worry that because we're saying that it all should come from the hospital and not necessarily. So how do we take the fear out of the conversation and really try to figure out what's right so that we all can thrive and it doesn't mean that we're going to do it all and take it over. We actually, that's why we're thinking about an umbrella that's not the hospital. We call it something else but how do we get this accountable communities for help that we're so integrated in talking about and how do we do that through a system locally because that's where capitation can be successful. I hope that helps a little bit more. That's great, I think you've definitely touched on some of the themes that are starting to emerge from the task force including the telehealth and partnerships and buy, don't build, all those different themes that even in just our first couple of meetings have come through. Great, super. That makes sense, great. That's actually the only question I have. Well, I'd like to join the course and say thank you for a great presentation. There is a lot of stress in these situations. Six, $7 million operating deficit is a bit scary but if you're targeting $240,000 operating deficit for 2020, that's not too far removed from a couple million bucks which gets you to where you want to be so I think there's cause for optimism here because you need to recognize your problem and embrace it and are tracking it down. And like Jess, if people go before you, ask questions that you were going to ask so I don't have to do that again. But on the bad debt issue, I did note that over the last three years the bad debt has grown at a rate of 22% a year and free care at a negative 0.1% so that dynamic that you said you can't explain but are gonna work on with the healthcare advocate just seems like fertile ground because a $7 million bad debt is a lot having grown from over four. But I do have two remaining questions there. In your Bridges document, there was in the expense side there was a collection expense at $369,000 and so I'm just wondering what that was because that's an up, that's a new expense. Yeah, so we I guess for lack of a better term outsource that billing function and so we're kind of what you call like a first day out goes to the collection agency for them to send our statements and do those collections and then from there, if they do not, if they're not successful just by sending out the statement or doing that friendly reminder phone call if they are not successful at a certain point in the collection process, then they actually move that on to a collection agency. So there's two different stops or two different places that collections can go within our organization and so we were, there's a couple of things going on but we were notified from our collection agency who used to handle both of those. So the items that were still good debt and they would handle the items that were considered bad debt and then let us know that they were not going to be providing those bad debt collection services anymore and so we had to go out and find a different vendor so more than anything, that's what they're seeing there is just us having to change that process. We've kind of dived into our bad debt expense of it because it is high and we're trying to understand what the differences are between us and our peers and we know that about half of what we are writing off in bad debt is for people who have commercial insurance and that would mean about half of them do not and so I do feel like part of our issue is also just a classification, getting things into that right bucket and doing things to get people qualified for free care. When I listened to Northeastern speak and they said, we posted at all of our registration areas and we have a dedicated person who works with people to get them qualified and it's part of their admission packet and I was posted on the website and I'm like, yeah, yeah, yeah, I'm doing all of those things too but obviously there's something that we could be doing more and so I'm excited to dive into that and figure out what that is. And I think from your statement, I imply that you were here at this morning session. So I won't repeat the whole thing but the state does have a program called the offset program and it was there when I was finance commissioner in the 90s, it raises quite a bit of money and it's served by human, it's supported by or used by human service programs, state colleges, VSAC, VEDA and I would just think given the situation you're in, it might be a helpful tool to generate some revenue and I'm just wondering, it's a well-established program, it has all sorts of appeal processes in it. So if the state were to offer to allow hospitals access to it at their own choice and placing whatever debt they wanted to it, it's just an annual cycle. Would that be something you would be interested in or do you think that you're happy where you are and where you might be going with a healthcare advocate? Yeah, I mean I think it's definitely something you would be interested in. So of course we'll do our work with the healthcare advocate first and then we would look at the details of that program and the cost associated with it because if it can be a win-win or a benefit to our patients it doesn't really cost more of Western anything additional then of course we would be open-minded to that option. But what I'll do is I'll send you a program regulation just so you know what these things on the horizon that we sorted it is because this is very clear. Yeah, thank you. My next question is, I was looking again at the ups and downs and for Medicaid there was a $600,000 down associated with utilization and a $1.2 million up associated with reimbursement and payer mix and in the narrative, your narrative says that you're not assuming any increase in reimbursement rates for Medicaid except the amount associated with one care, this five-tenths of 1%. And I'm just, so is that what five-tenths of 1% looks like on the ACO rate of about $1.2 million? That seems high. That's definitely a detailed question we can think of. I worked with a back-to-back website and a digital number and I thought this doesn't, I'm missing something. Yeah, and now I used to have to look at that one and absolutely are happy to get back to you on it. Okay. It's related to Medicaid reimbursements. We also have heard from a couple other hospitals and confirmed with Diva that there actually was an outpatient reimbursement change. I think it was July 1st to increase outpatient Medicaid rates. So when you're looking at it, you might want to factor how that fits into it. Yeah, absolutely. Next item I have was on bridges again, there was an indication of inflation increases at three-tenths of a percent. While in the narrative, there was an enumeration of inflation rates for supplies at two percent, surgical supplies and drugs at three percent and four percent for the cost of raw food. So I'm just wondering what kind of, what inflation rate should we look to that we think you're looking to? Yeah, we can go back to that table and figure out if there were certain items within our expense budget where we are assuming zero or if we, because of our cost reduction efforts are actually anticipating some sort of a negative in that area. I think we have spoken to specific items and then when we roll it up together, it's just creating a different answer so we can provide that detail. Okay, and thanks. So my last area is having to do with the cost shift and so I'm looking at a couple of items that are on the income statement that are not related to each other but they just happen to be on the income statement. One is the provider tax and the other is dish. And if you look at kind of how they are trending in your budget, in 2017, a dish was near $6 million, sorry, the provider tax was near $6 million and dish was at 1.7 and for 2020, you're projecting a $7.3 million provider tax and a $934,000 dish receipt. So combined, in 2020 these, just these two moving parts are about a $2.2 million hit to your bottom line. And I'm just wondering how much of a role you folks play watching what goes on at the folks that control the provider tax which are in the building and across the street from where we are. Do you fully engaged with them in terms of saying, hey, this $2.2 million is the entire bottom line that we want and as we're out here working very hard, that kind of money is being siphoned out of our income statement. So the answer is in a two-fold one is absolutely locally and getting together with our local legislators and providing that education and understanding of what is happening. But more collectively for a collective impact working with the hospital association and all of my peers to try to leverage that in our local conversations as well as our rolled up conversation. It's a tough word when you think about it and how are we going to eliminate the cost shift and how we move forward to capitation? How is this all going to hold in? I mean, this is a huge issue when you talk about getting together and aligning incentives and prioritizing, we have to be able to talk through this. But those are the ways that we're working on it. I can't tell you we're having huge success, but I think it's we're keeping it on the table, we're keeping it relevant in the bigger scheme of how we're going to transform this delivery system with an action payment system. So let me close with this. It's not so much a question, it's just kind of a statement. I've been here for about a year and a half now and kind of watching things flow by. And in terms of the cost shift, I'm just looking with this hat on that I have now at some opportunities that may, that could be helpful. One, for example, just little things. I noticed that the auditor came out with a report on Dr. Dinosaur and the fact that there were folks that were, that the Vermont Health Connect system that was not tuned up enough to collect premiums and not make payments. And so there was, just on a sample of about 257 households, there was a $2.4 million opportunity there, which they said once Vermont Health Connect gets further fixed, that will be cashed. So I'm sitting there going, well, there's $2.4 million. You have the last year, just about this time at the end of the state's fiscal 2018 to 2019, there was $78 million transferred into the Human Services Caseload Reserve. And that was from the reconciliation of all the accounts by and large in Vermont Health Connect. And that reserve went from $22 million up to $100 million. I'm big on reserves in the state budget, but all of that money was generated, that new money from out of the Medicaid appropriations that were finally reconciled. And I'm sitting there thinking, what's the interest on that fund? So you'll leave the fund alone, but what's the interest on that? And that might, and might that be available to help with Vermont hospitals. I looked at the $50 million revenue increase. At the close of the last fiscal year, $50 million in revenues over target. I looked at the state budget. They did a very good job. The state budget transportation fund and general fund grew at about 2.8%. So I mean, they're a big organization, very complex, and they did a good job, but there is our revenues that they did not expect that came in. So I would just, I'm just urging folks to learn some of my old hats, is just make sure you're in the game, because these opportunities come and you've got a compelling story to tell during your important organizations in every part of the state. And I think there are some opportunities to take this wind in your face and have it become a wind at your back in terms of dealing with the cost shift. That's great, thank you. And then talking about alignment and really having these conversations together and understanding this arena, that's very helpful. Thank you. Thanks, I also want to echo that you guys did a great job with your presentation and kind of addressing the questions we may have.  So I think you did a great job of addressing. You know, I'm concerned about your hospital. You've had losses on the operating margin for the past four years. You know, and if not for the cash on hand that you've had and the ability to get some investment income on that cash, you know, we probably in a much different place than you are now, you know, because we haven't been able to absorb that. So a couple of questions. The first one's kind of a loaded question here.  What are you asking us for, you know, because your budget request is the 5.9, put on 8.5, and I don't know where we'll go with this, but just trying to get clarified. We're clearly asking for 5.9% to go lower. And I mean, and the consideration clearly about where you see us and where's the right time to invest, but we're asking for 5.9%. And we'd like to have that approved. Thank you. I'm just going to page, well, first I'll talk a little bit about the ACO and you've talked about the risk and the reserves and just want to get a handle on of what you have on the P&L right now. So you're losing about $6.7 million obviously in 2019. And how much of that risk did you have to put up in 2019 because, you know, as a hospital that's in on all three payers, the percentage of risk you have to take on two-year NPR is high and it's higher than most of the hospitals have to take on because they're either not at all payers or more people are getting service in their area. So just wanted to ask how much of that went into your 19, 6.6 million loss? Yeah, so when we ended fiscal year 18, we had almost 1.7 million of risk reserve on our balance sheet. So the fact that that has grown to nearly $3 million does mean that in the current year, we have had a negative P&L impact of just over a million dollars related to adjusting those risk reserves and getting them kind of where we needed to be as we head into this year end and into our audit and into next year as well. So I hope that answers your question. And then for 20, you're not really increasing at all because you've taken up 3 million and say, we're gonna see where 18 finalizes with 19. Correct, yeah. I mean, it's been, it's very difficult. The folks at OneCare have been incredibly good to work with and they're very responsive. And I know that there's just challenges around data and claims run out and the lag that's associated with all of it. So I know that 2018 is almost settled and they are awaiting some information from Medicare and we've been told that that's coming anytime now but I don't expect any major surprises as it relates to 2018. 2019, we only have one quarter of data and we actually just received it really recently. So I would love to say that we won't need 75% of our maximum risk or that we could back that down or that if the program grows, I won't have to grow my risk reserve. But I still think it's early and the data coming to us is just early and it does change quickly and significantly and so we're just trying to work closely with OneCare, work closely with our auditors, make sure that we're covered but not overly covered. I think we don't want to be in that situation where I've got a million dollars from two years ago and two million dollars from a year ago and I got three million dollars this year and but those years are pretty much done and settled and gone and so that I'm being overly conservative. So we're just trying to make sure we strike that balance. But I think the transparency that you're putting forward and then you'll launch it as it goes on, I think your position seems reasonable. Yeah, I know that if OneCare is able to bring on some self-insured plans such as ours and is really able to grow that number of treated lives and if we do get really into fiscal year 20 and it's looking like we're approaching 50% of people being in the capitated program then of course we'll go back and we'll look at it, figure out if those risk reserves need to be adjusted but for now I don't want to unnecessarily say that I have this liability that needs to increase. I think we want to be as we go ahead. And then do you have the ability in your system to track for those patients who are attributed and who get their care in your hospital but the kind of trailing or tracking for the fee for service would be for those? Because that's obviously another risk or reward if you will that would be running through. Yeah, we are able to indicate within our system who those people are so we can individually flag them once we have our attribution lists. And I can follow up with you to give you a better answer to that question but again we just received an attribution list related to Lee Cross. I know we're kind of seven, eight months into the program year right now just 2019 but we just got that attribution list and so are working on pulling together exactly that information now sort of that concept of shadow planes. How would we have done under fee for service versus in this capitated environment? So we just got that data and we're really happy to follow up with you. Okay, that's great. And then in your narrative you had talked about kind of the Medicare write-off rates things related to 18 and 19 and I believe you also said that's all resolved and is there a negative impact in 19 that's going through? Not a significant one. So we had worked really closely with OneCare as we closed fiscal year 18 to work on this Medicare error in the formula when they made the capitation payment to us in the first place. And there was an issue of some duplicated payments from Medicare going on. So there were a couple of different things happening but again the folks at OneCare have been really good and we worked with them really closely when we closed fiscal year to 18 to make sure that we were covered. And so the ultimate bill, or invoice if you will that we ended up getting from Medicare to sort of work through all of that and resolve those issues. It had a very small impact on our PNL less than $200,000 ended up flowing through our PNL and we were talking about a number that was more than $4 million. So we were adequately accounting for that as we went into this current year which thank goodness because I wouldn't pay more boundings. And a year after year you guys have presented a class savings program so let me put in and I think you have a very good program. And just wanted to touch on a couple things. One, other things other hospitals can maybe learn from programs that you're saving money. And two, what alliance are using one of the alliances with you to help get those cost savings or how are you identifying them? Well clearly our work with the forum we have a forum management of organization and they provide through their contract folks that actually come in and actually do assessments of all aspects of the organization. So that really helps us look at opportunities. We've clearly had education in lean strategies and have an innovation team that has a diverse group. I think one of the opportunities as we're evolving as hospitals across the state is how do we have this conversation at the hospital association in order to how do we actually have the learnings from each other and I think we might be able to do more of that. So the other thing I'll mention here under the inventory surgery there's so much to talk about and is having an opt to come in and really look at our inventory surgery central like operations. So we do engage outside of support and to have us take a look at our current systems and how we can involve them. So we have just finished that consultation and are implementing our inventory surgery central like operations. I really do wish this for all small community hospitals. I know that's what I advocated for through this whole process because our world is changing in surgery and we need to be looking at that differently and how we deliver that care. So we engage consultants and also different partners in looking at our strategies for cost containment. And were you able to quantify what the surgery center and Colchester the impact of that might be on you? It's really early at this point we do have a surgeon that has left. We do, some of those surgeries can be absorbed by our remaining surgeons but I don't think we've had an opportunity to quantify that because they really just opened their doors in June. So we have not seen a significant changes there ramping up on what that means for us. But a year from now or as we watch this play out we should have a better lead on that. Okay.  But when you look at the whole meta tech is there any recourse against the providing of the, I guess the IT right I know I've done implementations before and sometimes when they're over budget and things like that there's a way to get some money back for them to give you concessions in the future. Is that what we've meta tech themselves? Yes, so yes, we're holding their payments for one thing so that we have a little bit of negotiating power and some leverage in the conversation. And as I talked with the CEO just yesterday to outline the impacts that we're having on revenues and expenses, they are sending folks our way. They are giving us additional resources that we're not paying for in the moment. But beyond that there will be a reconciliation discussion of exactly what the impact is and how we're going to own this together. The changes that we're making are in meta tech. Some of these are significant to not only us as meta tech users but other organizations that are going to benefit. So we are doing, we almost like have a little, our little testing center of their code that they're developing and where they're consultants. And we, I can see our little warm room that we have right now that someone's in all the time to test this new code. So we will be having this negotiation and figuring out who owns what in this. So right now we're trying to keep them focused and on the clinicians that need this code to be able to deliver the care that they want to deliver. And that's certainly up to us as administrators to figure out how we're gonna financially kind of battle this out. Are you sure IT system able to attract where your patients are coming from? Where they are coming from. We certainly have their demographic information. So we know what their home address is. We are able to capture some things related to referral. So we know they're coming from another practice or some are specific that sometimes we can capture that information as well. But it, you know, I was here earlier for the conversation about crossing state lines and how would you go about getting that data. And I would agree that it can be really difficult and it can be tricky. I don't know if that answers your question but those are a couple of the ways. I was just curious based on that conversation, you know, you're also close to Canada and I was curious, you know, how much traffic you're seeing there and if you're seeing the same thing where they're actually paying you pretty much the same as commercial reimbursement. Yeah, the reimbursement is not bad. So I will agree with that as well. And we anecdotally, I'm not sure I would be able to produce real hard and fast data or reports either. Anecdotally, you know, I can tell you earlier this year we had a couple reach out to us because they wanted to have their baby in the United States. And so they wanted to pay cash for that service and had a research test and wanted to come to our family birth center. And so I think you are starting to see just that overall whether it's Canada or New Hampshire or whatever it may be, just that higher level of consumerism, right? And where we get our services. And so people are paying attention and are looking at that. So they had seen what our prices were and what our, you know, quality and outcomes were and had reached out to us for that. So we were able to, you know, give them a cash price and go ahead and provide that service. And so it makes me start thinking how other cash, you know, services can be offered. What else can we do? Because I think as much business as we are able to draw from that area, we should know. And what about across the pond? Are you kind of static with your New York business or? Yeah, we are. We have not seen growth in that. Okay, great. That's the only questions I had on staff. No further questions. Great presentation. Can I have this one, be very quick? Go ahead, Susan. So earlier in the week, I had asked one of the hospitals about diversity and leadership. And I had pointed out that in recent studies, you look at the decision-making, healthcare decisions are made by 80%. 80% of the time are made by women. 65% of the healthcare workforce are women. But only 30% of the C-suite of healthcare companies and hospitals and payers are women. And only 13% of CEOs are women. We obviously have one of our two CEOs in Vermont before us today. And I thought if you could share, Jill, your philosophy around diversity, not only with women, but with TQ or any of that work that you've done on diversity, because it's pretty impressive to see three women presenting to us today. Yeah, thank you for that. I think it's really about balance and really qualifications. I think that's first and foremost. I know it's dumbing my nails, as far as CEOs on the C-suite, I do understand that, but I always feel that it's really about those qualifications. And I do look at diversity. I have an ear to it and eye to it. I think more about our staff and making sure we're making the right accommodations for staff, and I know Jonathan's in the room, and I can't think of the organization on the top of my head, but working with them to make sure that if folks want to transition their work and they may have some level of handicap and how we're accommodating folks in various ways. And I'm so pleased with the Working Bridges program from the United Way, because I remember being on a panel for that and now our organization is a part of it where it's really helping individuals and get the skills that they need, build the confidence, and also like transportation. How about social determinants in building the confidence and helping them seek entry level jobs and giving people second chances or third chances and wrapping around them with the resources. So I think it's very important to look at diversity. I can't tell you that we talk a lot about it, but I can tell you that we practice it, and it's just innate to who we are. And the fact that we're sitting here as women and two others in the room, and maybe the women have now tipped the scale and our leadership team, it's really about skill and expertise and it's about fit. And I am so fortunate to be working with an amazing team that really embraces learning and growth across the organization for all. I'll be at this point, I'm gonna turn it over to the Office of the Healthcare Advocate, Julia and Mike. Thank you. So, and thank you for being me to the function line. I appreciate your recognition of some work to do and I don't think it would be a dead first. I did sort of raise that question of Northeastern this morning about what are they doing well. Just for your information, I also raised that same point with Rutland earlier in the week and plan to with CBMC Monday, because those are the three hospitals that are still on that side of having better for equal free care. And then I also just, I do want to say, and I look forward to meeting you and thinking through both of your free care program, but also to try and understand and honestly, I don't have an answer as to what it is and why there's this variation in those numbers. And it might be that you're doing exactly the same things as one of these other hospitals and she and I took results. So what would happen to us? I'm diving into it with you. But I do also want to say that I acknowledged from my other role as running a helpline that we do see in the bad debt numbers. And this is a little bit response to some of the conversation about bad debt of people who are Medicaid eligible but who for one fault or another in our funky systems end up in the bad debt category or people who have commercial insurance. But because of an error here or there they end up in the bad debt. So there are mistakes in our complicated systems. Names that are too long for a hospital system to put them in or something like that, believe it or not, that leads somebody to be find themselves in the wrong category and end up in the bad debt. So that's it. Thank you for your invitation to look forward to seeing us. You too. We look forward to it. We want to figure it out together. Yes, thank you. I just have one question about your narrative actually. And so in your narrative you stated that it was understood that the Green Money Care Board did not intend for the approved price increase till no matter what the ability of hospitals to negotiate more advantageous payment rates with payers when possible. And you said that it's not the same as the rate increase which is restricted by the Board budget order. I was wondering if you could explain the distinction there when you went by that statement. Devin Batcheller. So the order that we received from the Green Money Care Board is a rate increase that is applied for a pricing. And so our overall average pricing is not allowed to change by more than that rate is approved. The negotiated reimbursement rates are rates that can be, it's the payments we receive from our commercial payers that are not necessarily related to pricing. It's negotiating a different percent of charge discount or a higher or lower bundled payment on a particular procedure which also can result in that patient revenue. So it's certainly part of the regulation when it comes to the medication revenue cap but it's not the same as the price increase in our budget order that we receive. So you could potentially see an increase that would exceed the cap even if, so you could see it at a rate increase that would exceed the cap even if your prices don't exceed the cap, is that accurate? Yeah, I mean there are a lot of things that affect your total net patient revenue in terms of dollars and that's what the cap is related to. This is one of those variables, eventually. Okay, thank you. I just wanted to open it up to the public for the comments, if you could. If you could stand up and state your name and direct your comments to the board. It's Friday afternoon. It's Friday afternoon. And it's gonna be a beautiful weekend. So we thank you for your presentation and hopefully you will have an uneventful drive home. I know that was a bit dramatic this morning for a number of people. And so our thoughts are with anybody who is affected by that access. Great, thank you for the opportunity and again I want to thank everybody that's here from this organization and those that are back there that are totally leaning in to get to a better place. Thank you. Is there a motion to adjourn? So move. Thank you. All those in favor signify by saying aye. Aye. Any opposed? I heard that, Jeff. He didn't move. He didn't move. He didn't move. He didn't move. He didn't move. Jeff, who would argue if you could make a six block?


Thanks to the funding from the European Union, FAO promotes environmental sustainability in agriculture with the ACP-Mies3 programme. The programme supports the government of Zimbabwe and smallholder farmers in four main areas. Policy development, research, highly hazardous pesticides and ecosystem-based practices through farmer field schools. The ACP-Mies3 project aims to support mainstreaming of biodiversity into agriculture in Zimbabwe and the sound use of pesticides. The government of Zimbabwe, through the Ministry of Agriculture, recognises the importance of agribusiness in terms of improving production and productivity. The government aims to further change climate change, and to further further further fertilisers. And we are also very excited to be able to increase the number of children in the family and to provide them with the resources they need. We are very grateful. thanks for talking with me it's been a while my next change of life I spend a lot of time veteran and it's been a long time long time I spend near a house next to a pizza and it's gone since it's only white so my stesso nronics powder it thank god you can problem When we employ diverse methods that don't deal with synthetics, we are not affecting our health, but we are actually promoting the growth and retention of biodiversity in terms of the environment. When we employ diverse methods that don't deal with synthetics, we are not affecting the growth and retention of biodiversity in terms of the environment. We are not affecting the growth and retention of biodiversity in terms of the environment. When we employ diverse methods that don't deal with synthetics, we are not affecting the growth and retention of biodiversity in terms of the environment. Quite a number of farmers have actually done away with pesticides, which are hazardous and they are very costly, you know. So this has been one major, I would say, product which we are really proud of. You know the agricultural environment is so dynamic, it's an open factory, there's no roof. One of the biggest strategies that can be used to change a system is to actually look at the people that are implementing the extension, the education system in a country. Now this is important because we generate information that will help policymakers to mainstream biodiversity into these policies. The project is actually looking at the possibility of Zimbabwe coming with their own organic agriculture standards, which are managed and enforced by the government of Zimbabwe, so that the organic produce is actually meant for the local people of Zimbabwe. This form of education, remember, it's got no cost except a piece of land in our time. Yes, and a little bit of resources, thanks to the European Union via FAO, Food and Agriculture Organization, we're getting quite some support there, as well as our own efforts. The two complemented, we are smiling. The ACP Mears 3 program has helped to create a more sustainable and resilient environment that promotes sound pesticides practices, while safeguarding the biodiversity of the region. One of its major achievements has been the contribution to develop the National Agro-Biodiversity Policy Framework, which aims to mainstream biodiversity across the agricultural sector. About 180 farmers from nine FFS groups have participated in training sessions on the use of ecosystem-based practices, helping local farming families to have access to better living conditions and opportunities. For more information about the program, please click on the link in the description.