haven't slept a wink and I caught some bug on the way back here I guess we still have to use masks in crowded settings I feel like I'm having a near-death experience and D and this is the topic of today's video and I want you to know I will not let death interfere with my daily schedule I will release videos for your edification and entertainment even post-mortem death and such other trifles will not prevent me from fulfilling my duty to humanity because I'm pro-social and communal and bloody sick if you ask me okay Shoshanim let's delve right into someone else's near-death experience a few days ago there was a fascinating study published mind you there were only four people involved but even saw the results were nothing less than startling these people were having a cardiac arrest followed by essentially death they died and they died while being connected to an electroencephalogram EEG machine machine that records the various types of waves in the brain and in two of these four people there was a burst of gamma wave activity gamma wave is a very interesting wave actually possibly the most important way gamma wave or gamma rhythm it's a kind of neural oscillation it's a frequency between 25 and 140 hills and gamma waves are correlated with what is called large-scale brain network activity also known as cognitive phenomena such as working memory attention perceptual grouping and consciousness yes gamma waves are the waves of consciousness and that's why we can modulate gamma waves via meditation or neuro stimulation we also observe an alteration in gamma wave activity in mood disorders cognitive disorders such as dementia alzheimer's epilepsy and schizophrenia so gamma wave seem to be super crucial when these people were dying as they were dying their heartbeat picked up and then their brain erupted with gamma waves it's as if they have regained consciousness at the very second of departing this world now reports of near-death experiences and I refer you to the two books by moody reports of near-death experiences have been around for like eternity these are people who clinically died whether their heart stopped the brain stopped they were pronounced dead and then suddenly returned from the dead to us to tell us about their experiences and the experiences were uniform and almost monolithic all over the world different cultures different societies different periods in history people reported the same having died and resuscitated or reborn or whatever you want to call it all of them describe or most of them described a white light visits from departed loved ones or meeting long deceased people people who passed away a long time before hearing voices and floor floating above one's body looking down as if from the ceiling looking down upon the medical proceedings the attempts at resuscitation the panic the urgency the emergency the blipping machines the IV drips the sweaty doctors the nurses they were it's as if it's a kind of astral voyage if you wish as if these people have abandoned their bodies down there and then soared to the ceiling and contemplated the whole scene in a kind of this interested way as if they were watching a movie there were no emotional reactions these this is the classic near-death experience a tunnel leading to white light meeting deceased or dead significant others floating above one's body hearing voices some of these voices carry messages messages of encouragement and so the new study was published in the proceedings of the National Academy of Science and it's I think the best of my knowledge is the first study to provide evidence of a surgical activity correlated with consciousness in a dying brain there were various scientists involved Bojijin and others and so Mashaur and others so if you want to look it up you can find it easily online now signatures of gamma activation were recorded before in the in the dying brains of animals and in people who suffered hypoxia a loss of oxygen following cardiac arrest Mashaur says how vivid experience can emerge from a dysfunctional brain during the post process of dying is a neuroscientific paradox dr. Bojijin has led an important study that helps shed light on the underlying neurophysiologic mechanisms says Mashaur I want to compare this nerd near-death experience to the experience of being a narcissist and may I remind you this is a first-hand account the narcissist is in a constant state of near-death experience constant he never emerges he is never resuscitated he is never reborn he's never resurrected he's in a limbo area between life and death about to die but not yet zombified but functional and so this constant state of NDE near-death experience is perceived by the narcissist as life itself the narcissist has no other experience of reality of life and of the world he inhabits an inner landscape of internal objects it's a kind of frozen nightmare he is absent from reality in contrast borderlines are in constant state of near-death experience as well but they are not absent from the world they're absent from their inner world so they're like mirror images and no wonder borderlines and narcissists fit well together it's like a lock and key so to summarize the narcissist inhabits an inner landscape and is divorced from reality borderline inhabits reality and is divorced from her inner landscape and both are in a state of kind of suspended suspended mental animation the abused and traumatized children who become later narcissists and borderlines were not allowed to become they were not allowed to self actualize these children were not allowed to separate to individuate to set boundaries to recognize the distinction between themselves and the world the indivisible so these children remain stuck in a phase that is partly symbiotic partly merged and fused and meshed usually with a maternal figure and partly emergent partly about to enter the world about to explore reality about to attempt to become distinct and yet they never make it abused and children abused and traumatized children who later become narcissists and psychopaths and sorry borderlines in adulthood never make it into becoming persons they don't acquire personhoods they do not develop develop an integrated self narcissists have no ego that's the irony look it up on my channel I have several videos about this issue narcissists have no ego no self same with borderlines and in this state of suspended mental animation borderlines and narcissists are already dead their bodies have to catch up with the psychological reality but psychologically they're dead they're dead inside it's a state of emptiness as Otto Kernberg had observed it's a state of an empty schizoid core as Jeffrey Seinfeld country Winnecott and many others he looks at at the core of the narcissist and at the core of this of the borderline there is no core there's no identity there's nobody there it's totally vacated it's a void it's deep space it's a black hole and so whenever the narcissists or the borderline experience themselves they go through a near death experience they are near death because they are death reified the introjects in the narcissist mind represent significant figures the same way the typical near death experience patient meets up with deceased relatives the narcissist constantly interacts with internal objects and introjects that represent long departed significant others healthy people do it also it's the same happens with normal people but they also interact with external objects the narcissist is confined limited to interacting only with internal objects which represent dead departed object people that abandon him so the narcissist mind is a giant graveyard it's a cemetery of people who have passed through his life who passed through his life and then died or just walked up walked off walked away the narcissist's introjects and internal objects are his only reality and he wanders among them and he interacts with them as if they were alive but they're not alive of course they're figments they're fiction in other words they're all dead and he wanders dead among the dead dead talking to the dead a kind of psychic in his own world a medium and he tries to revive and resuscitate and resurrect these internal objects he tries to imbue them with life but he has no life to give because he is not the narcissist was not allowed to become there's nobody there there's no person there so there's nothing he can give sometimes the narcissist wants to give desperately attempts to give but there's no giver borderlines on the other hand depersonalized depersonalization is a dissociative mechanism it's the feeling that you're not inside your body it's as if your body does not belong to you it's an alien estranged entity borderlines go through this experience of depersonalization in sex very often borderlines depersonalized whenever they're stressed whenever they're anxious whenever they anticipate rejection humiliation and abandonment borderlines dissociation depersonalization derealization and amnesia resembles very much the way near-death experience typical patient hooverers above her body and observes the resuscitation attempts the near-death experience patient even mentally healthy one divorces her body exits her body floats above her body observes her body that's precisely what the borderline does does borderline clinically is in the state of near-death experience whenever she's stressed whenever she's attacked whenever she's anxious whenever she catastrophizes near-death experience is the most common experience of the narcissist and the psychopath and the borderline i don't know what's happening to me today with the psychopath maybe because borderline is a secondary cycle but okay near-death experience is the most common experience of the narcissist and the borderline both the borderline and the narcissist hear voices the same way a near-death experience patient does but the borderline and the narcissist do not misidentify or misconstrue their sources of the voices as external in other ways it's not a psychotic element it's not hyperreflexivity the near-death experience patient is actually clinically psychotic at the moment of death because he believes the voices are coming from the outside at least these are the reports given to us by people who have returned from the dead so there is an element of psychosis in near-death experience that is absent in narcissism and in borderline except in extremis except in extreme situations extreme situations the borderline and the narcissist become psychotic they have what we call psychotic micro episodes and there they converge with the typical near-death experience patient and they hear voices the same way he does all in all the narcissist experience of life itself is an experience of death the borderline's experience of life itself is an experience of death and they as opposed to classic near-death experience patients they never come back they never have hope to be revived or resuscitated or resurrected in borderline the prognosis is pretty good after age 45 the disorder itself can no longer be diagnosed but dysfunctional behavior patterns persist lifelong still borderline is a lot more optimistic as personality disorders go than narcissism the narcissist is utterly beyond hope and beyond redemption


Okay, it's May. Endgame's been out. Skipper, you're late. Yeah, I know. Even though I'm late, I still want to make this video. You probably already know the deal. I got to choose one Marvelous scene. If you haven't seen the other videos in the playlist, go watch them. There's some interesting perspectives, and this thread even happening is pretty cool. As soon as I saw the thread, I was surprised by how many iconic scenes have been covered. Personally, I love it. But it was covered by a lot of different people. Forgive this. But something I didn't see covered enough was scenes with one of the best-written characters in the MCU, Captain Marvel. If you thought that was serious for a second, you're delusional. It's Rocket Raccoon. James Gunn is a brilliant man who wrote one of the most interesting characters in the MCU. So you might be thinking, hey Skipper, what scene are you going to cover with the rabbit hamster trash panda? That's the thing. Rocket is such a unique character. It's hard to describe just one great scene. There's scenes of redemption, confusion, guilt, awareness. You have his breaking point, his snapping point.  Let's talk about one Marvelous character, Rocket. If you go in order of the films that include Rocket, you can tell right from the start there's some different traits and behavior that happen in each film. That's because he develops and progresses as a character within every movie. Yeah, Rocket can be cool because of his brains, his guns, this kick-ass scene, but what makes Rocket such a good character are his morals, his lessons, and his heart. When we're first introduced to Rocket, he's a hateful, selfish, and sadistic creature who doesn't care about anything or anyone else besides himself. You're some saint all of a sudden? What is the galaxy ever done for you? Why would you want to save it?  Abla, we're all very fascinated, Whitey, but we like to get paid. Rocket is a Frankenstein's monster who has been ridiculed and mocked his whole life, causing him to always be a defensive, aggressive, and pessimistic creature.  The ending of Guardians 1 has Groot sacrificing himself and Rocket doesn't understand this. We are family, we are friends, we are Groot. Rocket doesn't understand selflessness and sacrifice because he's never had to, and when losing his friend, he breaks down. While mourning, Drax pets Rocket and Rocket lets it happen because Rocket now understands Drax's pain for when he mocked his dead wife and daughter earlier. Rocket understands true loss and now decides to share his pain, as hit tops films once said.  In the next movie Rocket is now sarcastic instead of aggressive and conversates more. Rocket isn't drawing weapons and caring only about money, he's accepting his new friends instead and even takes the responsibility of keeping Groot safe. Showing he cares for someone other than himself now.  Rocket still lacks sensitivity and doesn't know how to conversate without insensitive comments. Rocket makes jokes and quips about people's vulnerability because he's afraid of being vulnerable himself. The guardians are his only friends in life, Rocket doesn't hate them, he just doesn't understand why he is the way he is and struggles to put feelings towards. If I was forced to pick only one scene in this video, it would be Yondu confronting Rocket. Rocket's ego, narcissism, and feelings are confronted by someone who could relate with him in this scene. Rocket's been making excuses to not accept his feelings the whole movie. And when they're challenged, he gets emotional and scared. He attempts to name call and keep a hard attitude but he's truly afraid. Yondu pushes his friends away previously and he also dealt with neglect his whole life and Rocket sees this, he sees that he has a chance not to do the same thing and decides to accept his new friends and accept his emotions. Rocket becomes vulnerable. In the end of the movie, Rocket mourns Yondu who became his friend that he had to let die to save Quill so he could redeem himself. He becomes aware of the choices he's making in his life and is emotional to see that the friends Yondu pushed away came back. Coming to the realization that he has a chance to change before it's too late, he reflects the decisions he's made and Rocket has now learned and decided to change. And Quill lets Rocket know that he will never chase his family away, no matter what.  Now that's character development. In Infinity War Rocket's more mature because of Volume 2, Thor calls him a rabbit and turns the other cheek. Thor mourns and Rocket doesn't make fun of him for being vulnerable because he understands where Thor is coming from. He even acknowledges that he has a lot he could lose in his life but then he loses it. His friends, his family, his child and like before Rocket is alone by himself, mourning, saddened and vulnerable. Rocket is one of the best written characters in the MCU for how much depth he has.  He could have been just a gun wielding asshole and still be loved if instead James Gunn gives Rocket more of a character in Volume 2. I love superheroes but without loss, challenge, sadness and vulnerability you get a hollow character that lacks relatability. That's why I did the Captain Marvel Gag because everyone in the MCU has challenge and vulnerability making them relatable because without that you don't have a hero.


Hi everyone, thestockswush.com will be holding an event extraordinary. We'll be holding a 5-day trading conference next week, June 6th through June 10th between 9 o'clock and 11.30 every morning. It will be held in the Stockswush Trading Room and you can log in every day anytime you please after 8.30 a.m. Between 9 and 10.30 you will enjoy an open house trial at the Stockswush Trading Room. It will be business as usual for us as we spend the time between 9 and 9.30 rating possible golden-gap plays and focusing on the likely morning winners. 9.30 to 10 is intense trading time. Usually we are done trading by 10. Sometimes it may last a little bit longer. We'll then take questions and review the morning activities. Then at 10.30 each day there will be a different lecture topic.  On Monday Melissa will discuss trading with size and risk to reward. On Tuesday we will have a guest speaker. Mammon Mia from a brokerage firm will discuss prop trading. On Wednesday Paul will discuss a topic near and dear to everyone, how to handle slippage. On Thursday Gerard, a student of Melissa's, will talk about his life as a trader and what he did to get there. When he's done Paul will give a quick review about the proper path that new traders should follow. Melissa will close out Friday with a lecture on perseverance and what it takes to make it as a trader. This is a five-day event you don't want to miss. Please log in anytime after 8.30 to make sure you have access. To register send an email to info at thestockswush.com as you see on the screen. Be sure to include your full name and phone number. You will receive login instructions. During the open house part of this event you will be seeing the strategies that students learn in the Golden Gap course. Our next Golden Gap course is going to be Saturday and Sunday June 11th and 12th that's the following weekend between 9 to 5 a full weekend each day Saturday Sunday 9 to 5. Be sure to call 9293200 Gap or simply email Melissa at thestockswush.com if you're interested. We'll see you next week at the conference everybody.


Thank you. Thank you for having us So we're we're delighted here to represent come here today and represent North country Can we ask somebody to quiet the hallway? And while we're quieting the hallway can the court reporter swear everyone in Thanks for having us here Today what I have it takes a team to Manage a hospital and so I have quite a few team members here represented and I want to just give them a second to introduce themselves, so I'm Tom Frank. I'm the chief operating officer Andre Bissonette. I'm the CFO And then in the audience today we have Gary Gillespie he's our board vice chair Anita flags are controlled Adam is our staff accountant Okay, we have from the we have Gary Gillespie in the audience who's our board vice president Anita flag as our controller Adam is our staff accountant and And Wendy wasn't able to make it today So just a couple quick accolades for North country hospital to start with In 2018 we were delighted to be independently chosen by advantage as one of the top 100 hospitals in the country and then also we were awarded the most wired hospital for the third straight year so 2018 2017 and 2016 and Recently this spring. We were given the governor's work side wellness gold award And This year is a special year for North country hospital. We're celebrating 100 years We've been around for a hundred years and our original hospital still stands. You can see pictures of that It's an apartment complex now, and you're all invited to come celebrate another hundred years with us if you'd like Hopefully both buildings will still be up so you've heard you continue to hear from a lot of the hospitals in our state and It's true. All hospitals are are unique Small and large, but overall our industries continues to be challenged to remain solvent and To be relevant to to remain relevant to be real relevant to our communities Just as a reminder for North country hospital our service area is roughly 30,000 Lives we live we have 45 minutes to the closest critical access hospital in two hours to the To the closest tertiary hospital, and of course we're at the border So most hospitals would have a circle around them. We have a half circle when it comes to our service area and a reminder of our structure North country health systems operates North country hospital and Within that hospital. We also Branched out and we have North Northeast Kingdom health care collaborative, which is an LLC with st. John's very and We also offer a rail so operate derby green nursing home So we have for you a presentation. I believe it's very vanilla we are seeking Nat patient revenue increased within the Green Mountain Care Boards guard rails and the last year We have had a soft start and and it's really come around with a lot of effort from the team to manage finances and We've projected a gain at this point greater than one million dollars in our operating margin for FY 19 and The last that's a significant improvement from the last two years where we've had operating margins For FY 17 and FY 18 losses of two million dollars each year So we're really seeking to establish a consistent healthy operating margin. And so We're pleased to put for you forth in our budget a plan to Operate within the guard rails that Green Mountain Cards care board has requested So our opportunities and risk Along with you know managing and reinvesting in our institution You've heard this time and time again is to recruit and retain workforce We're not unique with that that need we have market pressures on compensation. We compete naturally For for our staff and there is a limited availability of qualified staff we We continue to pour in additional resources and to our population health And managing the complexities around that Examples of the mental health and opiate use and we continue to respond to the regulatory pressures at a federal and state level Being those regulations regarding a critical access hospital how we operate our 340 v and our crediting bodies such as So continue with opportunities to the things that we have a lot of activity on currently is Coming up in September early September will be meeting with our board to have strategic discussion about our service line road map and in Tandem with that on a parallel track our physician development plan So there's services that we are required to provide as a critical access hospital And then there's services that we desire to provide as a Small rural hospital, so we'll have discussions about those What's the difference between those our contribution margin of each of those and and then pair that with our our study that we've Recently obtained from three health that helps provide insight to our demographics and what our community can support across all specialties So we like I said, we serve about 30,000 lives and understanding the demographics of that Of our community helps us to understand how many primary care docs do we need how many orthopedic surgeons can you Support cardiologists urologists all those specialties And then also Acknowledging what's the what's the retention plan of the docs that we have the doctors that we do have We employ 95% of the doctors And so we want to also have awareness of doctors are have retirement plans And so looking at forward in three years. How many of those doctors will still be with us Working with us and it's honest conversation Our physicians will be part of that discussion in early September They complete a survey We also had with 3D health. We also had calls cold calls to residents on behalf of residents to our Our care practices our primary care practices and so forth just assess how hard is it to get in to see a doc We may say that we have an open practice, but how hard was it to? To call up and say I need an appointment within a week, so we believe we have opportunity there to Continue to evaluate what how we're managing Our scheduling, but also how we're managing the workforce when it comes to those key drivers of our physician base We continue to work on new staffing models to reduce cost we have one example that's in the works right now With our med surge and ICU department They've been separated for years and we are converting those over to be a shared shared workspace to manage that a shared nurse workspace and we'll we'll rebrand it as a progressive care unit We have done some changes in You know our support departments We have a revenue cycle department that's had some changes in the last year and that's resulted in some Staff efficiency changes which included also a decrease in one director role We participate in programs much like many of the hospitals in Vermont with the the NIA the New England Alliance for Health through group purchasing and We use that heavily with our 340 b program and then a big a very big change for our hospital in May of 2018 was the conversion to our all-in-one medical record, which is Athena health and that's helped with increase our operating efficiencies decreasing our operating costs and capital costs and and really has challenged us to Really look at how we're managing the patient record in an inpatient and outpatient setting It's not perfect by any means, but we feel like we have a good partner with Athena health And through this result. We've also through attrition. We have been able to reduce the FTEs to support our information system That's amounted to roughly eight full-time equivalents For those were information technology and three were in billing and one was in transcription So looking at our Some of our financial indicators Indicators of our health our operating margin when compared to us critical access hospitals is slightly above We're at 1.6 percent and the US average is 0.9 percent Our days cash on hand currently are roughly 200 plus days and the US average is 78 days And our average age of plant is twelve point seven, which is higher than the average US average of ten and a half And I'm going to take a break and pass it off to Andre to share some more financial information This is our P&L the same P&L that you guys have seen You know kind of a vanilla flavor as Brian discussed the two highlights, you know 3.4 percent NPR growth and then you know talk about expenses. We had a 2.3 percent expense growth Some of the stuff that Brian just talked about enabled us to actually lower that growth rate from what we'd seen in past years We put a cash flow slide in I didn't actually put a cash flow statement in here This is our year-end cash balances over time from 2015 the current As you can see 2018 was low We actually ended up dipping into or needing to dip into a line of credit in the last quarter of 2018 in the first quarter of 2019 Our cash is improving right now We have a much healthier status and we no longer have a balance We were able to pay off that line of credit. It was just under two million dollars. We had almost maxed it out But we've actually been able to pay that off And then our balance sheet again pretty pretty vanilla overall All right checking account balance basically has been improved that top line That's the one highlight that I have for the balance sheet Compensation and benefits and locals and travelers have been our cost drivers That's probably a common theme that you're you're hanging throughout the hospitals Our locum expenses have definitely increased this year and continue. We don't see any slowdown of that even though our salaries as a percent of total have remained pretty constant the locums are are increasing These are two graphs that kind of represent those trends over time As you can see the locum expense is a percent of the total expenses Even though they may look like small numbers. That's a pretty significant increase from where we used to be And this is just to come combined trend line over time bad debt This is an item that we've watched grow over the last year The 2020 bad debt is at the highest level that we've seen We've got some different pieces that are related to that. There's a self-pay. We do have Probably about half of our increase is related to some commercial, which is our other payers third-party payers Blue Cross we still have some Claims out there from their their transition January 1st We have some claims in Medicaid that are in a suspense status Some denied claims that had to be reworked from Medicare and then a few commercials So that's about half of it. The other half is our self-pay Self-pay we do we try not to send self-pay to collection to bad debt We try to work with our self-pay patients to get them on a payment plan if possible They can't pay that bit that bill in full. That's Just under two million dollars is what we have in our self-pay payment plan balance is right now the question on Projections do they hold from where we when we initially submitted our budget? 2019 projected is roughly 1.4 million Year-to-date June our actual was 709 Thousand dollars on our bottom line the budget was 408 The budget for Total year of 19 was 900. So yes We believe our projections are actually going to exceed a little bit Currently from one of our projections were submitted This is the graphical representation. This is where we were Over the course of the year as you can see in December we bottomed out We were losing almost two million dollars. We put a plan in place to turn that around That's the blue line The black line is our year-to-date budget trend and we can see that that blue line is tracking Above our budget trend and we just closed July out and that trend is pretty much holding at the same level So more of a hospital story when it comes to one care We made the decision this year to jump into two payers, so we've been we're in our third year of the Medicaid risk contract and And we've done favorably with the with the Medicaid program So we've jumped in the commercial with the blue cross for the the future 2020 year and I would say that I I need to give accolades to to Tom Tom Frank and his team because what they've been working on with our primary care has really prepared for us To be in the ACO years in advance and we have a strong medical home model that's pair blind and and we we've operated that environment for For quite a few years, and I believe it was that work ahead of time that helped us to have a ease ease within the Medicaid ACO and So we attribute that to ongoing good work from the past We we do have you know growing concerns with What it takes to continue to be in the in the product and we We continue to support that we do have dual reporting requirements for for that ACO and so that requires extra work on our staff, but we are we're handling that in-house and And then when it comes to just understanding the ACO it's important I think to remember that it's a shared risk So although the hospital our hospital performed well and received its full risk return Because it's a shared pool and not all hospitals performed at that top level our hospital Ended up getting a decrease from the overall expected Reward for being in the program and that I managed to roughly about a hundred thousand ninety thousand dollars And it's still estimates right now So we support being in it together and what the ACO is about, but it's just an illustration of it does take investment Whether our hospitals performing well or not in the program and it takes quite a few years I think again good work to the team here of the year's past to prepare for us, but there is a lag time and in working with the with those ACO products, so So we talked about You know our soft start to the year and put in some measures to to rebound from that We also measure our the productivity our staff of the with the program called premier And that's a labor tool that allows us to compare our organization to Hospital departments of similar size and scale and right now we we try to be in the ninety to a hundred and ten percent productivity range And so right now as a hospital as a whole or a hundred five percent productive the three forty three forty be contract management is another tool that's added revenue to the operating margin and And and has worked well for us. I think like many of the hospital project products You can make or break your bottom line by one component 340 be could if it went away would would break our bottom line So we're always balancing all these scales We are exploring a retail pharmacy because in our environment. We have most of our Primary care settings and and positions on specialties on campus, so we believe that there's an opportunity to capture And capture some retail pharmacy business Developing staff we host the Vermont technical Institute program At our clap at our at our site and developing future staff through through that program again, the New England Alliance for Health offers us Savings with group purchasing through supply chain the pharmaceuticals There's an education model module called Elsevier that we use to on board 100% of our people for annual compliance and and then we also use a 340 be auditor through this this shared program that that we benefit from we Through the course of the last one to two years have done facility upgrades on energy efficiency right now We calculate that's about a forty thousand dollars a year savings in our efficiencies And I've already talked about Latina health a reminder of how we collaborate Much like many of the hospitals in the state we collaborate with UVM specifically we collaborate on outpatient human Dialysis and a forology clinic clinical pathology a physician supplied through that program Neonatal intensive care and transport Collaboration with OB quality initiatives and then with Dartmouth We we participate with them on a stroke and stimmy collaboratives. They supply Through a contractual relationship our cardiologist oncology as a venture that we We Support out of st. John's very telemedicine and teleneuro telepsych telepharmacy the list goes on and on and And of course the group purchasing this We collaborate to to make our environment a healthier stronger place Locally so we partner with the FQHC northern counties healthcare just several years ago We provided a hundred thousand seed money to open a dental clinic in Orleans Northeast Kingdom human services We we use their psychiatrist to embed in our in our primary care setting with a physician and a Nurse practitioner north Vermont regional hospital partners in our LLC currently we're providing the sleep lab services We provide our general surgery coverage to upper Connecticut Valley regional hospital Because they don't there's a they're very small hospital and have a need so we're able to send a general surgeon out there Roughly one day a week and provide services there And then we also have a long-standing orthopedic surgeon that comes part-time We have one full time on our own, but we have one from little Tim It comes So our capital budget is spend of three point six in our budget, and it's funded through operating cash We put that on freeze earlier this year when we had the soft start, but we still It's important to continue to maintain Fiscally sound Institution with that with your infrastructure So we continue to push forward with that that spend and amounts to about two point three million in medical equipment almost nine hundred thousand in technology and about four hundred thousand in facilities and one of our other big projects that we're we're wrapping up is our facility master plan and Looking at what what work we need What work is ahead of us that we need to consider for the moderate modernization planning of our campus? as I said earlier our age of our infrastructure is a couple years older than the US average and we need to continue to keep line of sight to protecting and reinvesting and in the physical structure The the Medicare ACO I shared that we're in two of the three project products for us It would be an additional one point two million dollar risk to be in the in the Medicare portion There's still there's still a lot of work to Sort through on critical access hospital status as it relates to Being involved into in a capitated Program such as the Medicare ACO Once we want to make sure that we position ourselves to continue with a hold harmless with the critical access hospital reimbursement and We're not part of a system and we don't want right now. We're just Reluctantly optimistic about that work and supportive, but we we want to make sure that we know As cost reports settle out which usually take a couple years how that Health CMS is going to interpret that and so we're pleased to hear about the work that the ACO is putting in that even as of last week We have we expect, you know locums as Andre illustrated that's kind of continue to be a problem Whether it's physician or nursing staff. We have started to work internationally and recruiting staff and so we have one nurse on site now and About six more coming through the course of the next four or five months that will be on board it. These are positions we've posted for Numerous months to no success and and so we're attempting to fill the gap with it With this program I've already talked about the facility master plan You're not blocking out I Speaking of infrastructure So I won't go through the master plan activity again, that's that's redundant And I did mention again that the the medical Home model that we had is pairblind. We're doing that that work on all high risk and very high risk patients regardless of What pay are there with or even if they're self-pay? And then again the physician development plan is a key driver for The next three three years what we see and the development of our medical staff maintaining the medical staff we have but also Really come into grips with what our populations needs are and meeting that This is the total cost of care And as you can see our area in Newport is one of the lowest at 2.9 for growth rate And also the 479 Below the at the state average So this is I think a big positive for our area And this is from the blueprint Now we're in the bottom left quadrant, which is where we want to be I think this goes back to what Brian also talked about With the medical home model and the blueprint that we've been doing for many years So it's not a one or two year endeavor. It's been going on for a while. I think that's had a huge impact on on these numbers And then as far as being in compliance with past budget orders North Country Hospital has been in compliance with past budget orders. So we didn't see any any issues with that So like I said our presentation, I believe is very vanilla. That's that's for you to judge and Thanks for your consideration of our budget and we are prepared to answer your questions Super we're going to start with board member one If you could So let me back up and tell you why I'm so interested as you may know There's a rural health service task force that was established by the legislature to report back in January I'm the chair of that task force and And What the task force is charged with is looking at sustainability of our rural health care system in Vermont So I was very interested to hear that you're embarking on a your service line or map in your physician development plan And I wonder if you could just speak in a little more detail about What goes into that? What kind of considerations do you look at? I know you mentioned demographics, but if you could just go into that in a bit more detail Sure So we for the last several months we engaged like I said with the organization called 3D health and It starts with the survey first fact it starts with a Conversation about defining our service area making sure that we understand where our patients What we believe draw from and so we we predominantly are Essex and Orleans County and But then also understanding Where does our left over, you know hospitals overlap that and so there's a primary and a secondary Area that we seek to understand we also We also have a conversation in regards to You know a population of 30,000 roughly We have to understand that a hundred percent of those people are kind of access healthcare. I mean There's there's people that need to and there's people that they're not going to access it until You know, it's apparent that they need it And that's that's part of the challenge rolling back to the ACO is making sure they've identified the people that need it before they Sometimes understand that they need it But then so then we once we set the guard rails of parameters for that We had we included a medical staff. We did a short survey. It took them three or four minutes to complete We had greater than 50% participation if not more and they they tell us What do they through all specialties what do they hear from patients or what do they believe are the needs for the For for their patients that they that they interact with so we get their perception and what they hear and then And then we look at national data Or 3d help does looks at national data and they look at based on the demographics your population when I say demographics It's male female at age groups You know income level understanding them at a deeper level and what their potential so we have a higher Senior population we need to understand that they're going to access health care differently than the zero to 17 So so that all rolls in together to to populate Based on that those those populations and the demographics of what I'll cross each subspecialty and you can you can support so We this is preliminary, but we believe that we It validated that we need to recruit to retain one additional primary care doctor And that's already been on our recruitment plan Cardiology what has been an area where we've been short and we've been providing historically maybe two to three days and The surprise for us somewhat of a surprise is we really could support up to two cardiologists full-time and we use that as a validation for When we look at recruiting and resources and putting that in knowing that we can fill a full-time position And keep them busy and it's serving the population And so we pair that together and also Come am I am I am I hitting the points that you'd like me to I Don't want to be too long-winded they might turn the lights out So so I guess what I'm trying to illustrate is it's fairly detailed. It's a three-year plan And by the end of our September meeting we will be on the same page with and I'm not saying we weren't but it validates Okay, we're going to spend resources. We know that it's in the right spots We're not going to recruit for a You know full-time position that our community can only support say point two five We know based on the specialty what is What is revenue producing such as like a surgical Physician is going to you know generate business most likely with a Higher contribution margin, but a psychiatrist on the other hand is more of a support services So what part of our conversation will be in September is the understanding that when we for psychiatrists for example Our primary care physicians are ready are already they fill the gap of so many shortcomings What we can't recruit and retain so whether it's urology or cardiology or psychiatry That's really the catch-all and so what we can do is make sure we understand if we invest in some of those I'll call support FTEs Physician categories that lists the load for primary care and allows them to practice primary care so So they they can focus on What they do best and the physicians that we hire can focus on what they do best I've had also a clarifying question from your narrative When This is on page four of your narrative if you happen to have it and that would be helpful, but the question was about The commercial self-pay other revenue assumptions commercial insurance revenue estimates should include the latest assumptions And your answer was that there were no significant changes for commercial reimbursement other than people opting out of health care due to Individual mandate penalty, which I found interesting because you were the only hospital who mentioned that And what we've seen in the enrollment numbers in Vermont Health Connect statewide was no change So I was just curious your data source for that or whether that's more anecdotal stories You're hearing because it was it wasn't outlier in terms of the information that we've received elsewhere Yeah, that was a little more anecdotal Robin We have six navigators That help people get enrolled both in both QHP products, but as well as Medicaid And they've seen a little bit. It's not huge, but they have seen a little bit of a shift Thank you Robin Tom Thank you, I Spent some time up at North Country Hospital a while ago and it was I Tell you all these hospitals is I think I said on my tour If you dropped me into the middle of it and asked me to how to get out it would be impossible there Such a matrix. It's But the drive-up is lovely So my first question has to do with some some of the data that was in the updated Bridges document That that you presented and it shows It profiles a decrease of 5.6 million in Medicaid NPR from 13 1 million to 29 in 2019 budget to 7.4 Million in 2020 budget Essentially a flat Medicaid revenue and an increase in commercial from of 11.4 million from 37.1 million to 48.6 million and these seem like Big movements to me and the reference on the on the on the bridges document was mostly that this was a Changes in payer mix and so I'm just wondering if you can comment on that Not really without digging into the data. Are you looking at the budget the budget or actual I am looking at 2019 budget to 2020 budget Yeah, other than that there may have been a shift from what we had initially budgeted for 19 So actual because we build our budget for 20 off of our current run rate So that's without actually digging into that deep My next is looking at bad debt the bad debt friend it's Since 2018 it's been on a kind of a 46 percent Growth rate and the free care is growing at about 10 percent And I'm just wondering how you're managing the relationship between those two programs Yeah, the free care Kind of answer two different answers the free care again, we have six navigators that The rest is probably it may not be the right word but go after and try to get our self-pay patients enrolled Either in free care or in Medicaid or in the one of QHP products We have a number of different avenues and touch points with our patients because we do have six navigators Hopefully they can get get those people on free care Those people who are not willing to come in and apply for free care would end up The AR age out and become bad debt. So I don't know if that fully answers your question That's the relationship between the two Like a lot of a lot of times look at it as one big bucket because it falls generally the self-pay When we try to manage that so we get it captures many of those patients and either again one of those three three products Does that answer your question? Yes I noticed on appendix nine and I think I think this was discussed last year a little bit But on appendix nine, which is the kind of salary profile You have the position of being the highest percentage of total salaries in the 300 and thousand dollar and and above categories at 23.6% and I think I have a recollection that we discussed that at one point and a lot of it had to do with longevity and Just the you know people kind of coming and working at North country and liking it there and staying there And this accrues over time as opposed to kind of starting salaries I'm just wondering if you can comment on that Yeah, my only other comment on that would be that part of it And I think the other part is the fact that we employ 96% of our physicians right now So that also changes your percentage as opposed to we only employed 50% of our physicians And again on utilization I'm looking at 2019 projected over 2018 actual There just seems to be some you know fairly dramatic movements there in terms of adjusted missions are down 14.4% Acute admissions down 24.2% while acute average length of stay and operating room procedures were up 36% and 15% Respectively, so I'm just wondering if you can comment on that kind of remixing of those metrics Yeah, the comment I had I'll have is we started out this year and we ended last year Kind of when we came to a rebasing meeting in March where we had a really weird shift in our volumes coming in Our ER had decreased which had the flow through the rest of the organization particularly inpatient that had decreased But our OR had increased We're I think we're utilizing our our surgeons are much busier and then what they had been And our diagnostic imaging we continue to see some Additional volumes in our CTE program particularly Revolving around our low dose lung screening for lung cancer Not just the volumes are there, but we're also catching a lot of lung cancer a lot earlier than what used to be caught Which is very beneficial to the patients. So those are the two really almost opposing Utilization issues that are going on right now and my last question is under Other operating income you have I'm sorry under other operating expenses There's a line called other non-salary expenses and that is up from twenty one point eight million in 2019 budget the twenty five point three million in twenty nine 2019 projected So I'm just you know What is other non-salary expense? Yeah, the driver to that one, which I think we answered in our narrative was Where we classified the locum expenses in the 2019 budget? They were actually up in the salary area and in the actual for 18 and they projected and budget for 20 They're down in the other category. So that's the major difference. I see yeah, and I might have one more quick one here in terms of fringe benefits for doctors budget in 2019 at one point one six million, but now it's One point eight million and then for twenty twenty budget. It's back to one point one seven million So there's just this one one-year bump in there, but it's a big bump and I'm just curious about it I'm not a hundred percent sure what's driving that I can look into that Okay, it's a all you have to do is you can look on your operating statement You just it's the Fringe benefit MD line item that's got a one-year bump, but you can take a look at it Okay Great, I'm first. It's really good to see the turnaround that you guys have are showing this year, you know from going to negative I think 200,000 or about flat in operating margin in 16 and then a negative 1.8 and 17 and negative 1.8 and 18 This certainly was a hospital. That was a great concern last year to be able to you know, see that turn around I have a couple questions on your income statement if you could just maybe pull that up and I Think really was just trying I did have the same question Tom had about the fringe benefits Maybe that's something you know definitely to look at because that's giving you about 700,000 of favorability from your projection to but from your projection in 19 to your budget in 20 I just wanted to talk a little bit about the other operating revenue and I think you alluded to this before as far as you know the 340 b and That's really driving it looks like the big changes through your P&L and the improvements In your budget, I guess you went from 18 actual 5.1 million to a budget of 6.7 Then you actually came in you're coming in at 7.1. So that's great And then in 20 it's going back down by 700,000 and just wanted to talk about you know, is there any opportunity there to get that back equal to where you are for your forecast right now For the other operating revenue Yes, I'm assuming that's probably a 340 be a large part of it that that's a piece of it. We also had We do have grant revenue that goes through there And that has decreased Part of the decrease we had a grant was last year for what ended up Basically for Recovery and addiction that grant moved over to an agency that started up about a year and a half ago called journey to recovery They are actually utilizing that grant for For addiction recovery And we actually are have contracted with them to have coaches come into our ER So even though it's a decrease on a revenue line for us It's going back at least into our community and that's coming in So that's one of the decreases in revenue and the other operating revenue Okay one of the larger ones and then Just want to talk a little bit about the ACO reserves and how you guys are rolling that through both for 19 And then again for 20, so I'm assuming it's about the same each year right about 375 And you know, where do you see you'll be ending in 20? with your reserves Well in 20 well, let me go back in an 18 we close the year and we were closed it fair favorably for those reserves So the plan is to kind of keep those reserves in there and roll them forward Hoping or assuming that that continues on For 20 that will still have reserves in there Or we don't won't have to take if anything out of our operations to both of those reserves So for 20 or you're not putting in an additional 375 or so to put it back. Yeah, okay good I Answer that that because we did well in Medicaid it created that optimal opportunity where we could keep the reserves and Net it against with what the rebate reward We could use that to offset the new reserves that we have to create for the commercial So our hope is that those will Flatten each other out balance each other out. So neither going into the second product will not hit our Operating margin good. Yeah, you know, well, I'll see as we go down through this process But I think that seems reasonable because you guys had already built your reserve some reserves in 19 And are you able to track? Within the hospital kind of the trailing fee for service that you have for the ACO Patients that you handle within your hospital and how that reconciliation is working You're talking like for the shadow claims. Yeah, I mean just to understand like within your hospital even for those For those attributed lives that actually come to your hospital for Services, you know, whether that's tracking Favorably unfavorably because obviously you have to cover the participation fees and some other fees out of what you might be getting Yeah, we currently can't track the shadow claims Medicaid does have a methodology so that They can identify them but in our current system we we aren't able to track those those claims That's something that I think going forward into next year We're going to see if we can have something built in our system So we can track those because it's almost real time where right now the information we're getting is from one care And there's a lag to it. So You know, I couldn't tell you what our last two months shadow claims were but for the first quarter We can probably get that information. Oh, it's just something for you You know for you as far as looking at and can you talk a little bit about your cost savings programs and your alliances that you have I think with any age in different areas that you know, what's your philosophy on the cost savings? Some of the cost savings we with NIA alone We've had a supply chain savings last year just under three hundred thousand dollars That was a big one Facilities we put in Facility why we changed all of our lights out And just from the energy usage alone the estimated Brian said about forty thousand dollars by putting LEDs in On top of that savings, which we haven't actually calculated is we were changing Every week every day our facilities guys would go around for an hour Changing light bulbs not the best use of our higher-end facility guys. So you have a recycling kind of embedded component there as well as Buying new light bulbs plus your energy costs. Those are some some of the larger ones cost containment we've As Brian said, we've eliminated Almost four positions in our revenue cycle through attrition or three through revenue cycle four through IT So that's staff reductions because of our our new EHR system And then it's just continually looking at our contracts Which NIA has also helped us with not just supply chain, but contract savings Getting better pricing on our contracts. Okay, and then this one I think we'll probably have to follow up on because I too is looking at the change in commercial as a percentage of your revenue and some of those reports that are generated through our system in the end of 2018 actual was about 43 percent and then in 19 it went up to about 47 percent and Then in 20, it's actually not consistent with the number the big increase again But just really making sure we understand that shift to commercial payers because that seems like a pretty big jump and you weren't getting it You know really through commercial rate increases, so I think we can talk about it offline I can show you what I'm looking at But it's really just to see to make sure you know your assumptions are in line with what's really going to happen because obviously if you Assume more in in the commercial and if it doesn't occur, you'll be lower reimbursed by the other payers So just want to kind of look at that assumption to make sure that's valid, but I can show you the information after. Thank you Hey, Jess And I also just wanted to add you know I did a recent tour I remember and one of the things that I walked away with was an incredible impression of your primary care practices and Building and the patient flow and all and how you manage that and so I think to some degree I do think that your success in the Medicaid model is built on the foundation And I hope I wish you success and the children happy to see that you're jumping into that Cool, too, and I would say I hope that you can be Unreluctantly optimistic about Medicare because I do believe and I think some of the information is hopefully coming out Getting out to the hospitals the critical access hospitals, but there is work being done by the ACL by the Green Mountain Care Board and by our partners We've seen them lie to You know hold harmless through the Medicare and have more information about how the Medicare cost reports are going to affect you So Wanted to just hope for unreluctant I'm like Robin. I'm curious about this service line roadmap and In particular what struck me which was interesting was The assess and I think it's a great idea and I hope all hospitals do it And it's in line with some of the questions that I've been trying to ask many of the hospitals around. What is the appropriate? services that hospital should be offering And one of the things that you said though is that the you know, you're trying to figure out We know what is revenue producing We know What the contribution margin would be some of these service areas I was struck by that because we had asked in some of our Q&A for the hospitals to share the departments where expenditures exceed revenues and where Departments where revenues are exceeding expenditures to try and figure out where are the Margin the positive margins and where are the negative margins where the service lines And your terminology and where are the revenue producers and your answer was that you could not provide that information So I'm trying to figure out if you couldn't provide the information, but yet you're doing this service Assessment service roadmap. How are you figuring that out? And how can we ask that? I guess my son said we probably asked the question in a wrong way We're trying to get at exactly what you're doing and understand that at each hospital So how can we ask that question in a better way so that you could provide that information? I'll start in an object and clean up sure so the contribution margin isn't an all-in I Doesn't have all the cost of the organization in so We we park well vkd our auditors help provide this assessment It's one way to look at On our service lines, so all the overhead expenses aren't in there. So You know that drives that that margin down. So what we try to do with and this work is just identify So for example Or the pedics might show a contribution margin of two million dollars But when you put in all the other costs of support, it may be far less than that So it's just a starting point to say, okay, what how are these services doing and helps us out? Really line the site to there's outpatient practices and and that's not in there So when we look at primary care, we know that that feeds you know those service lines such as general surgery and OB and so forth in patient care. So those are all components. So so it's just one way of looking at it It's not a it's not a full accounting of the income and expenses for that that that service line So just that just to clarify that that tool that we're using isn't isn't maybe what you think it is No, no, no, I'm just I'm in some sense the tool that you're using or the methodology that you're using Not necessarily a strict accounting, but we know for example that Disclose their birthing center Orthopedics So we have some sense of where the revenue producers are and where some of the cost centers are but not across all service lines And so what you're trying to do at your hospital I think it's really important and it's something information that we're trying to get a little bit of a handle on here As we live across the hospital network So I'm not sure how to ask the question in a way that doesn't require a strict accounting of overhead and how you allocate costs, but how to get a sense of what are the areas where we realize this may not make Money, but it's providing service and generating rather than other places in complimentary services or things like that So that's I think what we were trying to ask and so I was curious about this through your Process and maybe we'll think about a better way to ask it if you have advice. I would welcome it Again in that my second question was related to that Are you looking at and this is again a little bit of my theme for the last couple days, but my concern about very small hospitals with small Populations is of course volume. So when you're thinking about what is the appropriate service mix in your new plan Are you looking at minimum volume standards or things like that that would say hey We know that there's a relationship between the number of cases and the quality of outcomes We want to factor that into our I That's an excellent question. We've been having robust discussions with our medical staff quality through in our medical exam About that specific thing and then how much is under the purview of medicine and surgery? How much is under the purview of us senior leadership saying wait, we need to we need to have a minimum standard so We've been having discussions about especially with the surgeons. What are transferable skills? So they may be that they're not doing certain procedures a lot But it's a skill in that procedure that they use all the time and another procedure So so it's a it's this kind of delicate balance between medicine and those minimum standards But we also want to drive that our quality metrics and we need a certain amount to have statistical significance about whether the Complication rate is accurate. I mean, it's also very hard when you look at all of the medical associations to find Where they say that the standards are it's very very difficult. I've been looking actually Yeah, it's almost impossible to find any any standards But that we are in Big conversations about that our surgeons backed off in the last two or three years from doing as much vascular surgery Because of that because we didn't have the volume and the risk was too high with small volumes And there may be I mean, I've been looking a little internationally. So for example, Germany won't let anybody do less than 50 So that's something in Germany So I don't know if there's I've been looking elsewhere. So what should look like? Can you just talk a little bit about you mentioned in there $250,000 for a community health expense to improve population health human sense of what that might look like So it's a placeholder So there's not it it's I would say it's for innovation We wanted to build that so there's things in our community that we are either part of or not part of that We want to get involved in and help other organization organizations continue their good work So in the area of child care, for example, there is recently an opportunity where there is a collaborative of most a few organizations coming together to provide a service to some youth and also a Service to moms and and It's called Northeast Kingdom learning services Thanks learning services. And so it's a collaborative of Local and federal Grants to start this program. I wish I can't I can't speak Confidently about it, but that's something that we Have volunteered some dollars to the support as an example Rather than us being the Instituting it we can we can provide some resources for that So so we're looking at how we can use that for innovation to get involved in And the good work in our community is it as we see it advancing community health rather than Starting it all back, you know from the hospital. No, that's great. That's great My last question is just about the HCA HCA asked a question about the ratio of Commercial payers reimbursements and Medicare reimbursement and I thought it was an interesting question many of the hospitals have answered it You directed us here financial statements, but it would be helpful for me to hear directly from you If on average Medicare pays a hundred dollars for a particular service, what would your commercial payers average? Reimbursed for that same service And if you have to get back to me on that that's totally fine I just really want to be here from you directly what yeah, I can get back to you But I think you know off the top of my head if Medicare pays a hundred commercials probably paying in the hundred and sixty Thank you Do you believe your technology issues of the past are behind you? Technology issues are never going to end It's a continuing saga as we move forward What we've tried to do is mitigate that and sort of slow down the process of where we struggle with technology We've been very fortunate that we've had an excellent team of folks As you saw we were the most wired to get the third year in a row We do our best to utilize technology to help the patient care But that's constantly changing by going to Athena We've run into some challenges with respect to what they're able to do on the inpatient side But what they've been able to do is partner with us They've been helping us from an efficiency perspective and we do now have one medical record Which obviously is a huge benefit, but they're not behind us But I'd say at least right now we're low Okay, is Derby Green in the black No, could you tell us by how much? Okay and on the 4.2% how did you determine that that that was the appropriate change in charge request and What methodology did you use to? allocate that change in charges to your service lines and Will the allocation with a weighted average? equal out to That change in charge request I'll start with your second question first The allocation is we apply 0% fee increase to our practices and it was 5% to all other service lines So that one's pretty straightforward As far as coming up with the fee increase we look at what our Inflated expenses are or change of expenses look for what we want to have for a bottom line And then work that into what our net patient revenue ceiling is and come up with a fee increase So there's no increase to Any of the physician practices? Okay And the 5% is across all other lines. Yeah Yeah, I think that's all the questions that I have Certainly Yeah, it's to two reasons That's the the major one most of the payers are fee schedule and with our primary care They're on per visit based on either Medicaid or Medicare So it doesn't change what we're actually going to get and we you know a long time ago We took into consideration if we're going to have patients coming in at least for initial visits And if they happen to be self-pay that's one way of trying to help them out Okay, so at this time I'm going to turn it over to the health care advocate Precares about And those are both I wonder if you can Remember what happened in seven other than that it did it did go down I'd have to dig into that to see why it could actually drop Yeah, and bad and bad that We have a reserve amount for any AR that's outstanding and reserve for anything over 120 days So that's one component and then we have AR that we would actually write off or send out to collections That would be bad that the the Medicaid common is what's in our AR? That's over 120 days. That's aging out. So we reserve for that You