And it's 8.30 on my computer. So I think we will start, if that's all right with everybody. Really looks ready. We'll get this morning off to a good start. So my name is Jessica Holmes and I'm currently serving as the interim chair of the Green Mountain Care Board. Today is day four of our Green Mountain Care Board hospital budget review process week two, but day four. So we'll be hearing from Rutland Regional Medical Center this morning and we'll hear from Mount Ascotney Hospital and Health Center this afternoon. Just as a quick reminder, I've been saying this at the beginning of every day, but for us to arrive at decisions for each hospital's budget, we look to our statute, we look to our hospital budget rule for guiding principles. Just as a reminder, we're gonna have to balance several often competing factors that need to slow, the growth and healthcare expenditures, while also trying to ensure that our hospitals have the resources that they're gonna need to recruit and retain healthcare workers and also to provide the high quality care that we expect in our communities. So as we're attempting to balance cost containment access quality and health system sustainability, we're gonna have to be mindful of this year's unique circumstances and the significant headwinds that we're facing. Historically high inflation rates, workforce shortages, provider burnout and the continuing impacts of the pandemic. So both nationally and in Vermont, hospitals are facing unprecedented financial challenges as our businesses, families and individuals. So over the next few weeks, our immediate task is obviously gonna be to set these fiscal year 23 hospital budgets for the 14 community hospitals that we regulate. But I wanna remind everyone that the board is working closely with the agency of human services to begin the work outlined in Act 167, which aims to move us closer to a sustainable hospital system that will ensure our monitors have access to high quality, affordable care. That work is gonna involve extensive data analysis and hospital and community engagement, but the end result will hopefully be a more sustainable path forward. As we turn back to the hearing today, I wanna extend a thank you to both the Rutland team and the Manuskatni teams for the time and effort that they've taken to submit the documents for our review. It will be a really interesting and informative day. A few housekeeping notes about the hearings today. This presentation is a public meeting. It's being recorded and transcribed. So there will be a publicly available record. If a hospital's leadership team believes that there is some confidential information that the Green Mountain Care Board should consider, either as part of the hospital's presentation or in response to board or staff questions or HCA questions, please alert us before responding. If needed, we can go into an executive session and review confidential information from hospitals. Executive sessions would have to be limited in scope as provided by the open meeting law and limited to just that information, such as contracts and information that will be deemed confidential under the Public Records Act. So if an issue of possible confidentiality arises, I will call on the board's legal counsel to determine the scope of what could be discussed in executive session, and if deemed appropriate and at the appropriate time, I would then ask a board member for a motion to go into executive session. Oh, with that, I see all the board members, right? I saw Tom there in a second ago. Tom Walsh, you're here, right? Okay, perfect. And the reporters are on and the escutney team is on. So I think we're ready to go. I hope everybody had a wonderful lunch and a little rest. And at this point, Dr. Parris, I think I will turn it over to you and Dave. And then we look forward to hearing your budget submission. If you have slides, I know you do. You can just load them up now. Oh, okay, sorry. Let me do that. I wasn't sure who was going to be projecting. So let me bring those up. Jessica, a few poems. Yeah, go ahead, Russ. I think you're gonna say what I was gonna say. Oh, shoot, yes. Sorry to interrupt, Paul. Oh, you forgot. I swear in. Yes, thank you, Russ. Happy to serve everyone in. Dr. Parris, who is presenting for the Manuskatni team? Myself, Joseph Parris and Dave Sanville are CFO. Great, thank you. I'll swear you both in. If you could raise your right hand. Do you solemnly swear that the evidence you shall give relative to the cause, no under consideration shall be the whole truth and nothing but the truth. So help you, God. I do. Great. Thank you. You're sworn in. Perfect. Thank you, Russ. I almost forgot that important thing. And I'm gonna hold all board questions until the end of your presentation just so that you can go through it without interruption. Okay. And can folks see that slide? Yes. Okay, great. So thanks for having us, board members, as well as members of the public. God, I wanna say this is my ninth time between being CMO and then CMO slash CEO, presenting the budget along with my partner, David Sanville. Do you wanna make a quick note that our controller, Teresa Tabor, who's usually presenting with us is unfortunately leaving our finance team, our well-oiled finance team. I won't say it my suggestion, but at least I planted the seed to take a position in the western slope of Colorado. So normally I'd say she's off to greener pastures, but it's high desert and it's sandy and rocky out there, but we're gonna miss Teresa. She's done a lot of great service for us and has helped us for many years, this year included in presenting the budget. So we will go through the agenda as listed here. We have a lot of slides. We'll try to move through them efficiently. I know board member Holmes just said they're gonna hold questions, but if anything pops out or seems odd, please flag me down and I will stop there. I seem to only be able to see my own slides on the screen, so you'll have to pop in audibly if there's something you'd like clarification on. We'll go through the overview. So our mission is to improve the lives of those we serve. That's been a simple and succinct mission statement for many years here. We often do choose pictures when we are marketing ourselves that focus on our rehab presence. That really is a prime focus for us. We do have the 10 bed acute rehab in addition to the 25 bed critical access hospital. Our rehab is the, I believe the only car for accredited acute rehabilitation facility in Vermont. And something we're very proud of and we continue to care for hundreds of post-acute patients from Dartmouth-Hitchcock and from around New England yearly. This was especially pronounced during the pandemic when we were receiving rehab and post-acute patients from all over New England, in New York, and even Pennsylvania. Our org chart remains unchanged. I do wanna just make a quick comment. We continue to run our historic homes of Runamid, which is an assisted living facility in downtown Windsor. We had unsuccessfully applied for some congressional earmark funding to help renovate and put some much-needed infrastructure investment into that facility, but we were unsuccessful there. We have kept that- Can I just interrupt you for a quick second? For me, at least your slides are not advancing. Oh no, okay. I'm not sure if others are experiencing that as well, but I just thought I would check in. Is it advancing for other people? No. Okay. Did you say yes or no? I see the Green Man Care Board budget presentation, the very first slide on my screen. Okay, let's go back here. And I was gonna say, if Kara, you wanna help in any way, I know it's also not in slide form. I wonder if that's part of the issue. That may be part of it. Hold on. Okay, let's try this. You wanna go see who's here? You wanna go see? I'm just gonna ask everybody to put their microphones on you. Okay, it tells me that I'm sharing. Let's go back here. Let's stop sharing. Try this again. Sorry about that. Do not worry, this happens from time to time. Yeah, open share tray. You guys use Teams and we use WebEx, both of which are awful. Agreed. Let's try this. It should be noted that Joe is the more competent of the two users here, so. Anything? Okay, now it's advancing. Perfect, thank you. Okay, but it's still in slide show form. It is, but at least you were able to advance it and we were able to see that, so. Okay, how about? How about that? Is it advancing? We see the agenda. I see the agenda. All right, it's still not advancing. No, it's advancing, yeah. How about that? Yeah, we're on your mission page. Okay, seem to have a hold up when I try to make it the whole screen. Is this acceptable or is this going to be problematic for you all when I try? I can see it, it's fine. As long as it advances, Dr. Barris, I think we're okay. So right now we're on the DH integration activities page or the organizational chart. So I'll go back to the org charges to finish the thoughts around the historic phones. Okay, sorry about that. I don't want to be, no, probably on my side. We have historically filled that ALF with majority government payers, especially those with Medicaid long-term care insurance. It's been an incredible resource for our community. However, hasn't really given us enough of a margin to do the significant infrastructure investments needed in buildings that are 100 years old. So we are facing some sustainability headwinds when it comes to our assisted living. It would be a real loss and I really tried to play that up when applying for some congressional funding. Real loss for the community because we kind of like the hospital. We run it very lean, but it's a much more affordable assisted living option for folks in Windsor County and Sullivan County environs around here. So hopefully this will continue to stay on the org chart, but we may end up having to repurpose some of that assisted living for some workforce housing or some other creative options down the line. Our integration activities are far flung throughout and widely dispersed throughout the organization and it's everything from finance to IT. Do want to make a note that we had planned to be up to our eyeballs with a complete IT integration with Dartmouth Health over the course of both fiscal year 22 and into 23. This was going to be a significant investment by us as well as Dartmouth Health and would have required a CON submission on our part. We had already done a lot of legwork there Dave had because of the financial challenges faced by the system now that work has been put off. Probably for 12 to 18 months. So we'll probably again be talking about it at this time next year and we'll have a CON to submit around that time as well. So we will continue with our current IT platforms which we actually enjoy. They're mature. We've been in the same revenue cycle in clinical EMR software for nine years now and it works for us, but true sentiment system integration will require us to go on to the epic EMR and adopt all of the financial and HR platforms that DH has. Our current service lines are listed in this slide. The red ones are directly supported by providers from Dartmouth Health. There's one correction to note here is our last bullet the neurology service line. That was a neurologist who actually trained it at Dartmouth Hitchcock for her advanced fellowship, but we ended up hiring her full-time. So it's actually a monoscutney provider doesn't need to be read there, but most of the providers you see here, even the ones that are not read have spent some clinical or training time at Dartmouth Hitchcock. So the long tentacles from the system continue in our neck of the woods. Just a quick comment on our inpatient patient satisfaction scores. These were downloaded, I believe, just the day before this presentation was due to be submitted to you all. We continue to do really strongly. Our inpatient experience scores are very high. In the last couple of years, we've had in seven or eight out of the 10 modalities surveyed for hospitals in Vermont, we've had the highest scores continue to exceed the national and Vermont average in almost all of these. We focus on these surveys and our performance on them. I like most docs, especially inpatient docs, used to discount some of this because it really takes a team, it takes a village to have strong satisfaction scores. You could be doing the best job in the country in nursing, but if your hospitalist is a jerk, you're gonna have a lousy score. Your hospitalist and doc in your nurse could be the best team, but if the unit clerk and the pharmacy tech the experience they have in radiology is suboptimal, then the score for the whole stay goes into the tank, but I think we've tried to create that relevance across all of our staff and have everyone thinking that patient satisfaction is driven by every staff member in the hospital, whether they're touching patients or not. I think at this point, I'll transition off today for a number of slides and then it'll be back to me. Dave, you can just tell me to advance as you need it. Okay, great. So good to be with you folks again this year. As I discuss with Sarah Lindbergh, this will be my 25th year of Biska slash POC slash Green Mountain Care Board. So we've hit a milestone this year. So our rate increase, our price increase is, we were in 12th of the 14 hospitals and ranked sixth out of the eighth, lower being, higher being better for this year's submission. Our NPSR FPP increases is a blend of volume plus net receipts on the rate increase. And obviously the utilization is the driver here. I just wanted to mention, I greatly appreciate the requested change in charge chart. I think it's a good way to look at things over time. And obviously we have a fairly low average through those years and we hope to continue that going forward. Obviously our lower end of the range is a little bit better than some of the other, but it's really good to see some of the other facilities being pretty tight year to year on their rate increases. We won't talk really about the next three slides. You get, they're part of your standard materials and I don't think they add a lot of value to this conversation, but certainly we can talk about that at the end with questions. So if you maybe just jump to the cash flow, Joe. Yeah, one or two quick points on this one. Essentially, if a cash flow is functionally break even for year to year, but two things to point out that you've probably heard in other presentations as well that we're all behind in our capital investments and we've really made a concerted effort even in FY22 to try to catch up on some of that, but the throughput, the bandwidth, the supply chain delays, all of those making it very difficult for us to properly capitalize. Additionally, this cash flow statement is far less than ideal due to the expected investment returns. Next slide, Joe. So volume, this is probably the most robust estimating that we've used. We kind of grabbed what was normal prior to COVID. We did look at what we budgeted and what the actuals were during COVID and but we put the most amount of weight on how we're running FY22 year to date and projected. Obviously where we're appropriate, we tried to look at anything that would be limited due to COVID, whether it's patient processing or whatnot, but we're really working off how we're progressing at this point of recovery through FY22. I guess the most important thing on this slide for me is that when we submitted our budget and completed our budget in June and sent it in in early July, we had expected that acute days would continue on the trend that we had been experiencing up to this point in this fiscal year and over the end of last fiscal year. We've had three months now where the acute census has actually diminished and we've had lower than expected inpatient surgeries. Not that we do a lot of those, but our N is so small, it's fairly material to us, but we've seen a reduction of acute to acute transfers from Dartmouth and we've also seen some of the other regional facilities being able to take what they were taking before. So we actually made a little bit of a bet here on acute days and right now we're not gonna see that trend unless something changes over the next couple of months. Really no risk with swing days or inpatient acute rehab days. Those are functionally flat. Our patient, a couple of things going on here as COVID has continued to progress. We've seen a reduction in emergency room visits. Laboratories obviously going down with less testing. People are testing at home now. And infusion, we had really, this is kind of how small we are, we had one patient who moved the needle significantly on infusion and we do not anticipate that that patient will be continuing to receive these services through the following year. The operating room is essentially flat, which might be a little bit of a bad bet sitting here in August versus June. Respiratory therapy, we've had a lot of staffing issues. And so we've kind of pushed the staff more towards inpatient to make sure that we're solid in that area. And so we've had to cut back on some of the programs that we run on the outpatient side until we get back to full staffing. Physical therapy, occupational therapy, speech therapy, all going to be down from where we're annualizing now, mostly through staffing issues. And that's, we have limited capacity. We have one speech therapist and we were contracting for a point two, that point two person retired during the great retirement of the pandemic. And so we have a reduced capacity and those things have to be pushed towards our inpatient acute rehab business because that's our flagship service and that service cannot be rendered without those folks. Clinics kind of all over the map. We've initiated a walk-in clinic aspect for our primary care here on Windsor. So that'll take a little bit away from the ER and hopefully we'll be increasing our volume in the internal medicine primary care area here in Windsor. OHC increasing significantly, mostly through staffing changes, psychiatry going down. We made a commitment several years ago to attempt to build a psychiatry program here, which we were successful at doing, but we have a part-time provider who has also retired and obviously recruitment is very difficult in that area. Oncology down kind of commensurate with infusion to some degree, pain management, we're decreasing by 50%. That is a service that we rent from Dartmouth. We have a provider that comes down and Dartmouth is short on pain management providers and has pulled back that pain management provider through their shops. So that will definitely put some pressure on. We've got a couple of potential solutions for that and we budgeted for that, but it'll be down from where we have been operating at. Physiatry, we have a new full-time provider that started at the beginning of this fiscal year and their practice is building and they are working point to FTE more than their predecessor. Ophthalmology, we've been recruiting in that area for a couple of years without success and our ophthalmologist is on the glide path towards retirement and so that accounts for the 15% reduction in that clinic. And neurology, as Joe mentioned, we've committed to that program and that clinic continues to grow as it matures. Relative to the payers, we don't expect any material or significant changes in our reimbursement rates. Medicare, predominantly cost-based reimbursement for us, as you probably know. We have budgeted for sequestration to come back into play which brings us from 101% of reasonable cost down to 99. We do receive PPS reimbursement for our inpatient rehab unit and it's clearly going to be less than inflation and the provider fee schedule also expected to lag inflation. Medicaid, we really didn't expect much change at the time of budgeting from Medicaid and typically they lag inflation pretty significantly. I would say the most important thing on that slide is really what we're experiencing right now is pre-authorization issues with the commercial payers asking for certain services to be pre-authorized that are rendered within the emergency room and quite frankly are fairly small potatoes in the scheme of things which is probably going to lead to additional write offs as some of those are just logistically impossible. These are relatively new issues that have come up over the last few months and so we have not gotten back to the table for contract negotiations which will probably start next month and will be addressed at that time. Additionally, we're having a lot of inpatient pre-auth issues with some of the Medicare Advantage payers who are being incredibly stingy on approving days that are clearly medically necessary, UHC in particular. So we're requesting an overall 4.7% gross price increase, 5.5% on the inpatient side. Generally we're a little bit cheaper on the inpatient side than the average and a little bit more expensive on the outpatient side. So we'll take less of an increase there and professional service is really anything more than 3% is really vapor revenue. So our weighted average is 4.7% for men's kidney. No adjustments or provider practice transfers or any changes in reporting or accounting. Other operating and non-operating revenue, we've, I probably have irritated Joe every year that he's had to share this experience with me that 340B in our ongoing dependence on other operating revenue to make a margin every year is more than concerning. We have come to that point for 340B as you've heard from other hospitals. The manufacturers have limited our ability to maintain our historical levels of funding. I will tell you that over the last three months that has kind of come to a head here at our facility and that reimbursement has literally dropped off the table. I expect that will be our experience next year unless we throw money at it with FTEs and some information system changes, we'll probably drop off the table far more than we budgeted probably to the tune of 200 or 300,000 annualized. So a big concern there. Our blueprint funding, we are receiving reduced reimbursement. I think there's some additional uncertainty going forward on that funding in general. So that's very concerning. The rest of it quite frankly is standard fare and probably not significant changes from prior years. Expenses, so salary, wages, benefits, we put in a 3% rate increase for all employees, effective 10, 1, 22. 2% of that will functionally be merit or cost of living. Additionally, there'll be 1% for market and or replacement costs. And for, I haven't really heard this mentioned in a couple of other presentations I've watched, but replacement costs is today I'm paying $40 an hour for this position they leave and the going rate to get somebody in the door is 45. So we'll be trying to look at those markets and the replacement costs for critical positions and we'll be trying to manage that all within 3% for the year. We actually have a fairly favorable renewal expected for our health benefits and we're hoping to migrate fully onto the Dartmouth Health Benefit Platform. We have 3% for retirement budgeted. FTEs budget to budget are essentially flat. We have six FTEs that are tied up in COVID related screening and things of that nature. But the rest is pretty much flat. And I know that there's been a lot of discussion regarding how we budget travelers. And essentially what we do is, and we've done this for years, is we budget for the FTE salary and benefits and we budget a differential between the cost of salary and benefits for an employed position versus a traveler based on current trends. So that is booked in contracted labor. So supplies, if I were to throw an average out for what we built is probably 8%. We have some things that are running at double digits, some things that are running to three to five. If I were to assign a number, a weighted number, it would be about 8% and then obviously tweaked by volume as well. Purchased labor is up. Some of that is additional integration. Some of that is the traveler factor. Purchased services are going up 8.6%. And these are the allocations from the Dartmouth Health System to Mount of Skutney and utilities, no surprise, 21% heating fuel will be in the big driver. Depreciation also increasing 11% generally driven by trying to catch up on some capital investment and to catch up on age of plant degradation. And just a little editorializing on our expenses. We have been working kind of a multi-year project with across the health system to align around a comp and benefits philosophy for all system members. One that's not driven by everyone doing the same position and every hospital gets paid the same. There'll always be some discrepancies amongst critical access hospitals, community hospitals, academic health centers on what we can actually afford to pay. And it has proven to be a pretty challenging project. Most of the hospitals are in New Hampshire, we're in Vermont, and we have different guardrails, I'll say, in putting together comp and benefits. And what we have seen is with our attempts to stay within a certain range of system comp and benefits, we end up unintentionally putting a fair amount of pressure on our neighboring hospitals in both New Hampshire and Vermont. So we expect that pressure will continue as the need for recruitment of nursing and technical professionals just continues to get worse. And Dartmouth Health has to respond to those pressures. The cycle will continue, the larger players will raise comp and benefits, we'll try to stay closer within reason or within what our comp philosophy is calling for. And then, oftentimes we end up setting the new market or DH sets the market, we're scrambling and other institutions are feeling some of the pressure. We expect that, unfortunately, that cycle will continue. Sorry, Dave, back to you. No, that's fine. And so kind of some other kind of big items that have come up, I'm sure, in a number of your other presentations. I always look at what are the big things that are driving margin. And we had projected to make 1.7 on operations this year, we're probably gonna come in around 1% and really no change from the narrative that we submitted to you folks. And we're budgeting a 1.7% operating margin for next year. Some of the things that are affecting us this year are the ED borders, which I know that you're more than familiar with, but I thought I would give you a little bit of a perspective on it. We get paid for, as a CAH, we get paid for provider downtime within our emergency room. And based on the diminishment of downtime because we have folks staying for so long because we can't get them placed down at the retreat or wherever appropriate facility, we expect to lose somewhere between $60,000 and $80,000 in reimbursement from Medicare alone next year on that item. Additionally, to put some perspective on it, we've had, if I were to look at only ED visits that last more than 24 hours from the time they get checked in to the time they leave the building, we have 202 patient days out of 365 covered with continuous stays. Normal downtime for us pre-pandemic was 30 to 35%. Obviously having an ED is a condition of participation for a critical access hospital. But right now, or last year, 21, we had 15% downtime. So our downtime of having no patients in the ED has been cut in half. The cost lost on that in probably total is somewhere around $200,000 to $300,000 a year easy. And one of the things that we appreciate the extra $200 that the Medicaid program would like to send us for these types of patients, but the fact of the matter is that probably doesn't do much than cover our cost to get that authorized in about an hour worth of nursing care. So appreciate the help. Probably really not gonna make a significant difference to us, you know, 200 days. Our average length of stay for people who stayed more than a day was 3.3 days. And our longest last year in the last 12 months was 13 and a half days in the ED being unable to send them anywhere. Similar problem on the subacute border inpatients. We estimated 2,000 border days over the last year. And generally, if we're able to get them on Medicaid, then we're probably going to get about 150 bucks a day. And our costs probably are close to $1,500 a day. So we're not even covering costs on that. And it leads to a pretty extensive write-off. Much of this is driven by our inability to place to SNFs, most of the SNFs in the area are capping Medicaid percentages. We've talked about this in prior presentations where Genesis and others are lowering the percentage of Medicaid patients that they will have in their census. So the V&A struggling throughout the pandemic. We have a lot of patients coming in right now. It's some very complicated social issues and discharge planning. I meet with the care management folks each and every week to go through. We typically have, you know, anywhere from five to seven or eight borders at any given time. And it's very problematic. I don't know that we have a good solution for it. We have a very aggressive program here to get people out and into the most appropriate setting. But we've got more than our hands full. And then the, you know, obviously traveler, locums, contracted labor, you guys have heard all about that, the great retirement. Kind of when we looked and responded to some of the questions regarding turnover rates, really what the conclusion I've come to looking at the data is that our turnover rate really has been better than many facilities over the last two years. The problem is our fill rate is not keeping up with our turnover rate. So as a result, our vacancies have trended up despite doing what we can for wages and benefits and doing good recruitment. Inflation and supply chain, you guys have heard all about that. So I don't feel that there's any point in belaboring that, but if you have any specific questions, certainly we'll answer them as best we can at the end. All right, we'll transition back to me for a while. I feel like the last number of years we've, I don't want to say lucked out, but it's been fortunate that some of the focus by of the Grimond Care Board and the healthcare advocate has been around projects that we've been deeply engaged in concurrently. So it makes summarizing what we're doing a little more straightforward. Previously, we had continued to do a lot of work around substance use and misuse and the slight shift in focus toward equity kind of stays right in our wheelhouse. So we've been focused on this work in our community health department and within the community health department, our Mount, what we call MAP, the Montesquat need prevention partnership devotes significant resources to both studying and increasing health equity in our communities. For 21, probably about $112,000 coming in and grant funding to support some of that work. We do trainings in both the community and for our own workforce. This can be trainings in trauma-informed care. We've had at least half of our staff gone through a trauma-informed care curriculum. We have a cultural competency curriculum covered in some of the yearly compliance modules that we do for every staff member and it's part of every orientation for every new employee that we bring into our hospital, into the health center. We have a specific role as designated by both the state and the prevention partnership and that's as the Prevention Center of Excellence for our region. And this is particularly work around reducing disparities and substance use rates and increased protective factors for use. So we've built dashboards at the community level that allow us to track indicators on where really the stress points are. The youth risk behavior survey helps to inform some of this and then we try to, as we give out sub-awards to various groups, we try to highlight or try to align those stress points that we're seeing with the funding support to nonprofits in the area to support the work. So that may be restorative justice programs in Springfield for example, LGBTQ plus and other parts of programs and other parts of Windsor County. And a lot of this work doesn't necessarily translate very well to bulleted slides in our HCA questions as we, the responses to those questions that we submitted, we provided a pretty extensive review of everything we've been doing in our communities over the last couple of years. As the group that generates the most data, we sharing that data I think is critical. The Windsor Jedi Committee and Jedi stands for Justice Equity, Diversity, and Inclusion have invited our Montes County Prevention Partnership to present its YRBS data on health disparities and protective factors in the Windsor County schools. We have focused on substance use and mental health, LGBTQ plus students and students of color. This led to a presentation for the Montes County School Board back in December and those conversations with our Jedi Committee and the School Board continue. We have a strong role within the school districts that we serve and again, we try to share the data with them so that it's both for both awareness and program development at schools to help our kids. I can continue on with some of the wait time works. Dave and I can do this together. What I'll say as an overriding theme here is that anywhere you see non-primary care or specialty-based work, cardiology, gastroenterology, oncology, pain medicine, urology, you'll see more extensive wait times. These are limited time providers that we are either securing through locums or predominantly from Dartmouth Health. And they come down to us, we fill their schedules, we could fill more of their schedules if we had more of them, but Dartmouth Health is suffering with provider staffing woes just like we are. We've made great gains in primary care. We are as close to fully staffed as we'll ever be on the provider side with primary care. There's been a noticeable shift and a volitional shift from having a really physician-heavy clinic to one that's more of a mix of physician and associate providers. And now we have more associate providers than we do physicians in our primary care clinics. And that is the response to the workforce. That's the workforce that's available to us. So we can't just put our heads in the sand and hope for physicians to materialize and want to come work in a rural healthcare practice. But there are some real outliers here. Pay medicine is one that's only gonna get worse as DH pulls back their pain provider. Rheumatology, we've had a part-time provider from the Yale New Haven system that had a vacation house up here for years who's been coming up one or two weeks, one or two days per month for many, many years and he's approaching retirement. The rheumatology recruiting market is just horrific nationally right now. We're not training enough and there's just not enough internal medical residents going into rheumatology. So you can see some real brutal wait times there. But we're recruiting in both of those sections right now and just facing a lot of headwinds as we try to improve those numbers. We are one of the few, if only, primary care practices in the region that are open to new patients. There was a recent series in the Valley News, our local paper about the difficulty in finding primary care. So we're happy to share that we were open to new practice, new patients, a little bit of a wait list to get in but usually within a month we can get all the medical records obtained, evaluated and then have people assigned to be appropriate provider. Yeah, I think the only thing I would add on to that is probably what you've heard elsewhere is that we don't have a lot of downtime for our providers. And so therefore any methodology to address this is gonna lead to additional costs and revenue, which I don't know, you guys are gonna have to give us the green light on that before we can recruit. And some of them functionally, to get another 0.1 or 0.2 cardiologist is not going to happen. And we're onesie twosies. I mean, the rheumatologist is very important to our practice here, our medical infusion program generates a fair amount of revenue, provides an important service to this region outside of Dartmouth. And we're not gonna get another 0.1 or 0.2 to relocate to the area. So more wait time data regarding some of our ancillaries. And obviously what sticks out is a 53 day wait time for a non-urgent echocardiogram. I think that's a nutritious number. We have been working with DH to lower that. We've also tried to come up with our own plan to get equipment and rent a echocardiographer that could at least create the studies where we could then contract with cardiology to read them. But that's a sore spot for us to say the least. We are in anything that we are struggling on the clinical or technical side, we are forming closer deeper relationships with Valley Regional Hospital in Claremont. We'd love to get to a point where we're sharing technical staff and sharing the equipment to allow for better access and capacity for both Windsor and Claremont patients. That work is ongoing. It's been ongoing for a number of years and I'll dig a little bit deeper into that in a couple of upcoming slides. We just, you know, we've been trying to get, you know, ultrasound cardiac specialist technologist and we rent that from Dartmouth as do most of the regional CAHs. And Dartmouth is down several techs in their shop. And so therefore that impacts us as well. Normal outpatient ultrasounds we're actually in pretty good shape, but it's when you need the subspecialty cardiac study that things get dicey. So we take care of our inpatients, number one, and then whatever we can do to fill out their schedule on outpatient but in Valley's in the same position as is Springfield and I believe Alice Pecday. So well, we almost got hold of a unicorn about six months ago who wanted to come work for us and in Valley and had actually filled in as a traveler both facilities at one point. And it was like, man, if we can get her in it'll be a beautiful thing. And she ended up hitting the traveler market for big dollars. So we're kind of Dartmouth has been very gracious in flipping us techs when they really can't afford to but it's not a good plan going forward. And more on wait times. We do every month in our primary care operations meetings we review all of our stats. We examine capacity and access, tweak schedules. The biggest thing that we have down at least in primary care is since last November we did start a walk-in clinic embedded in primary care which has increased capacity substantially in primary care for our own patients and for again, anyone that walks in they don't have to be one of our patients. Unfortunately, what we've seen is at least as a summer has drawn on is that the walk-in has become busier and the ED has become busier with their original hope was that the walk-in would decompress our emergency room and allow for folks to be seen in an ambulatory setting for ambulatory sensitive conditions. And what we've seen is initially there was a definite decompression of the ED but now both are quite busy. And I think that's mirroring what a lot of other health systems and centers across the state are seeing with rising urgent and emergent visit volume. We do everything we can at the primary care sites to allow for same-day access to their own providers but that can be challenging and can lead to open slots at the end of the day which we definitely don't want as well. We've restructured primary care so that it is a purely salary position for our docs and our associate providers. There's no productivity incentive. We have somewhat longer visits than most places. We have 30 and 60 minute visits only. So we're really not trying to hold too many of those spots available. We try to have same-day providers available and then we have our walk-in in clinic for overflow. I think we're gonna probably have to expand the walk-in services if the current numbers continue. And for patients who don't wanna see their own specific provider, whether that be a doctor or an associate provider, there's the because of the access we have, it's rare that a patient can't be seen that day for an issue that arises. There are questions around how we manage referrals. All of our referrals are electronic so that they can be tracked so we can make sure that the loop has been closed. The majority of our specialty care is happening at Dartmouth-Hitchcock. So there are, as mentioned previously, more substantial wait times for specialty services, whether that be GI, cardiology, dermatology. These are real issues and as I mentioned earlier, they share the same staffing stresses that we are now. Our admin staff in the clinic work with providers to triage referrals appropriately. We do a lot, myself included, make a lot of calls up to DH to say, hey, you really gotta see this person and whatever it is. I think for my first few years here, Dave would say my only added value was that I knew everyone at DH and could get patients in. Hopefully it's moved beyond that a little bit, but we all, that's part of the business. We are often making calls to try to squeeze people into already packed clinics and outpatient evaluation at Dartmouth Health. And this really ought to be fair, hasn't really changed much during the pandemic or during new endemic times. I think we were asked for some recommendations. So Dave, I'm not sure if you wanna take a shot here. Yeah, I think until we're all ready to invest in some of the solutions here, in other words, hiring staff and providers and whatever infrastructure costs and revenue that comes from that, that's what we're willing to do that. I'm not sure it makes a lot of sense to keep measuring it. I think a simple measure like what you folks asked for in this year's request, I think is reasonable. And I think you can see over time, whether it's getting better or worse. You know, if we're ready to address this from a financial perspective, then it may make sense to make that more robust reporting over time. You know, I think it's a little bit difficult when you're a border hospital versus someone who's kind of landlocked in the middle of the state. You know, for those of us who bump into New Hampshire in particular, you know, they feel like going out and getting a cardiologist and paying a large subsidy and they don't need a full-time cardiologist, they just need, you know, whatever, three days, they'll do it because they don't have any restriction on that. So, you know, it's a little bit problematic. And I think it goes back to Joe's earlier comments about, you know, coming up with some rational service line alignment within this region which would include across the river. And I think that's kind of where Dartmouth Health is going. That's certainly a portion of the time we've been investing over the last couple of years and trying to figure out what opportunities are there with Valley Regional Hospital to share staff, technical, clinical, as well as providers. And that may be a solution for us, but right now we really don't have any open slots for a majority of our specialists. I would add that to date our success with Valley Regional in Claremont, New Hampshire has been in the sharing of senior leaders and folks at the manager and director level. I think the Holy Grail is, or the Holy Grails are going to be, you know, joint staffing pools, whether it be nursing, hospitalists, ed docs, technical positions, radiology techs, lab techs, respiratory therapists, we're starting to share there. So there's a lot of opportunity, I think, to have a more regional approach to this. Some of that sharing, especially at the manager, director level does depend on that hospital coming into the health system, which is likely on track for some time in the next six months. And hopefully we'll continue to grow the foundations that we've put in place there. So, you know, risks looking forward, you know, can't get through a presentation without mentioning COVID and new variants. You know, we have got acute and chronic labor shortages in trying to maintain all of our pillars of the COVID response. It's been challenging at times. There was a recent letter to the Vermont digger from a dissatisfied family member of one of our pediatric patients that we couldn't get the booster to. This was one of the newest, you know, approvals in June for COVID vaccinations for our youngest pediatric patients. And when you're on an electronic medical record, like we are, at least with ours, CERNER, when there is a new formulation of a drug or a vaccine, especially with a vaccine that changes dose and the frequency with which the doses are given, like occurred with this younger age group, we need to partner with our EMR vendor to create a new water set that we can then use so that we can safely administer and document the vaccination in all the different places we have to do that. And there was a delay. And this poor woman was not able to get the booster that she desired in a time that we would have been happy with until the order sets were in place. We've since fixed that. But it's an ongoing, again, it's just an emblematic of ongoing stress as we have to continue all the work with COVID, but at the same time, keep the wheels on or keep the train on the tracks and everything else we're trying to do. The other huge risk, and you've heard this from every presentation, is around the health care workforce. I compare this to Maslow's hierarchy for health care. I can't self-actualize with dedicated staff to do all the cool stuff we want to do if I don't have the staffing at the bedside to care for patients that need to come in the door. And we're struggling with that. I think while we have low turnover rates, successful recruiting, there's still about 30 FTE under budget right now. And that's just open positions. So we have more travelers than we'd like to have. I think the reliance on a traveler workforce, the reliance on a temporary workforce has led to some issues and serious safety events that we have typically performed incredibly well on, both at the state and national level. But when, again, a temporary workforce that may not be totally bought into the safety culture and quality measures that we put into place, it can reveal kind of cracks in the foundation. So that is a real worry of mine. We've kicked off a back-to-basics campaign across our inpatient units so that all of our nurses, new, old travelers, longtime, stable staff here, have the opportunity to take a breath, recenter, and focus on the practices and strategies that have gotten us to where we are. I know there's been mention of the new patient care tower at DH. Yeah, that's going to be a draw on resources, certainly. As part of the system, we've engaged with the nurse residency program, with local nursing schools. There isn't a day where we don't have a ton of learners, either in technical positions or in the nursing staff, moving through the organization. So we're hoping that for the folks that we serve as a training site for, we'll be able to keep some of them, and they'll like to stay at a small place, as opposed to the Rolicking Academic Center. But that's going to be a stress, there's no way around it, not as stressed out as I am over it. I know that DH nursing leadership is just as stressed out because they've got to staff these beds. I'd just throw in one thing I thought was interesting in looking at our travelers last week, working with my staff, doing some analytics on it. We had 2 and 1 half traveler, FTE, October 1 of this year. We're currently running at 11 or 12. So our traveler issue has grown over the last nine months. It hasn't been a pandemic issue in its entirety. We kind of kept it together for the first couple years. But really, this year, since October, we've gone from 2 and 1 half to as high as 12. Another risk to consider is related to our ACO engagement. When this slide deck was submitted to the Green Mountain Care Board, we hadn't heard whether our request to remain in the two core programs, I'm sorry, that should be for 23 Medicare and Medicaid, that request hadn't been processed by the One Care Vermont Board of Managers at the end of last week. I was notified that that was approved. That is a slight reduction in our participation because we had been previously in both Medicare, Medicaid, and the Blue Cross Blue Shield programs. The level of our engagement in the ACO has been an ongoing stressor for me and the management team. With our board of trustees, we have a very engaged, sharp board who questions the value of everything we do, knowing that we don't have a number of value of revenue generating clinical service lines, and knowing that we can't volume or revenue our way out of any problems, they question everything that we do. And there was really no enthusiasm to increase engagement beyond Medicare and Medicaid for FY23. And part of that has been, and I've said this for years at this presentation and others and at the system level, all of our specialty care, all of our expensive care occurs elsewhere. We're a small critical access hospital. We view very closely to what we think a CAH should be doing with focus on primary care, general surgery, some real, any specialty work is deeply rooted in the need to support primary care. So we don't have orthopedics. We don't have any other specialty surgery program outside of ophthalmology. And when you look at where our spend is in our health service area, it's all orthopedics, like in specialty care, all occurring at DH or elsewhere. And virtually all of our regions of orthopedic care outside for some that is staying in Springfield, almost all of that care happens in New Hampshire. We're fundamentally on the hook for that. So it's always been some tenuous decision making when it comes to our ACO work. That said, we have been part of Medicare and Medicaid for all but one year on Medicare and every year for Medicaid. So that work will continue in 23. We've already mentioned wage pressures. Housing seems to be this immovable object that despite a lot of efforts by our organization, our leaders, and serving on every housing coalition for 50 miles in any direction until the cost of building affordable and workforce housing drops. And there are more private public partnerships moving in to do this work. One of which I will say DH and the Mascoma Bank have done incredible work. They've actually started a fund to help support builders who want to focus on workforce and affordable housing. That all came from our corporate council work on the vital communities nonprofit that I work on. We're hoping to move the needle. But I think our housing struggles are going to be generational in nature at this point. And Dave and I both already mentioned the uncontrollable inflation that hopefully is leveling off at this point. We've mentioned the work that we're doing with Valley Regional. We expect that work to increase and its momentum to increase over the next six months. We are working to stabilize and grow our urology program between us and Valley Regional to meet the need. There are long wait times for any urology care within the system right now. But I would add that, again, we have no other immediate plans to add to the current portfolio of service lines on the Mount of Scottney side of the river. Not much to say here except our budgeted upside-downside risk for calendar year 23. That was a number that was tolerable for our board of trustees and the Dartmouth Health Board. My bosses as well felt that that was reasonable in the time of significant financial headwinds. So this is a direct response to questions about our value-based care participation. And again, tough to put in a bulleted slide. But our organization's desire was to stay within the very well-run Medicaid program that we find to be predictable year over year allows us to plan appropriately. Medicare still remains a concern for us. I have not wavered much from my notion that the Medicare Next Gen ACOs are not the ideal vehicle for health care reform, especially in rural health care settings, and particularly in critical access hospitals, especially critical access hospitals with operating margins that oscillate around zero year after year. Downside risk, when I discuss it at national meetings through the AHA, is just something that is most rural CEOs in other parts of the country find shocking or untenable. I'm the chair-elect of the Rural Health Services Committee for the AHA. And I share our journey both in the Next Gen ACO and how we're planning for what version 2.0 of health care finance and delivery reform looks like. And most of the responses are along the lines of, wow, that sounds very interesting. Glad I'm not you. But that's us, and that's Vermont. And I think we're going to figure it out. I believe that there's openness across the state trying to figure out what version 2.0 of this process is going to look like. I'm just always on the record of saying 1.0 has been a little bit rocky to this point. But we are still actively engaged in trying to make it better. So this was a tough question. And in our organization, it is challenging to tease out what part of the PHM funds or the pre-funding of the blueprint is actually going into a specific bucket of, well, that's covering that bit of comp and benefits for that community health team nurse or continuing care nurse when those folks have been subsidized by the Blueprint for Health for years. We've never been fully subsidized by the Blueprint for Health or for the other complex care management work that we have had in our clinics. And those are nurses, care managers, social work that have been there for years. We've always had used the funding that we've gotten from Blueprint from PHM funding to actually reduce the subsidy that the hospital has already have in place for all of our community health team and community health section efforts. The pandemic really hasn't had much of an impact on our complex care management. It's been going on for years. Our overall bandwidth in primary care, we actually probably had more when volumes dropped substantially early in the pandemic to focus on care management. And now it's kind of more right-sized. But what we've seen year over year is our hospital subsidy for all of these programs has increased. I would say I would not say that our Blueprint dollars or the ACO payments fully subsidize that work in any fashion. And, Dave, do you want to add something there? No, I think you definitely really evaluate this as a specific question. So more follow-up on value-based care participation. The only thing that really we have seen as we moved from pandemic to endemic phase, at least for now with COVID, is we have seen our paramedics change a bit. We have more Medicaid patients coming through the door. In our adult populations, we are focusing still on our core bread and butter, general internal medicine work, focus on preventative screening, COLO, work around diabetes and pre-diabetes. Where we have seen the stress of the pandemic really has been in our pediatric care teams. We have built for a hospital our size a really remarkable behavioral health team that spans both adult pediatrics clinics but really has a much bigger footprint in pediatrics to help deal with the social drivers of health with behavioral health, food and security, housing, substance use misuse being our primary targets. Our community health teams, our community health department pursues over a million dollars in grant funding each year to help support efforts around family wellness, as well as our work in behavioral health, food and security. It's not all just family wellness, but it's the whole portfolio of community health work that we're doing. I'll be honest, that's a lot for us to manage a hospital of our size. The impact on Dave's finance team of bringing in that kind of dollars can be onerous. So, as we look at every new grant dollar to make sure it's actually supporting a program that our providers want and will continue to do that. But bringing in those kind of dollars year over year, it takes a remarkable amount of effort to do that job well. Our providers are well-versed in both their 1K Vermont data, blueprint data, practice profiles. We are tied into the Dartmouth Health System with our quality and safety dashboard where they see measures regarding patient access, our performance against screening measures, our performance with diabetes and hypertension. So, there are many opportunities for our providers to see how they're doing and help brainstorm on ways that we can improve care of the patients that we serve. And just kind of really repeating the prior side. We have a lot of data. I find that one of the best parts of our engagement with 1K Vermont is real-time actionable data on the clinical front. Lags, obviously lags a bit financially, but on the clinical front, we get excellent data. And I think an accurate profile of how we are caring for the lives attributed to us by 1K Vermont and the Medicare and Medicaid programs. Again, same thing. We're sharing this data regularly with our providers and with our community members. What we have found across at least in our HSA is that Mount Scotney Hospital Health Center is doing the majority of the work around complex care management. We, that was kind of predictable, I would say. But I use that data to leverage some of our community partners to step up with their engagement in complex care management, whether that be our designated agency, our home health agencies that we work with. But what we have found in our experience is that it generally falls to our continuing care nurses in our clinic to do the necessary complex care management and provide the coordination that these patients need. I've already mentioned there regarding settlement information and where investments of those dollars go, all these dollars go into our clinic operations and adding to the subsidy that we already provide in primary care and pediatrics and covering gaps in funding for some of the programs critical to what we see as mitigation to the social drivers of health. And again, I mentioned this largely in the pediatrics and family wellness work that we're doing. And we did not have a loss in 21 or projected 22. Dave, you wanna comment on our capital budget? Yeah, nothing terribly exciting or sexy in this, really trying to catch up on mechanicals and routine replacements. We have no CONs to be executed during FY23, but we do plan on filing one based on a potential go live of a DHIT platform project in FY24. I know there was some interest in knowing we underspent in capital by about 4.5 million, which was about 38% less than what was budgeted for the last couple of years. Many of the rooftop units, which are about the least sexy thing we could possibly do with capital money, those things are running at almost 100% markup for cost and install. So we had actually planned to have had a couple done by now and now the thought of doing two a year will be lucky to get one a year done and it will cost the same as two. We just ordered, just committed to a project within the last couple of weeks and the lead time on it is 62 weeks. So we've already screwed up that line item on our budget next year and we haven't even gotten to next year yet. So those are probably pretty typical of what you've heard elsewhere and they're no different for us. And then the supplemental data, probably the most controversial response I'm going to have today. So I talked to Sarah about it a bit and appreciate the info, really couldn't validate this with our own internal data per se. I think that as it relates to market share, we're kind of more driven in our budget process by our own study of where folks are coming from for our existing service lines. We don't advertise or market in other service areas. So that market data as provided really wasn't very valuable to us nor would it be. Reimbursement, we found some anomalies in the data. I think maybe the data is valuable. We just couldn't determine it as a first glance without understanding all of the definitions and the math behind it. But I offered to Sarah be happy to sit with the folks and kind of go through there, kind of mush some data together for our swing bed and rehab into our normal inpatient data, which of course made length of stay and some of those things look a little bit goofy on it. So I think there might be some value in that. We've testified in prior hearings that from an outpatient perspective, we are very expensive and we've made material efforts as best demonstrated by our rate increase, but also by our price reductions last year. And I actually have another one sitting on my desk now, but it seemed a little self-serving to send it in the week before our hearing, but with another marked decrease that we will not request that our submission be changed. We'll just eat it. So we're making steps towards that and I think it is valuable for us as a state to look at that data and we'd welcome the opportunity to go through it at a detailed level. And lastly, I know we've already hit most of this already around COVID-19, in fact on us, we are still carrying FTE, COVID specific FTE regarding for things like screening access to the doors, to coordination of our activities across the help system. That's been the same for a couple of years now. I think we're always gonna have to carry five or six FTE for this kind of work. We have invested in our infection prevention team. We've made hires into our quality and safety team that were somewhat motivated by our pandemic response, but that's been a fundamental tenet of my tenure here and that's been investment in quality and safety efforts and growth of that team. So those folks will always be here. That FTE will always be with us. But the final mention really is just workforce. It's workforce, workforce, workforce. Dave has mentioned the great retirement. Some people talk about the great resignation. I refer to it as the great reckoning. There's just been a lot of folks that have left the workforce and the folks that have stayed in the healthcare workforce, they're tired. And I would say brittle when I'm covering on the acute rehab or in our acute inpatient units as a hospitalist, people are just fried. The level of burnout is significant. We've weathered much of this. We've had, historically, have had quite high employee engagement metrics. The Dartmouth Health System does a system-wide press-gainee employee engagement survey twice a year, a pulse survey in the fall, and then a major engagement survey in the spring. And we continue to have really strong scores as high in the fall. We're in the 80th percentile nationally and employee engagement dropped a bit to the 76th percentile for the spring full survey. But that's just due to Herculean efforts by the dedicated staff that we still have. And, but I always feel like we're gonna run to the engagement well one too many times and it's gonna be dry. And we are tiptoeing toward the cliff edge on our staffing right now with multiple senior leader meetings each week. Typically, Monday is a couple on Fridays where we're talking about, do we have enough nursing staff to keep ED beds open to keep rehab and acute inpatient beds open for the next few days? And while we've done a reasonable job in staying reasonably full, despite staffing woes, we've seen a bit of a summer swoon. Part of it is there does seem to be less patient volume or less inpatient and rehab volumes coming to us. But there's also been nurses and other staff providers taking much needed vacations. So it's an organization that's under stress right now. I'm hoping that our strong engagement or our safety culture pulls us through this, but is certainly of concern for all the leaders here. And with that, I will finish up and stop sharing. Great, thank you both. I really appreciate the candor, appreciate all the information, some really impressive programming you have going on in initiatives that was exciting to hear about. I think what I'm gonna do is, before we started with the board questions, is maybe just give us a 10 minute quick recess, little bio break and a chance to stretch your eyes and also board members to compile your questions. So we will come back at three 10, 305, sorry, 305. Okay, so just a quick 10 minute kind of regrouping and we'll see you all back here at 305. Thank you, okay, great. It looks like we have all the board members back and see Dr. Paris, I see Dave, wonderful. So I think everybody's here and I'm assuming the court reporter as always is on. So, I knew you were, fantastic. Okay, with that, I'm actually gonna turn it over to board members for questions and I'm gonna start with board member lunch. Do I have a question from the court reporter? Lisa, you have your hand raised. Okay, I'm gonna assume that might be a misraise. Robin, do you wanna kick us off? Sure, thank you very much. Hi, Joe, hi Dave, nice to see you. Thank you very much for, as always, a very clear presentation. So I'm gonna start with a question that I've been asking all the critical access hospitals to speak a little bit too, which is, could you talk about how some of the higher inflationary pressures that you've seen in fiscal year 22 will flow into your cost report and the timing of that just so that we have a sense of how that will impact things? Yeah, so I think the answer will be similar as you've heard from other critical access hospitals, which will be that, obviously, we will submit all reasonable costs as Medicare defines them on our cost report. And so the benefit of being a critical access hospital and the detriment are connected. One is when things are getting expensive or volume plummets, we never feel all the pain that a PPS hospital would feel in that circumstance. The flip side of that is when things are great, volumes up, payer mix is good, all those things, we never enjoy the upside completely. So the long and short is, yes, it'll be recognized, Medicare's fair share will be recognized on the cost report that will probably not make up for the fact that we're locked in for 90% of our commercial experience with current rate, current reimbursement and certainly not gonna get anything from Medicaid. Does that answer that question, Robin? Yes, thank you. Sure. The next question I had was related to the travelers and just understanding what assumptions go into the numbers. So you had mentioned, Dave, that you're back in October, you were looking at more like 2.5 FTEs in travelers. Last couple of months, it's closer to 11 to 12. I know we've certainly been hearing that also the dollar amount, the hourly wage for travelers was very high and seems to be coming down. So what I was curious about is are you seeing, I'm assuming you're seeing that same trend, but it'd be good to know if not. And also, what did you base your budget assumptions on in terms of those dollar amounts and numbers? Okay, so a couple of things is we budgeted specific amounts based on the type of traveler. So an RN versus a lab tech versus a respiratory therapist. And those rates, they do vary pretty significantly. At one point, I think we were up to about $220 an hour for an RN.  And lab techs, rad techs, and respiratory therapists, RNs is predominantly what we're experiencing right now. RNs being the most expensive, but I believe in one of the prior presentations, they were trending down to $120, $130. That's pretty much what we're seeing at this point as of like kind of today. And then what we do is we just budget the differential between the traveler rate, less salary and benefits for a like position if they were employed. And so I hope that does it. Yeah, yeah. What I was curious is, so when you did your budget, did you assume it was gonna stick at like the 120 rate or did you assume it was gonna come down more or be higher? I think at the time for nursing, we were like 130, 140. And I definitely can get the specifics for you because we literally line item, budget that. And then the rad techs, lab techs, RTs are kind of the next level down. So they would be probably 100 to 120 off the top of my head. Great, thank you. And once that's the housing, which to tell you, we just had a discussion the other day that one of our travelers for an apartment that would have rented pre-pandemic for $900 a month is paying $2,100 a month. So guess who's paying for that? Yeah, all of us. Housing is a big issue in the state. Okay, let me just flip through and check my little sticky notes here to see what else I've had. My analyst just texted me that, so it's kind of the beauty of Zoom, right? So this just in. Yeah, so lab techs are closer to 90, rad techs are closer to 90. And we budgeted 130 for RNs and RTs are in the middle. So. And it's important to note that EDRNs, surgical, same, it could be the range, could be 160 down to 100 for a staff nurse on the acute unit. So 130 seems like a safe bet right now. Okay, thank you. I had a question about appendix one, which is the reconciliation table and certainly if it makes sense to follow up on this and not speak to it right this second, that's totally fine. So the top half of that table is the budget to budget and then the latter half is the projection to budget. And the part that I was a little bit confused by is I would have expected the rate effect from the rate increase to be the same in both tables since your rate increases, what your rate increase will bring in, what it'll bring in. So I was a little confused by that and I wondered if you could just speak to that or you can follow up if that would make more sense. So just to, are you talking about the, looking at the title here on these things? I have them in front of me. These are on the analytics, right? The five, six page. It is on, and I apologize because I don't know how you get it, but it's the appendices that are behind the budget narrative. So the first page is fiscal year 23, budget reporting requirements, appendices one to seven and it's appendix one. Yeah, I don't have that. I'm sorry, I don't have that with me or anything that looks like that. But I'd be happy to. So what is the... My question is in the projected to budget, there's nothing listed for the rate increase and I would have expected the rate increase to be the consistent factor between the budget to budget and the projected to budget since it brings in a set, sort of a certain dollar amount. But maybe you could just follow up with Sarah about that. Yeah, I'd be happy to. Yeah, I think I do know what, that was part of the submission though. We don't have it the way you have it, but. Right, I figured it could be something like that as well. We already talked about that. Okay, so the other question I had is about the blueprint. And I was curious about your statement that you're worried about the blueprint funding ongoing in part because the blueprint was asked by the legislature to do a legislative report on how to increase the blueprint funding. So the discussion in the legislature was pretty positive about potentially seeing if next session there might be more money, not less. So that's what I had been hearing. It sounds like you're hearing something different. I just wanted to learn a little bit more from what you were hearing and what you were thinking. Yeah, I think it comes from three different concerns and we're hoping is not a perfect storm. So one, we had a $340,000 hit to FY22 because we were being overpaid from that program for like two years or something along those lines. And we can go into the reasons why, but it was the contractor for the state miscalculated it and we had to take the hit in one shot. Month of May, actually. And then of course the ongoing, I think $10,000 a month going forward hit. The other part was as we dug down to try to understand what happened in this situation with the state of Vermont, we realized there's parts and pieces to this. And I think it was a little bit more complicated than we understood at the time. So between the spoke, the straight blueprint, the stuff running through the ACO, so it was like, and then we were hearing things related to the ACO that some of the payers weren't gonna play. So we didn't cut our budget, but we have these like an asterisks next to it for us mentally that I mean, if you've heard, I don't think I've heard what you just referenced relative to the legislature actually moving into that direction. I just heard it was talked about and we all know in healthcare, nobody ever wants to pay more. So we're skeptical, sorry. No, no, no, don't be sorry. I just wanted to understand what you were thinking. Okay, and then lastly, I'm wondering if you could speak to any cost savings or expense savings initiatives that you have ongoing. I know you're part of NIA and you look at supplies that way, but if you could just remind us of those efforts that you are making. Yeah, I think DH has a pretty robust supply chain, GPO model, which they've rolled out to NIA as you referenced. I think we found some of our biggest savings in that actually on some of the capital equipment. That's where we're really seeing large chunks of savings. Additionally, we continue, Joe and I kind of laugh about it. We're worried about workforce staffing, like how many times have we mentioned that in the last hour and a half. And at the same time, we're still sitting in position control once a week as senior leaders. We have an opening in registration. Are we filling it? We have a third shift nurse RN, are we filling it? And our HR folks negotiate with all the travelers coming in. So from that perspective, I think from a staffing perspective, we're doing as much as we can and looking at alternatives like critical shift pay to incentivize people to pick up additional shifts as opposed to paying the traveler. I think you've heard that in probably other presentations and trying some more creative ways of plugging some of the staffing holes. And some things we've just plain gone without because we can't get anybody in that regard. So all the things that we've historically done at Mount of Scott need to try to bend the rate increase and bend the cost curve, we're still doing even in the midst of all of this. And I wish, you know, I just think we're being largely less successful at each of those things than we have been for the last pre-pandemic years. Would you say that's a fair assessment, Joe? Yeah, and Robin, I'd add that you know, there is gonna be some consolidation of the leadership team with the Valley Regional work. There'll be some savings on both campuses there. And, but yeah, I mean, coming from a place where we've always been counting all the paper clips, it's, you know, we're still doing that, but the paper clips cost more. So I hear you, yeah. Well, thank you. And those were the questions that I had. Thank you. Good to see you. You as well. Great, thank you, Robin. Board Member Pelham. Well, good afternoon. It's good to see you gentlemen again. I'm struck by this conversation. It's clear that you both have a lot of commitment and affection for your institution at the hospital and your community. And people don't put themselves through the kinds of trial you know, that you've had on the ground in the last two or three years without that kind of heart beating about your community. So thank you. I wanted to ask David how his golf game has held up all these years. My golf game is horrible. Mine is non-existent. So I wanted to, I don't have much here. I mean, I almost got to the point of saying I don't want to waste people's time asking questions because the top side data is to me just very compelling that if you look at, you know, your NPR FFP growth rate from 2021 through 2023 budget, it's at 2.8%. For all hospitals, it's 9.2%.  For total operating expenses, your Mount of Scotland is growing at 5.7%. The statewide average is 7.6%. And you're in for a relatively small charge amount, but I think NPR FFP, it's about 10%, which is where all the other hospitals are. So you're definitely generally an outlier on the more conservative side. And I didn't want that to go unrecognized. The only key question I had, and it probably follows up on Robbins about travelers. I couldn't follow the bouncing ball through the document in that there was this line on the income statement that says other purchase services dash travelers and the line, all the cells on that line are not filled. In the reconciliation documents that Robbins was referencing in the appendix, it says in table two that there was a $376,000 increase in travelers between 2022 and 2023. But then there was a 629,000 reduction in travelers between projected 2022 budget and 2023. So I just couldn't find a number that kind of kind of tied it all together, that I could look at it and say, here is what they've been spending on accepting your methodology.  There was a line right next to the teacher's line on the income statement that said other operating expense and it was in the $14.5 to $15.5 million range but I didn't think that was your travel expense. So anyhow, I mean, when you're looking for answers for Robbins questions, just tag that one on it. And my final issue was last October the AHS submitted to us this workforce report and it had all these recommendations from this work, this committee that was put together. They came to the board and presented and I think we generally felt that it covered all the bases. And so there's, I have a list here of all the advisory group, it was an advisory group, all of their recommendations on workforce, just on healthcare workforce. And I'm just wondering if at the ground level whether you are seeing things happen, all the agencies are engaged here, AHS, the Agency of Commerce and Community Development, the Department of Labor, DFR, DIVA, they all have related recommendations. And I'm just wondering if you're seeing anything on the ground because all of these things were supposed to unfold in generally 2002, which is in this current budget year and the 2023 budget year. And I'm wondering if we should be anticipating any improvement in, you know, from those efforts. Joe, you might modify start and then you can kind of add color or whatever. So just to kind of back up, so all of those numbers that you quoted relative to the travelers are correct. Our actual is way higher than what we budget for the year we're currently in and next year we're budgeting far less. So why is that? Because we're actually budgeting that we have people employed versus contracted help and we're only budgeting the differential, which is why we left that staffing year to date line blank on our submission. I could read that. Good, good, good. So that's why, because we have always done that before travelers were even in issue. We've done that for literally years and we bet on ourselves and then we had you a bit. So right now we're running at 11 to 12 traveler FTEs and we figured we'd have some percentage of that but not all of that. So even the differential that we built into our budget is betting that we're gonna do a better job in the market for recruiting and retention. And then as far as the other initiatives, I've never seen that document. Doesn't mean it wasn't sent to me and I kind of filtered it out of my inbox, but certainly I think the things we're seeing here is we're just not building a workforce and a lot of people are hanging it up. And so we've got a lot of stuff going on which didn't come out in our presentation relative to working with area colleges, whether it's for a bachelor's RN or it's to get an X-ray tech built, so to speak. We've spent a lot of time with those and I feel like we're all fighting over the same people because there's not enough people to go around and whoever's doing the best job, self-marketing and recruitment retention, we just had a great job in the finance area that it's a professional job and we had it posted for six months. We got two horrible resumes and we filled it with a great person. She actually starts tomorrow and the only reason we filled that job was a friend of a friend of a friend recommending us. Dave's a pain in the butt, but he's actually a good guy to work for and so we were able to kind of network our way into that opportunity and then we didn't scare her off during the interview process and we did a good job landing her, so to speak and she'll start tomorrow and it's a great thing, but I mean, it was a great deal of effort for literally one position that four years ago, I think we probably would have gotten 2025 resumes for and people have been excited to come and here we are, we had to recruit her from well out of state, well out of state. And Tom, I'd add a couple of points about eight months ago, I kind of repurposed our CNO to really focus most of her time on workforce development. So she went out and built relationships with all the training programs, more around nursing, MAs, LNAs, to kind of grease the skids and make us a training site for all those programs. And I found that you're most successful when you grow your own. But those are, nursing training is well established, the LNAs and CMAs are more manageable, easier to bite off for younger folks or folks just entering the workforce. So I feel like we're making significant progress there. What we haven't focused enough on are in the technical positions and really the training and the cost of training for respiratory therapy, lab techs, PT, OT, those are structural issues where there has to be federal, state partnerships to lower the cost of training. I can agree to pay for anyone's training, but I can only do that for a handful of people. It shouldn't cost 30 grand to become a respiratory therapist. I mean, that's crazy. So we, while I think we're moving the needle through the outreach efforts that we're doing on the nursing side of things, it's the tech side that we've kind of missed the boat on. We have to kind of have to go back to the drawing board there. We never had travelers in the tech positions before. Now, every department has got a traveler. And as Dave said, we're talking about 90 bucks an hour for a traveling rad tech. That's unsustainable. I mean, we... Well, I know, thank you for that. I know that my question wasn't well developed is one of these things that just hit me in the last couple of days is I found this thing going through the files and it's pages and pages of broad and loan repayments, increased scholarship funding, revisit tax incentive proposals, explore opportunities to expand family practice. And these were all assigned to state agencies by basically the agency of human services. And I'm just wondering if folks on the ground are seeing any activity in that ballpark. But, you know, I would say no, not in our neck of the woods. It's all has been in all our success so far has kind of been internally generated. And Dartmouth Health has done a nice job with Colby Sawyer and Andover New Hampshire to repurpose what used to be a small struggling liberal arts college in New London, New Hampshire, sorry into more of a health sciences university. So, but, you know, as they've graduated all these nurses the Boston hospitals have looked north and said, hey, we have a new training ground. So, you know, my wife was a nurse in Boston. They didn't hire nurses just out of nursing school back in the day. You had to have a few years of experience and then you'd be hired by the general, the Brigham, what have you. But now they're taking them right out of training. So all those nurses that we are now training locally are filling the poll and, you know, a 70 bucks an hour non-traveler salary at a Boston hospital versus, you know, 40-ish up here which is even, which can even be a new nurse. It's really, yeah, it's tough. Well, thank you for persistence for your persistence. And I'll pass the ball back to Jess. Thank you, Tom. Board Member Walsh, you're on deck. Thank you, Jess. And hello, Joe. Good to see you again. And nice to meet you, Dave. Just a couple of areas that I wanna do explore more we are Jedi training and trauma-informed care. You're the only facility that we've met with so far that it has included justice in this approach. It's usually been equity, diversity and inclusion. And so you seem to be a little bit more at the forefront of this type of thinking and the only place mentioning trauma-informed care and particularly with the stresses on our community coming through the ending of the pandemic, there's been a collective trauma, right, that people have been through a lot. So I really appreciate that. And I was just wondering if you'd share some of your thoughts about the relationship in your minds about those initiatives and your budget. How do those things tie in with the spreadsheets when you're thinking through our guidance and requests? How do these come together in your minds? John, that's a really good question. I mean, historically, all our community health efforts, again, because they've been non-reimbursed by traditional payers, we go out and get grants and significant grants, both from private foundations and also from the state. So, you know, we've all had this long-term success in our prevention work, our substance use and misuse and alcohol prevention, tobacco, et cetera, through the Montesquati Prevention Partnership. So we've had that as a foundation that we've been able to build on. And it's, it is, it's not as hard to put a different lens on that work to look at substance use and misusing kids by filtering by BIPOC communities, LGBTQ plus. So we're actually get some actionable data that way. We've actually had some very reassuring data too. If you look at some of our youth risk behavior survey data, I'm not sure if it's because of our intervention or not, I think it's too early to say, but the number of kids that describe being listened to and recognized in their communities, despite being BIPOC or LGBTQ plus, is actually just a hair below kids who don't identify in those communities. So that's a great thing to see. But, you know, we, again, because this stuff isn't, you know, isn't reimbursed, we either have to, we have to figure out internally, what's the subsidy that we can afford, right? And we've tried to keep that in the two to $300,000 range over the years and try to manage to that and then make up the rest by, you know, working with foundations. And, you know, when we look at our charitable donations, the money that people send to us, a very, very small amount is unrestricted.  It's all big dollars out of some of the local foundations that help us, which in that work, those funds are restricted toward family wellness program, our substance use work, our prevention work. It's, so that's kind of how we build the budget. We just know that we're going to have to come up with some subsidy that we try to keep manageable and go from there. Dave, do you want to comment? No, I think the only thing, you know, I mean, when your CFO has taken trauma-informed care classes, you know, that's probably a good thing for everybody, but, you know, part of the reasons I sit in some of these things is to make sure that, you know, that we're following through on the commitment for the deliverable.  And I think we've put good things in place to ensure we're getting the maximum benefit out of it as opposed to, you know, we get to check it off and tell the Green Mountain Care Board about it. Well, it's nice that you check it off and get to tell us about it, but it's also pretty remarkable that you're doing what you're doing, right? There aren't, we don't hear a lot of people telling us about their CFO going through trauma-informed training. And I think just looking forward with the sustainability work in the future, so much of what we're seeing places where all payer agreements have not lived up to their billing or ACO-led efforts haven't held up to what we'd hoped they were doing. They've kind of fallen apart on some of the equity things and learning what we can about our population and then designing better tools to meet their needs earlier to keep them healthier. That's what we've always been after. And so the type of work you're describing I think is really at the forefront of, you know, evidence-based policy, if you will, and where things are going future-wise and the fact that the way that you're doing it is through donations. I think is an important thing for people setting policy and for regulators to understand that if we believe these things are going to have impact, they need to be funded. Yeah, and I do just want to clear it. We're various organizations very early in our DEI journey. As I think a lot of health systems in Vermont are. I should note that Dartmouth Health does have... Can I just ask everybody to mute themselves? I'm getting some feedback. There we go. Dartmouth Health does have a significant commitment. They just hired their, I was on the search committee for their first VP of DEIB who is great. I've just been appointed to the AHA's Institute on diversity and health equity. So I'll be serving on that role nationally for a couple of years. So the hope is that we will have the opportunity to bring more back and share broadly. You know, the AHA positions are often more in a listening role than anything else, but I think there's enough momentum here that we'll have some tools that we can use. That's terrific. And as we move forward with that, one of the big lessons coming in from the policy perspective so far is that we should be stratifying our analysis of what's happening, but predictive modeling, incorporating some of these variables, race, ethnicity, those tend to pull our biases forward. So the predictive models don't work as well, but we're certainly stratifying our analyses to see where there are differences is a good thing. And I really applaud your work there. I wanted to ask a question, one final question about workforce. Do you have a sense of where travelers are coming from? Where are they traveling from and then landing in our hospitals? I think it depends. I want to say in broad strokes, we get tech positions from the Midwest, we get nurses from the South in the summer, and then they return to the South in the winter. But that's kind of it. I don't, what I'm not seeing is I'm not seeing a lot of Vermont plates amongst travelers. And I know there was a concern that, well, I'm going to get a traveler that's coming down from Northwest Medical Center to come down and be a traveler for us. We're not seeing that. They're coming from further afield. And we could get more exact data on that from our HR folks. I'd be interested, but that's been my sense talking with different people. And I've wondered, again, as we're thinking regionally, sustainably, if it wouldn't be worth exploring, having a state-grown traveling unit, when COVID moved through, it didn't hit the whole state all at once. There were pieces that needed more care providers for a time. And there were ups and downs. And I just, over the last few days, listening to folks talk about workforce, I just wonder if there isn't a way to have almost a mobile team. Not that the team would go everywhere, but you could sign up to be part of this team that you'd go work someplace temporarily, then work someplace else. And it would be a feature for people who are interested in that, that might be helpful. So we're taking care of ourselves, not having to pull people from far away, who then ultimately leave. So I'll say that that is really hard. Health systems haven't even been able to figure this out. So DH and UVM, right? We always say when we're proposing integration that oh, we're gonna develop a staffing pool and it's we're gonna be able to send people around. So we have a system nursing staffing pool, but we're not all in the same EMR. And they tend to go to wherever places closest to where they already live, which again, could be a feature as opposed to a bug or depending on how it's framed. But it's been incredibly hard to pull this off even in a smaller health system as opposed to a state. When we, I'll use an example, when we do our mass casualty planning and we're getting pushed, well, you should open a place down at the, in the old Windsor Armory and like, no, I would rather load up my boardroom, conference room with gurneys and have my own people down there than have to rely on National Guard or Medical Reserve Corps, all of whom played very important roles during the pandemic. But I just, I'd much rather have things under my roof with people that know the system. But so it is a challenge. I think it's a good thought as long as it is designed, like I said, as a feature, but not a bug. So we can do it with a lot of thought. It would take a lot of thought and thinking regionally statewide rather than locally. Thanks for your thoughts on both topics, the how the Jedi work influences budgets and the needs there and workforce. And that's all I've got this afternoon. I'll pass it back to Jess. Thanks Tom. Thank you, Tom. And, you know, I'm gonna echo the thanks and for your clear and thorough presentation and a lot of the work that you're doing on equity. Really impressive. I just have a couple of questions. And one is the question I've been asking every hospital. So really trying to understand how a change in charge translates into an effective rate change, you know, on the ground felt by commercial patients. Obviously for every hospital, it's different depending upon their portfolio of payer contracts. So I'm just wondering if you can give us a sense of the historical relationship between change in charge and what the effective rate might be. And then what, to some degree, then what is the 4.7% change in charge translated into?  And then from a commercial only perspective, there's two ways to look at it. One of which I don't like and one I do. So, you know, if you look at it in terms of how we report to you folks and how we bucket everything relative to net revenue, then the realization is more along the lines of 3.2%. And that's mainly because of how bad debt and free care get reported from us historically, utilizing your tool. So that considers bad debt and free care. If I just say as a percentage charge, not thinking about who pays the deductible or out of pocket or whatever, then, you know, we're getting 3.6 out of the 4.7 as a general, it's pretty close. Yeah, okay, great. Does that make sense? Totally, and it's really helpful for us to understand. So I really appreciate that. My next, you know, topic area really is just the wait times and I really wanna thank you for sharing all of that data. I know some of it is hard to look at, you know, I'm sure when you're seeing some of these days rack up into the hundreds, it's obviously not a place you wanna be and I recognize that recruitment retention are big drivers and workforce issues are big drivers of that. This was kind of our first go at trying to collect this data in this way. And we, you know, every hospital submission now gives us a baseline to at least measure progress. And so we really appreciate your sharing of your data. I noticed that you didn't provide data on referral lags. I'm assuming that's because it's challenging to capture the date of a referral. And so therefore you can't track that referral lag. One of the things that I'm hoping is as I listened to you talk about potentially moving to Epic at some point in the future whether that might be a feature, you know, the IT change is necessary to track those referral lags would be an important part of that, you know, of your data ask there. We hear from providers how frustrating it is to not know when an appointment is made. And obviously patients do too or to be waiting for just an appointment to be scheduled. So in my mind, if we don't start measuring these referral lags we don't really know there's a problem when we can't start fixing it. So recognize that IT and EMRs and all of that may be a hurdle for you right now but in the hopes that when you move to Epic with DH that that might be something you can track. I think that's a possibility. Yeah, so we had a lot of internal discussion about that. And if the referral lag is the measure between Doctor X calling for an appointment for specialist Y and how fast that gets booked as opposed to when it gets booked, like what date the patient is seen, right? That's the wait time that we presented was how far out for the third appointment, right? To get in. The referral lag here is actually near zero for our internal providers. And, you know, the narrative that we provided, we do look at those. They get electronicized. I don't know what the right word would be. So if we get a call from an external provider who's not on our system, whether it's Dartmouth or Valley Regional or Springfield or wherever, those are put in and they are looked at daily here. So our referral lag is near zero even though we're not really measuring it. I think if we say that's something we're gonna look at next year, I'm pretty sure we have the capacity to do it. It's just not been set up because that's not been an identified problem for us. We've been more worried about third available. Yeah, no, I appreciate that. I would say that that varies across the state. So I think that there are some significant referral lags across the state. And so it's really welcoming to hear that that's not an issue for you and that's one of the reasons you're not tracking it. But if it's- It might not get seen for 200 days, but we'll get you in the saddle today. So I guess that's my question. So when you're referring to referral lag, I guess I'm trying to figure out- What that means? We can get the data, but are we looking for a measure of how bad it is to get someone into a specialist at DH or at UVM versus like someone calls and they want to get neurology with us or physiatry or some of the other thinner slice bases that we provide. I'm trying to, because I think we can- Well, the issue- I think integration will help. Yeah, no, some context here is that we heard in the wait times inquiry, we heard we had focus groups with primary care providers largely who would make referrals and wait weeks and weeks and weeks to find out when their patient's appointment would be scheduled. And then that appointment is scheduled, then it could be three weeks, three months, six months after that. But the referral lag refers to the time between a provider making that referral and the appointment actually being scheduled. And that's what I'm saying. We heard a lot of angst from primary care providers not knowing and particularly when they felt that there was an urgent visit need, not even knowing when that appointment would be scheduled. So it was a big backlog. And we recognize that there is a significant, COVID has had impact, there are workforce issues, there's a lot going on. And so, but just to start tracking that because in some areas of the state, the visit lag, right, which is when the appointment is scheduled to when it actually happens, maybe a significant underestimate of the true access issues. If people are waiting three months to have an appointment even scheduled on all the books. So that's what we were trying to ask and get a handle on in this. And it sounds to me, as if that is not something that you face, that you're able to quickly turn around and schedule appointments based on the referrals that come in within a day or two, which is completely reasonable. Yeah, I would say internally the answer is yes, Dave's totally accurate. There are a handful of departments at DH that are, they get the referrals and they tell us, we will process this as soon as we can and we'll reach out directly to the patient. And then, you know, we start negotiating. We start horse trading. Like, well, I'd really like to know too. And then I was, all right, well who's the attending today? I'll just call that person.  And I'm sure it's the same up north as well. Yeah, appreciate that. I think it may depend on whether you're an independent provider or a provider within a larger system, in terms of your ability to grease the wheel there and get folks in. We're just trying something we're trying to figure out. So my last just request is that if there's anything, you know, any known or likely changes that you're seeing since you submitted your budget or even since this presentation in the next couple of weeks, changes to federal or state payments, relief funds, any unexpected increases in Medicare, Medicaid reimbursement, anything like that. If you would just follow up with Sarah in an email, that was just a standard request we've been asking everybody. So no question there, just the request. If anything, material changes, we'd be helpful for us to know. With that, I'm gonna turn it over to our hospital finance team just to see if they have any questions. Hi, it's Russ standing in for Sarah today. No questions from the hospital finance staff. Okay, great. Thank you so very much. Then I'm gonna open it up to the HCA for their questions. Thanks so much, Sharoms. Thank you, appreciate it. Good to be with you again this afternoon. Hello, folks from Skutney. Just to, so Sam Paish, health policy analyst from the Office of the Healthcare Advocate with the HCA. Just a couple of questions from us. I wanna also recognize and appreciate your response to the health equity questions that folks have already commanded you for, but add our voice to that. And particularly wanna call out the collaboration with the school districts. I think that's pretty unique and innovative approach that really shows you're informed from a social determinants perspective. I haven't seen that from other hospitals that we've heard from so far. So I wanna particularly commend you for that. I wanna focus on page three of your budget narratives. First question, you wrote, quote, the growth of Medicare Advantage plans continues to reduce the benefit of critical access reimbursement. And there's always a delay in Medicare Advantage plans recognizing these costs. Could you please elaborate on the growth and how long these delays typically are for recognizing these costs? Sure, so a couple of things. So FY21, we'll just use that as the fiscal year for the example, ended 9.30 of 21. We file our cost report for that year by February 28th of 22. So a few months later, and that's kind of driven by the feds, they give us the due date. And so we submit that. And then Medicare scrutinizes that initial filing and somewhere's around late April to early June, usually the middle of May. They say, hey, we've accepted what you've submitted as generally reasonable pending detailed audit. And we're gonna recognize 80% of the receivable or payable as filed. And then we get that information and it changes what we get for our per diem or our percentage charges from Medicare. And then at that point, we take that document that comes in from Medicare, the intermediary, and then we forward it to all the Medicare Advantage plans. And then they have, generally speaking, 60 to 90 days is a couple of outliers, but 60 to 90 days to implement that in their system. So what I'm saying is functionally, the costs for September 30th, 21, are probably not recognized until August of 22. So we've lost the better part of a year, assuming that the general trend of healthcare is things get more expensive, right? And this year may be being more critical because of the higher than usual inflation rates. Got it, okay, that's helpful. Thank you, appreciate it. Next question. So you talked about a fair amount today and in your narrative about the lack of evidence benefit from participating in the all payer model programs. I'm curious if you're thinking around that changes at all in regard to UVM's decision to absorb parts of one care or all of one care into a population health services organization. And if that influences your participation in the future or it's too early to tell? I'll start with probably it's too early to tell. I would love, I'll be careful with my verbiage here. I think that we've done a reasonable job with cost control that is totally unrelated to a CO activity because of just of our regulatory structure. If you look at the bending of our cost curve, it's because three mountain care board oversight of our budgets. And I don't believe that one care Vermont efforts have made a significant difference in either direction there. And again, I don't think that's a function of one care Vermont. I think it's a function of Medicare Next Gen ACOs in a rural environment. So I think a statewide population health service organization would focus on the things that the providers I think really care about. And probably, and maybe that's a close partnership with the Vermont care board from the financial side of things. Cause as we know values, quality over cost and outcomes, right? We understand that, but right now the water's too muddy for me to say, well, one care did this or one care did that. I can say that the care management model has not proven to be widely successful outside of anecdotal stories that get put into slides and shared at lots of meetings. But I haven't seen population health changes. Some of the work that we're doing, we're not gonna see change and it's gonna be generational. Like our family wellness program, which is a terrible name for a really, for a full wraparound program for newborns and their families down here. I'm not gonna know until I get my workbench one report 10 years from now that shows I've got less pediatric kids down at the retreat getting inpatient psych care and less of a Medicaid dependence for their families. So I would like a disentangling personally of the population health work from the finance work just cause then I'd have a better, I'd have more opportunity to know which is working cause I can comfortably say that the Griemann Care Board has bent the cost curve. We haven't fixed everything, but it's bent in a more beneficial direction. But I do not think the population health or the complex care management work has moved the needle as much as we would like. And so I think version 2.0 of this is probably gonna be more along the lines of a global budget. I don't wanna go into global budgeting because it means different things to different people. But once we agree on a definition I think it's something that'll be more easily regulated. Performance can be monitored closely and then an entirely different population health services group to look at I think statewide utilization, practice variation, best practices, et cetera. So that idea, the idea of UVM taking a larger role doesn't frighten me, doesn't make me less interested in engaging in this work. And in fact, depending on what we do in the financial side could provide more clarity for everyone, for all of us on this call right now, right? I can see four people on the screen. I think we'd all have more clarity with a little disentanglement. Dave, any thoughts from you on that? No, I think that's entirely accurate. And I think part of the mantra here has been, if we do the right thing reasonably well it'll all work out in the end financially. And it's not that we're naive. We've taken great pains to do a lot of this stuff before one care even existed. I mean, this has just been a way of living for us. Thanks much. Really appreciate it. Those are all my questions. Back to you, Chair Holmes. I thought I'd make it by four, but not quite. 401. Close enough, close enough. And I would just, you know, I wanna add that I appreciate that those comments. And I think that the work that we're doing in Act 167 is gonna be really important and that, you know, your efforts in your region will be really informative and thinking about how, you know, how do you think about regionalization of care? How do you share services? How do you think about appropriate site of delivery and all of that? So I hope that we can turn to you as we start to engage in that process and gather some insights from you. I think it'll be valuable. All right, well with that I think I'm gonna open it up to public comment. So if anybody has any public comments they're welcome to raise their hand and that using the raise your hand function in teams. Okay, and not seeing any hands raised. If there's anybody on the phone that would like to make a comment about the Maniskatani budget, feel free to unmute yourself. Okay, and not seeing anybody on the phone or hearing anybody on the phone. So thank you very, very much. Maniskatani team really appreciate your time today and all the efforts that you're making to serve your community and keep costs contained. As you said, this is one of the lowest rate requests that we have in the state and that's most appreciated during these inflationary times. So that is it for today. The board will be back online Wednesday at 8.30 to hear from North Country and Gifford. So that is it for us. Do I have a motion to adjourn? So moved. Motion from Tom to adjourn. Second from Robert. Okay, all those in favor. Hi. Hi. Hearing none. All right, we have unanimous approval to adjourn for the day. Appreciate again, Dr. Parris, Dave, your time and energy and passion for your community. Thank you. Thank you very much. I'll see you all on Wednesday morning.