Good morning, everyone. My name is Kevin Mullinger, the Green Mountain Care Board. And today we're going to be hearing from three different hospitals. The first one this morning will be North Country Hospital. And just a public announcement that after each hearing, the public will be invited to make any comments they wish to concerning the hearing that just took place. And that throughout the time period of the hospital budgets, we have an open public comment portal on our website for anyone who wishes to offer public comment. So I see all five board members. The court reporter is here. We have North Country here. So Kim, if you could start us off by swearing in the witnesses from North Country. And Brian, if you could just let us know of who will be speaking. Yeah, sure. So we have speaking today, mainly Tracy Paul, our CFO, myself as president and CEO. We also have on the call with us this morning, Megan Sargent, who's our VP of patient care services and our VP of HR, Paul Giordano. Okay, so if they could turn their cameras on and I'll ask him to swear you all in together. Okay, there they are. Okay, would you please raise your right hand? Do you swear the testimony you're about to give shall be the truth, the whole truth and nothing but the truth, so help you God. I do. I do. Thank you. So with that, Brian, we'll turn it over to you and we look forward to hearing your presentation and learning how things are going in the North Country. Great. Well, thank you all for starting the day with us. I understand some of you have fog around you today. I can tell you that there is no fog in the North Country right now. So I'm gonna go ahead and show our presentation here. So give me a second to cue that up, please. Okay, are you still with us? You see that? Yes, we do. Thank you. All right, so this is just a reminder of the view of our campus from up above. I do want to encourage you that summer is still here. This is not a current picture. This is what fall will soon become here at North Country, but just a reminder of our campus. Again, our presenters today are myself as the president and CEO and Tracy Pauls, our chief financial officer. And we do have two other parts of our members of our senior team that may chime in, Megan Sargent and Paul Giordano during the Q&A time. So a quick reminder of our geographic location. As you know, we have a half bubble service area up here because of the Canadian border to our North and we're 45 minutes closest hospital, which is a critical access hospital, St. John'sbury in two hours to tertiary, which would either be Dartmouth or Burlington at UBM. Okay, so good morning, everyone. So the next two slides show the income statement that you're familiar with. I'm going to address any major differences that are showing in this throughout the presentation. So to get into the NPR and the fee increase, so the fee increase on the gross revenues for the hospital was 5.6 for the overall fee increase. We put no increase on our medical group charges. So it basically nets down to an overall fee increase of 4.9 overall the services. Regards to the NPR, we show an increase of 7.3% in our NPR. Basically it's two main factors. One is utilization and that accounts to about 50% of our NPR increase. And the other is the rate which accounts for about the other 50%. In regards to the other operating revenue, we're showing a decrease of about 15% or $1 million. The majority of that has to do with our 340B revenues. I'll be going into that in more detail later on when we talk about the risks that we have as a hospital. The balance of the decrease is just small decreases in a lot of different other operating categories. As far as the non-operating revenue, it says it's a 43% increase, but it's only $253,000. That's based on our projected 21 in our non-operating revenues. This is a graphical depiction of our total expenses over the basically the last five years. You will see from budget to budget, it's an increase of about $4.5 million, which is about a 5% increase. What has accounted for that increase? When you're doing a budget, a lot of the expenses go up and down, unfortunately, mostly up. But to summarize, basically it's four major categories of increase. Compensation is about 31% of the increase in the expenses. Benefits are about 27%. That includes inflation rates on your life disability vision dental from three to 5%. And also we're seeing and have been seeing a large increase in our health insurance claims. We are self-insured. So that as of year to date, as of June, we are over budget about $1.4 million. So, and that's expected to continue. So we have a large increase there. The other area of increase is actually our low-cups and travelers. So we showed a small decrease in the budget, but from March to April until now, there's been a lot of changes. But again, we'll go into a little further later in the presentation. The other big piece is the contract purchase service category, that's about 35% of the 4.5 million. And there's two major factors there. We're implementing a new EMR system, CERNR, set to go live in May of 2022. Part of that conversion process is we have large costs of about $700,000 associated with data conversions, interfaces and archiving of data from our existing systems. So that's about 700,000 of that. The other piece of that is that we have increased services from Dartmouth and our pulmonology area and our cardiology area. And then to round that all out, the rest of it basically is inflation. This graph shows you basically the benefits and locoms as part of our total expense. The message basically here is that it stayed relatively flat. We budgeted a little higher, but if you go from 2019 to budget 22, we're basically in the 62-ish percentile. So that stayed rather flat. The next two, the top shows the locom expense. And as I mentioned earlier, when we did budget, we showed it going down a little bit based on the information we had at that time. Unfortunately, at the time of budget, we had about nine nursing travelers. Now we're up to 15 at the end of July and we're projecting even higher for the end of the year and going forward, which is very unfortunate. And we also have travelers in some other areas, radiology and rehab that historically we haven't had travelers in that we've been able to recruit for. So we're expecting a large increase in our traveler expense over budget. The other graph shows your physicians to total salaries. You can see there's a downward trend there basically due to loss of providers. So tying it all together in a bigger picture as far as our operating margin, you know, here's really what it looks like. So up for some, when you look at this, you might look to the left side and see the big dipper if you're into the stars. And if you look at the whole picture, you might see a duck. There's the duck head on the right. And then the budget is represented in that green line. The actual is actually the blue line. So as we budget, you'll see our budget as fairly flat. But as we manage even our day-to-day, month-to-month, we're managing against this budget all the time. And just as Tracy illustrated, we seek to perform at or above budget. And there's lots of factors even when we made this budget and projected on it February, we're already having factors that have changed before our year end, such as she illustrated with the locums. So the, you know, overall three years of losses, fiscal year 2016 through 2018. And then FY19, FY20, and we project FY21 will be profitable. 2019 was an operating margin of 1.7%. And fiscal year 20, if you take out the provider relief, and the provider relief is at the top of the duck head. But if you took that out, it would come back down to closer to FY19, which would be roughly 1.9%. So here's another way to look at it. Overall, you know, our goal is to ensure continued financial and operational sustainability. So year to date through June of 2021, our actual performance is 2.1 million, which really amounts to 3%. This is attributed to a recent surge in volume. How long it will last is a big question for us. Day to day, month to month. And then you'll see our projected FY21 was to be 1.8 million, which was 2%. So it's really a 1% change, but between the two, on that February projection of 1.8, we, it's only 300,000. So 300,000 lifts it, you know, on average to about, or on a roughly 1 percentage point. And in our budget for fiscal year 22 is a budget of 2% or 1.9 million. So close in line to what we're seeing projected through June. So essentially the summary here is it doesn't take much to move that. Okay, so this is obviously the balance sheet. There's two major categories to known on the balance sheet, the cash and the Medicare accelerated payments, which I'm going to discuss in the next slide. So you'll see cash flow summaries. The top cash flow shows with the accelerated payments for Medicare that we received in it. And the bottom one shows without the Medicare accelerated. Just as you can see from this graph, our normal cash flow balance as of in 2019 was about 2.7 million dollars. We're looking at the ending of next year about 10.6. That does still, that 10.6 doesn't still include 2.5 million of the Medicare accelerated dollars that wouldn't have been paid back yet. Why do we have such a high cash balance? Basically, we returned to normal very quickly. We were very fortunate up here in the Northeast. Our normal volumes for the majority of our services came back by August, September of last year. We were actually at budget. So that helped our financial position. And also in the last spring as an administration, we made some really difficult decisions about furloughs and salary cuts and such that decreased our expenses and decreased our cash needs. So that's why we have such a high cash balance. As we talked about before, our overall change in charge request is 4.9% for this, we're requesting for this year. The charge increase effect on payers. So on the Medicare payer, basically the charge asking for a charge increase only affects the outpatient side of the service. Inpatient side is a per diem rate. So it does not a net increase in our charge, or excuse me, an increase in our charges doesn't affect our payment on the inpatient, but it does on the outpatient. For Medicaid, a charge increase does not affect our net reimbursement for inpatient or outpatient. On commercial, it does affect both the inpatient potentially and definitely the outpatient side of the house. And on self-pay and other, it would affect that. That's just a very small piece, less than 1% of our book of business. So that's how the charge increase affects the payers. Now the bad debt and the free care in general, we run about 1% of our gross revenue for bad debt and 1% of our gross revenue for free care. And that stayed relatively consistent for the last few years. So I had to highlight a few key service line adjustments in budget 22. We have a new general surgeon that we added and it was replacing one that was, we were seeking replacement last year, so we were down one last year. So that physician has joined us in building practice and is built very quickly back up to compliment the practice. And he has a colorectal training, so he's actually attracted some business in that profession. And the next one is urology. So we have a ramp up of that position as we've been supporting that full time that was new in the last year or two. Cardiology ramping up with full time, we previously had had part time and we've been ramping that up with Dartmouth-Hitchcock. So it flipped from an employee relationship to a Dartmouth contracted service. And we've also even brought in a second provider to meet growing demand from time to time. Our service area has said that it could support up to two FTEs, we're really at one FTE. So it does make sense that we would need to compliment that. Pulmonology, we lost the full time pulmonologists, the solo pulmonologists. We are looking at how we're, we have a trial right now with Dartmouth-Hitchcock where it's combined remote, meaning telehealth and in-person encounters. And we have that position posted as well. And then family medicine, we have some turnover there. We currently have two, one locum and we have a second one joining us and then in the next month to offset two family medicine docs that we lost to Adelmarket. And so we did include the revenue and expense in budget, but it's not locums. We hope to get those. We do have one that has signed that will start in January and we're seeking to get the Adelind field as soon as possible. Risks and opportunities, our hospital service line, we've had no success in finding permanent placements for these, filling our schedule. And we've been filling them by stretching our primary care physician coverage. So not only were they providing coverage in our clinics, but also doing extra shifts to cover shifts on the hospital. And with the loss of two family medicine, it's created even more obstacles to try to stretch and fill the schedule. So we've engaged with the national partner to help us to staff the hospitalist program. And that partner starts September one. And the overall costs with this partner is cost neutral. Another one of our risks, as I alluded to earlier in the presentation is the 340B pharmacy. I'm sure you're aware of the manufacturers started withdrawing from the pharmacy program last year. We started seeing large effects on our dollars in about January of 2021. For this year's budget, actual year to date, we're actually below 19% of what we had projected for 340B revenue. At the time of budget, the HRSA let it had come out mandating the drug companies to pay. So we actually did put a little optimism into our budget for the 22 levels. But if the drug companies do not pay and comply with the 340B pricing, we're at a potential risk of about $700,000 off our bottom line when it comes to the 340B. Competitive labor, this is probably a broken record. I'm sure you're hearing this from all the hospitals so far, dealing with staffing shortages and all positions. Tracy again shared that we had, we started when we were projecting, we were at about nine temp or locum staff through agencies, we're up to about 15 now and we project to be maybe about 22 by the year end. And then that doesn't even account the locum physicians that we've on boarded to. There's definitely wage wars going on. And it's not only just in healthcare but it's multi-industry for positions such as EVS, dietary, we have in the healthcare sector competition for RNs, even with long-term care where we've had situations where we've had a solo position on the counter. We've had situations where we've had a solo position offered another nursing home and offered quite substantial rates higher than what our working RNs here are making. And then we're dealing with the work-life balances. I think we all are, there's tremendous COVID fatigue within our industry and there's gonna be challenges if not already with compassion for dealing with a third surge, fourth surge if you will. I've lost count but particularly compassion and challenges for those that are accessing healthcare that have chosen not to be vaccinated. And so we get a research on that. We've also seen a resurgence back in our ED to prior COVID volumes just within the last two to three months.  We now, we were staffing pre-COVID, we staffed three physicians through the course of the day for our 15,000 visits a year. And now, and we dropped it down to two during COVID because of the drop in volume. And now we're back to three within the last month we've made that decision to staff that back up. And then some other things we're doing with staff, we've obtained the services of a clinical psychologist to meet with our leaders and do an in-service. And it was just really to, we called it a debrief although debrief is inaccurate as that would assume that COVID's over but it was just to connect with them and- Brian, all right, can I just interrupt for a quick second? I think the presentation is gone. So I'm not sure, are you also not seeing it Maury and others? It's gone. And something happened and I'm not seeing it. There was a strange noise before it went out too. Yeah. I thought maybe that was someone else that muted. Let me, I'm gonna stop presenting because I'll stop and then start presenting. Thanks, Brian. Yeah, thanks for asking. I haven't moved a slide. So you have to tell me if this was a slide you saw when we hopefully get it back up and running. Can you see it? So the slide that we're seeing is competitive labor. Okay, yeah. So this was the previous slide. Oh, hold on, it's frozen. That's not advancing. All right, let's see. I'm gonna try a couple of things here. Now it's disappeared, correct? No, it's still competitive labor and it's the view of the tire. Now it's okay. Okay, so you're seeing that. So I'm gonna keep it on this mode if that's okay. That's fine. All right. Okay, so again, under work-life balance challenges, I was talking about some help that we had with the clinical psychologist. And we're actually gonna roll that out with the staff as well, offering that opportunity. And really, it was very interactive and allowed people to give feedback and share and see that they're not alone in the world as far as handling the stresses of COVID. We also engaged at the beginning of the summer with a physician wellness coaching that has group and one-on-one coaching with our wellness coaching with our physicians. And it's peer-to-peer, so it's a physician. And so that program was well received. It just concluded a few weeks ago. We're extending it for those that weren't able to complete the six to eight week program. And then we're also extending that one-on-one coaching for up to six sessions a year, moving forward. So that's been well received too. So some of the things that we're attempting to assist with that. Our EMR is a risk reward, I guess. We had a couple of years ago on board with Athena and then they discontinued the hospital module and said they didn't wanna be in that book of business. So we had to go through, unfortunately, another exercise of evaluating EMR systems. We chose CERNR. We go live May, 2022. This will align us with one medical record. Increases greatly our optics on metric and quality reporting.  We have an investment in training into this as we kick that off, which kicks off next week. And we'll go all the way in through, go live. And of course, it's anticipation of the cash flow management with accounts receivable. So that's another big risk and opportunity in this next year. And we're also seeking to reinvest in our aging plan. So our hospital campus, we moved on this campus in the early 70s. Our main hospital building was built in 1973. In 2019, we started a facility master plan to assess what our areas of greatest opportunity were across all of our infrastructure and our buildings. And that led to a campus development, a focused on our high priorities, which were inpatient and ED. And then our work got stalled because of COVID. So we lost about, I'd say, nine months on this.  And in July of this year, we submitted a certificate of need for a new addition of 20,000 square feet and a renovation of 22,000 square feet of space. That will include a replacement of all our inpatient rooms. So 25 bed inpatient rooms, all private. It will replace our much-needed lab. We'll relocate it within the new addition. And then we will also be renovating existing space. We can expand our ED out into our existing ambulance space and take up that space to add more exam rooms, which will be more, will be modernized to handle not only behavioral health but other patient needs as well. And then we're also relocating our rehab department into the old med search space once it's vacated. And then that will free up more medical group space if needed in the years ahead. So that's it. There's a whole more to it. They should be explained on that, but that's just a rough sketch of what that plan is. And by the way, the cost of that project is roughly $22 million. Again, we need to continue to invest in our infrastructure which includes equipment. So our budget actually is 4.2 million this year. Typically it's about three and a half million. The funding for this year breaks out to 30% spend in medical equipment, 20% in technology, and facilities is 50%, which a big portion of that is a chiller that we need to replace, that we need to do before it, well, it's already passed its life cycle. So the more that the less we're spending on facilities, the more it's costing us in the longterm. And then our campus project, going back to that, here's the timeline for that. CON again was submitted in July. Construction, depending on the status of the CON, could be as early as spring, as late as fall in 2022, with completion roughly a year later, a year and a half later. Okay, on to value-based care. So as far as North country hospitals, one care participation, we participate in the Medicaid Blue Cross, Blue Cross QHP and MVP programs. One thing to note from looking at our numbers, you'll see that our Medicaid FPP perspective payment has increased greatly from budget 21 to budget 22. Basically, the reason for that is the Medicaid expanded population. Just to show for 2020, when we did the budget for 2021, we had 3,400 Medicaid lives. And then as of July of 21, we have 4,400 Medicaid lives. So basically it's gone up like 20-ish percent from then to now, which is accounting for that large increase in our FPP payments. We also, like I said, we're plundered the QHP Blue Cross and Blue Cross and MVP. Those are relatively small numbers compared to the Medicaid dollars. We are anticipating and staying in the same programs for FY 22. As far as impacts of COVID, some of which we've already touched on, but access to care and wait times, there's been a spike more recently in inpatient utilization for the last couple of months. And we are projecting that that's gonna be that case for a while through at least the next month or so with news that we received from Secretary Smith regarding a resurgence in inpatients for COVID patients. And what's concerning to us is we're already been at capacity for inpatient. So having that come on top of that is of concern to us and not only for space, but particularly because of labor and having enough labor to serve the patients. Our lagging ED volume really in February when we've created our budget we were expecting that to, we projected that that was content going to continue but now it's returned just in the last couple of months. We're not sure if that's just gonna be a summer thing and it's gonna go back down. So that's what we're expecting but it could end up saying this is back to the norm. But virtually all services are now open and utilization has been higher than it was pre COVID. Through the use of telehealth, really it was a great learning opportunity on patient preference. They prefer in-person visit now that they can come in person. I think that's a great learning for us as we've been evaluating how telehealth will be used and complement the care environment. My opinion is that we will be able to use it as an extension for people that use this as their primary source of their healthcare setting and when they travel away seasonally or for a short period of time they may be able to use the telehealth to reconnect with their provider and provide consistent care and treatment among the things that you can do of course through telehealth. And I see also in future generations as we see that the future generations tend to lean towards telehealth or technology I should say. As those people are growing up in our system those parents were treating their, the Peds patients and they grow up and we're using this telehealth now when I think of myself as when my kids went away to college and they call in and not feeling well I'm gonna want them to see through telehealth their provider here rather than going in to a clinic in their own setting because it would be a continuation of care. So that's why we call it a great learning opportunity. Okay, another impact from COVID-19 in regarding to safety protocols. So in the spring of 2020 we made decisions on the access to our buildings for the hospital, for employees and patients for the purpose of screening. So we used to have multiple point of entries and we basically brought that down to only a few points of entry and we've maintained that so far. The interesting part is we had a security audit and outside firm come in and look at our security as part of our ongoing safety committee and they basically reaffirm that minimal points of entry are the best practice. So we'll definitely keep that in place in the future which resulted from COVID. The other thing, testing and vaccinations. Basically our vaccination rates have slowed down considerably but we have, if somebody presents and wants a vaccination we have several ways that they can get that. We'll call a health supervisor we'll get them vaccinated basically. Just, but when it comes to testing unfortunately our testing has spiked considerably in the last week or so it had gone down and now it's way back up again. Just from the time I submitted these slides we were doing four days a week, four hours a day for testing and now we're doing eight hours a day, five days a week. So we're basically doing full, full time testing. And some of the reason for that spike is that the surgical professional society has recommended to returning to testing all surgical patients. That's something that decreased or that requirement was led up for a time and now it's back. As a reminder, we live 10 minutes from the Canadian border and the Canadian border has opened back up but you have to have a test 72 hours from the time you go to Canada and present that test results when you go to try to cross the border. And there's a lot of people here who have family and friends and such in Canada that are wanting to go across the border. There's been a lot of gatherings and visitors from out of the area. Obviously the Delta variant has increased concerns and we anticipate even a higher increase in testing once school starts next week. So if I had to sum up the impacts of COVID, this slide I think covers it. And if I had more time, I would probably make this look a little easier to understand, but really COVID required unity. And it brought not only Newport and Vermont but the whole country together to try to address a crisis. There was a single purpose early on, a single priority and a single focus on making sure we protect the wellbeing of the community. And that was really early on in COVID when everything was winding down for that short period of time. But since then it's really been a return to normal. And so a return to normal is still handling the complexities of COVID but now going to diverse special interests, diverse priorities and responsibilities. What can we do to cater to the individual and tremendous COVID fatigue. So really for our healthcare organization, there has been no rest for the healthcare worker or the weary. And reflecting on the last two years, I think if it's been, it's a blur, maybe it hasn't been too yet, but it will be. I think it's actually been more difficult to manage now than when we were in the midst of the first downturn because of COVID. So there's just a lot of competing priorities and they're all high. So and really in summary, let's see, in summary, as what we're requesting is a charge increase that's a net of 4.9%. Again, it's a hospital increase, no increase on the medical group side. That breakout really is 3.3% is for wages and employee health insurance, supply inflation, really continuing to invest in our workforce and pay market rates. It's a 1.6% increase for just alone for our CERNR conversion cost, which amounts to $700,000 to $800,000. And it doesn't, in fact, this budget doesn't factor in the risks we have with 3.4 to B and the exposure we have, if that continues to have pharmaceuticals not honor the payment and drop off of the program and also doesn't include the recent rise in locums. And as I said before, we're trying to manage a lot of variables here. So it changes month-to-month. So approval allows the hospital to stay on that track of three years of solid financial performance, looking to do good things to reinvest, not only into the people, but also into the much needed infrastructure that will also incorporate lessons learned from COVID and an operating margin, which is at 2%. And as I shared before, it doesn't take much to swing that. And so, in summary, just ask for your support and then a vote of affirmation to keep North Country Hospital on that positive track. And that's the conclusion of our presentation and we'll turn it back to you, Chair McMillan. Thank you very much. We're gonna start our questioning with Board Member Tom Pelham. Tom. Thank you and thank you both for your presentation. It was crisp and clear and I appreciate it. I do have a few questions and if I get through them in a timely manner, I reserve all my time for Jess Holmes. Any remaining time, she asks great questions. So my first question is looking at Medicaid and in 2019, your NPR FFP revenues were about $12.3 million in Medicaid and in your 2022 budget, they're at $12.9 million. So it's a fairly flat kind of profile here, but the mix has changed dramatically. In 2019, it was 6.1 million in NPR and only 6.1 million in FPP, whereas in 2022, it's 1.6 million in NPR and 10.6 million in FPP. And I understand that has to do with the Medicaid expansion to a great extent. But I'm just wondering if the fact that there's a higher proportion of your Medicaid revenues coming through fixed prospective payments, whether or not that encouraged any operational changes within your hospital in response to that. Think about that for a second. I don't think there's any operational changes that relate to that basically because when our patients come in, obviously we treat them based on who they are and what their needs are and not what their payers are. Sure, with care coordination, with the value-based system, we could add more care coordination because that's a huge help to that type of system. But I don't see us having any other things that we change operationally. Is that answering your question? Yeah, I could have gone either way and I'm just curious. It's a big shift in your mix and whether or not it induced behavioral changes was a curiosity. My next question is just a simple one. Do you have some fairly powerful legislators on key committees in the legislature? I'm just wondering how close in contact you keep with them about your, for example, Medicaid revenues. As I said, they've basically been flat over the last three years. And do you think that your legislators understand that? So yeah, obviously it's been more of a challenge this last year and we're starting to be able to get back together but I have fairly easy contact and access with several of them. And in fact, one I am in rotary with. So I had the tendency to see during, when they're out of session, at least once a week. And from time to time, I get asked questions and respond to those. But I wouldn't say that I get in and I say, hey, here's where we are with Medicaid and here's what I don't get that far into the weeds. We're trying to seek to respond to what education that they're needing with whatever bill that they're digesting in the House or the Senate. Yeah. No, I understand that. I'm just wondering in terms of keeping them informed on the cost shift. And so my next question has to do with bad debt. And I noticed that in terms of the kind of right that bad debt in 2020 was $3.2 million and in your 2021 budget, it was $3.1 million and then it dropped in terms of 2021 perspective to 1.8 million, which was a 40% drop or in bad debt. And in your 2022 budget, you have it back up to just a little over $2 million, which is an 11% increase. And I'm just wondering if you have some worry that that number might actually go higher or lower because it's a negative. Just looking at the acceleration rate coming into the pandemic and thinking that maybe that it rises back to its more normal level more rapidly than you budgeted. Yep. So in response for that, the increase, actually the increase that you see in the bad debt in 2021 or 2020 is basically more due to, 2021 is more due to a system issue than it is to anything else. Basically we went live with Athena and 18. We had a lot of challenges with the bad debt and the recording of the bad debt. So some of the bad debt that you're seeing in those years is actually bad debt from prior year. So that's a reason why that's higher. And you'll see that for the last like four or five years, we look at our bad debt as a percentage of our gross revenue and it's ran about between 1.07% and 0.95%. So it's been pretty consistent in the 1% range. So that's how we projected and budgeted for next year is in that 1%. We're not anticipating a large increase in our bad debt for next year. We have a very active navigator team up here that does everything they possibly can to get people either on Medicaid or in a payment plan or free care. So we actually think we can keep our bad debt at that level. Well, that's helpful. Thank you. Speaking of kind of a technical systems, I'm wondering how worried you are in terms of the CERNR implementation because a lot of times the early stages of those are pretty rocky. And I'm just wondering what your assessment of what the startup risks might be relative to the schedule that you profiled during your presentation. Yes, from the financial side I can speak to. When we were very concerned, of course, cash is a very big concern whenever you're going with a new system. But two things, one, we have a very healthy cash balance, which helps us. But the other thing is we are partnering with a company called R1, who is a preferred partner of CERNR. And what this R1 company does, they're an accounts receivable company and we pay upfront. And what they do is they do our CERNR billing from day one so that our patient financial service staff can focus on the prior system and working that AR. And then what they do is they slowly turn over the CERNR billing. We have a whole schedule of how they turn it over as the time goes on. So what that is, what that we're planning for that to do is to mitigate our cash flow concerns because we're gonna have the experts from R1 working the CERNR billing. And they're also gonna be helping us on the front end of the setup of the patient financial and the accounts receivable type information. So we're really hoping that all of that is gonna help mitigate any cash issues. And in addition to that, of course, there's the whole aspect of how much time and attention everybody needs to put forth now just on the training of the new system. And I would say at least the attitude here at the hospital, it's particularly on the hospital side is our slogan is actually the CERNR, the better. Meaning people are eager to get on the new system because it's been so difficult to try to retrieve good information from Athena because they didn't get there where we needed to on the hospital side. Okay, and just a couple of more quick questions. So I noticed in terms of your Medicare advance program that in after September 30th, 2022, there's still about 5.6 million outstanding on that. And I'm just wondering how much of that you think might be at risk of being lost and not being able to be relabeled as revenue in 2022. I'm sorry, the Medicare accelerated payments, which I'm sorry, I'm not sure which piece we're talking about. It's the Medicare advance program and you've been paying that back over the years. And so in 2022, there's still as I see it on one of the appendices, 5.6 million of repayments still outstanding with some hope maybe that some hospitals are saying that regulations are changing that they might not have to pay all that back. And I'm just wondering what your sense of that is. Yeah, I honestly don't know. I'm usually, you know, hope for the, you know, prepare for the worst and hope for the best. So I'm assuming that we're gonna have to pay that back. Okay. I mean, that's what your documents say. A couple more quick ones. During our rate review hearing, Blue Cross Blue Shield in their presentation to us basically said that they need willing partners, more willing partners to participate in their value-based programs.  But I'm wondering if you have any insights into even in your area, whether or not there's opportunities for expanded engagement with Blue Cross Blue Shield in terms of value and in their QHP program and in their value-based program. I mean, they're looking for willing partners. That was their stand saying that they're willing, they're ready and willing to go farther. They just need willing partners. And so I'm asking the hospitals, how much more are you a willing partner to participate with them? We basically follow the lead time of OneCare and what they set up. So we're all in on everything except for Medicare. And so if OneCare is able to create, it's really an enrollment thing. So if they're able to create a system where the commercial can enroll more on that program, then we're already in the product. So right now we could just say we're on it. And how many more of the covered lives do you have in the program? How can we, we haven't been approached about how we might advocate with them for that product. We have obviously up here, we have a lot of Medicare, Medicaid and a shrinking portion of commercial. So that's that I think is an obstacle just because of our environment. That's not really a direct answer I guess. And my final question is in terms of the border crossing, does the border crossing, whether it's closed or open, have any effect on your workforce opportunities? Yes, so we actually worked really hard with the borders during the beginning of COVID and established, we have a letter template that we give to those that live across the border and going home. We've had to accommodate in some cases, people's schedules where they have to leave. There's been a time where there was a curfew in Canada. So they had to, we had to change their shifts so that they could get home and not violate curfew. We've had to reeducate with different personnel on the borders, switching hands and different leaders. But right now we're, I mean, we're doing well. The people, we've normalized it. We're, they have a call to HR if they need anything. We're also provide housing if someone has situation where they, for some reason they can't cross the border, we'll put them up in housing here. Fortunately, it's going so well. We haven't had to do that. It's really a case by case individual basis. We have physicians and nurses and med techs all crossing the border. So it sounds like if we do ever get back to normal, it'll be a little bit less burden for you folks. Yes. Yes. Thank you very much. Thank you, Tom. Next we're going to turn to Maureen Yusuf or Maureen. Hi, thank you for the presentation. I'm just going to follow up on a couple of, start with following up on a couple of the questions that Tom was addressing. One, I guess on any money that's still out there for PPP, do you have any PPP money and has that been resolved? PPP, is that, can you- Payroll Protective Plan? Oh, we don't qualify for that because we have too many employees. Okay. And then the COVID money that you still have out there, you talked about being a little bit conservative in what you're looking at. You may not be able to claim. How much would you say that is? Okay, so I think we might be talking about two different things. So what I was speaking to was the Medicare accelerated payment money that we'd have to pay that back. So maybe I misunderstood. We do have provider relief money still on our balance sheet to claim. That portal opened up in the last few months and we have to, the hospitals have to submit all their information by the end of September in order to justify the claiming of that money, so to speak. So basically we have that on our balance sheet for now until we go through the process of making sure that we can claim that. Okay, and how much is this? It's two, it's two point, hold on. I think it's 2.4. Okay, yeah. Yeah. And then you're- The rest of it's been forecast. Sorry. I was just gonna say the rest of it has been realized into our financials over the last two years. So sorry to educate you. Potential for another 2.4. And then on top of that, your current forecast, you're actually showing some favorability, correct? Yes, for projected of 21, yes.  Yeah, and actually as of now, because again, time has passed, our volumes have been so strong that we may actually enter your higher than that. Okay. Which leads me really to the next concept, which is when we talk about your EMR, there's about 700,000 of kind of one-time costs that you're putting into rate this year. Is that correct? And the 5.6% about 700,000 of that is related to that. And why did you not just take that out of cash on hand? And I say that for a couple of reasons. One, because if we build it into rate, then that compounds each year, you really only need it once. And you are ending the year with significant cash way above where you historically would be. I mean, to the tune of eight to $10 million depending on where you net out. So yeah, I just wanna give you kind of my point of view right now. I mean, I'm really looking at that as something that should not be in a rate request. Yeah, go ahead. No, okay, go ahead. Yeah, so yeah, I understand that. And so I guess what we tried to do is simplify it. And through the course of the presentation did highlight some other factors that are coming in, such as our increase in locums, which we haven't factored in, but that's going in. And so we have other things. We just, we simplified it and said, okay, Asserner, that is, I agree, a portion of that is one time. We will have some ongoing cost. We acknowledge that we do have the cash funds. We are already seeking to use that cash for our other investments in our infrastructure, such as, we increased our capital budget to four and a half million over our three and a half million or what's it, I'm sorry, 4.2 million. So that's $700,000. We also have our building project that we're seeking to finance and we'll use cash for that as well. So we were just pairing all those together and broke this one out within our operating budget. Okay. And then just talking about the surgical increase, I think you've put in there about $4.2 million and you talked about the surgeon kind of going on this specialty, but where do you think that's coming from? I mean, where is that volume coming from? Because if you're picking up 4.2 million here, it should be coming from somewhere, other hospitals or something. Yeah, and I wish we had better data running with our Athena. So I guess what we first noticed is that the general surgeon that we have that just started, he picked up, you know, he loaded his practice and got the referrals immediately. It was just a period of months to build his practice. Usually we've had, you know, the one that had departed took a little longer. We do have one, we have three general surgeons. So we're actually trying to seek what's the balance between the three because one is not as, there could be a balance of business that's going internally. And so we're seeking to understand that. We have a hard time tracking of how many of our docs we're sending out, colorectal outside our community. Again, with CERN, I think we would have had a easier time to evaluate that. So it's more of a feeling right now. And just seeing how quickly he ramped up. Okay. And then can you talk about two or three cost-saving initiatives that you have going on right now and what type of impact we can expect for those short-term and long-term? Yeah. Yes, I can, I just have to find my magic sheet. So, okay. So some on the supply chain side of things, of course, we're part of the NIA buying alliance, but we've been doing that for a while. Some of the things we've done, we've evaluated and reduced our swim quest copier fleet. As you can know, there's a lot of copiers throughout our whole campus. So we brought that down about $21,000 a year. So for the next four years, that'll be about an $85,000 worth of savings. We're converting a lot of brand name commodity supplies to the Medline brand, estimating saving about $20,000 in rebates. We're converting our hand sanitizer through a different brand. We negotiated with Striker, which is really good with the trauma implant, saving about $170,000 a year for that. And we're working with our GPO from Vizient to maximize contract compliance. That looks like we might get about $90,000 more worth of rewards in a year. So that's some of the things that are kind of specific to the supply chain we're working on. But on top of that, obviously, like probably all the hospitals have told you, we've been concentrating on getting the supplies we need for our patient care. And so we can't always, the cost savings don't always come with those because we have to pay the prices that are being offered at the moment. But on the side, we're also trying to do some other stuff with the things that we can. Okay. And then just one last question on the ER. We've seen the trend is down across many of the hospitals and not really coming back in all cases. And in Ducey, is there any either behavioral change, people going more to urgent care or their primary care or telemedicine? I mean, hopefully out of COVID, we're gonna get some benefits and maybe people are changing or what are you seeing there? What do you think is gonna, how is it gonna return? Okay, go ahead. So I think initially people were just, everything shut down and so they were nervous. And we actually looked at our level of visits and our level of visits that were coming in the ED were true emergent, higher acuity and the bottom dropped out of those, I'll call it convenient ED visits. And just because this lit up within the last couple weeks, or sorry, couple months, we don't have enough data to evaluate how much of that balance is from the lower acuity, but we do have truly sick people coming in and that higher volume and a lot of emissions through it. So I think unfortunately the delayed encounters has led to more higher acuity encounters. And then you couple that here with us, we have more people visiting the area than before. And so we have some of that. I mean, we had an individual from out of state, I won't name the state, but we had an individual from out of state that came in and was COVID positive and met emission criteria. So, and they were multiple states away and a whole nother time zone away. So we're seeing more of those types of things right now. Yeah, it's very hard for us to predict because for, I've been at the hospital for 25 years and in the summer we always have a large uptick in our ER visits just because of the amount of population that comes up here and everybody's active in doing things and getting hurt. So we've seen that uptick just barely July is the first month that our ER revenues have actually come back to volume. So it's hard to tell what that's from, if it's from the visitors or if it's from people being more comfortable to come back into the ED or seeking that other type of low level care or whatever. Again, like Brian said, we haven't done that analysis yet, but we're kind of waiting to see, cause we really don't know if that's why our uptick has happened again. Cause it had been down way down since March of 2021. We are Marine, we are in discussion with Northern counties about doing a partnership for a walk-in clinic. We don't have, we've tried in our community walk-in clinics opening extra hours and it just hasn't worked. It's been tried three or four times and for some reason people just, they'll just go to the ED. So we just finished our community health needs assessment and that's one of the questions we asked our community groups about walk-ins and walk-in availability. And I think it's gonna end up being one where people like to know that it's available, but that doesn't mean that they're gonna access it. So it ends up being a, how much cost do we invest in that side? And I don't think it will pay for itself, but from a value-based side of things, it's likely the right thing to do. And so we're, that's something that we looked at to continue to put some activity and thought into in the years ahead or a year ahead. Okay, great. Now, as one of the smaller hospitals, it's good to see the strength of your balance sheet has improved. I mean, we don't like the reason why, but one of the reasons, but it is good to see that that's worked there and so thank you. Thank you. Thank you, Marie. Next we'll go to Jessica Holmes. Jessica? Great. Well, thank you very much for the presentation. I do have a few questions. Building a little bit on some of Maureen's questions around the projections. I'm just looking at the memo that you all sent in July 21st about the question around the projection, is it still valid? And the estimate there was taking the actual performance through June and then assuming that North country meets budget for July through September, you are projecting a net operating margin now of 2.4 million. So that assumption was if July, August, September were meeting budget, but my guess is as what you've described, you're exceeding budget still through the next year. So do you have a new updated, updated? I mean, what are you projecting? Okay, great. Could you just share that with us? And what your actual projected NPR now will be for a year end, those two numbers are really helpful. Okay. So without the first number at my fingertips, I don't necessarily have the second number at my fingertips, but I would be glad to get it for you after. So we just finished our July financials. So we're actually at $2.5 million at the end of July. So we're already past the 2.4. We had a very strong revenue a month. And I'm predicting we'll probably end the year at 3 million or so. Now the only thing that I'm not sure about there is two things. One, if the revenue contingent is as strong as it is in July. And the other thing is we talked about the traveler's expense and a lot of that traveler expense is just coming on board. So July was like a month that we had a higher traveler expense, but I'm anticipating that our travelers are gonna get much higher on the expense side for August and September, because of all the things we talked about before. So that's why I'm saying about 3 million or so. But again. First slide. Okay. It's great. Perfect. Okay. And then in terms of margin, that would be 3% instead of the two that you personally had projected. Okay. And then this total margin originally was gonna be 16.7. So what is that looking like now for you? I don't have that calculation. I can get it to you for sure. I believe that you can. That would be fantastic. So the total margin will be really helpful. And then also, the projected NPR. That year end would be helpful because it's helpful for us to see what is projected NPR and then what is the new budgeted 2022 NPR? What is that growth rate? So that would be really helpful. Okay. Absolutely, no problem. And let me just ask you, so I'm a little bit confused about the 340B and I know there's so much uncertainty around this with respect to the manufacturers failing to adhere to the guidelines and then HRSA sending a note. And I know I recognize that you're all under uncertainty as to whether or not the manufacturers are gonna actually comply with what HRSA is asking them to do. Brian, I thought I heard you say you didn't take into account the risk around 340B but I thought I've read in the narrative that there is a million dollars less in the 2022 budget than in the 2021 actuals. So can you just confirm for me what the assumptions are around 340B it sounds like that's actually incorporating some of the risk if you're actually dropping from 2021 actuals, there's a million dollars less in 2022. And also particularly I'd like you to address that a little bit with respect to now that your volumes are increasing. Will some of that 340B revenue come back simply because of volumes apart from what the drug manufacturers do? So could you address that? Yeah, I would love to address that. So like I think what we're looking at is that so in 2020 was our highest 340B revenue year, right? We had $5. million and then in January of 21 it stopped started dropping. So for projected as of the end of June we were projecting we're projecting out now this is from our financials as of the end of June so it's a little different than what we submitted but we're projecting that we're gonna end up at like 3.6 million. Okay, so we're a million eight off from 2020. We put in our projected for 3.7 million which is about what we were running at that time. So for budget 22 we said, okay, well we got the letter. We're not gonna go down as low as what we're running during this year. We're gonna have a little optimism in there. So we're gonna increase it from the 3.8 to the 4.5. So that's where we put the revenue budget, the 340B revenue budget up but we're like you said we are still a million dollars down from what our actual 2020 is even with our budget 22 numbers. Okay, so it's actual 2020, not 2021. I thought it was for some reason I think I must have misread them that it was. Or yeah, I could have put the wrong number but that's it. I could have misread. Yeah, and Jessica and our compliance meeting just within the last month and we had that 340B report out. That's where we're also learning that, yeah, although the pharmaceutical companies are being told to pay that out, they're still refusing to. And some are just that what's not built in the budget is them just dropping off. So we had a new one. We had a new one drop box. So that's not even in there. So that's kind of that was part of our commentary. Got it, got it. I mean, given what's happening with 340B and year after year, we hear the risk of 340B. We also know how it contributes to the bottom line of many of our small hospitals. How are you thinking about going forward with less reliance on 340B to make the bottom line work as clearly there's even more volatility and less slide. Yeah, so conceptually I think of it as going down a rabbit hole. Because the 340B is, you take that piece out and then the bottom line is decimated, right? But so we focus on that, but there's always one thing that's kind of, whether it's a regulatory thing, whether it's a critical access hospital, where it's value-based, where it's one care, there's the local, it's always, there's so many things to pursue. In this case, it's a matter of, there's only so much we can control and that it's a national discussion. What helps me sleep at night on this topic is that I have to believe for the sake of our country, if 340B was erased in a decimated hospitals, rural hospitals across the country, there'd have to be something to be that would rise up to take its place a different way. And it's actually the same really thought I had during COVID. When we were losing several million dollars in that first month, two months, and the hospitals across the country have the same thing, I have to believe in the goodwill of our country to say, look, we can't afford for the healthcare system to fall and not serve people. There's too much interest in our American society wants access to care and they want it immediate. And so I just have to think of a goodwill and a good nature. There's got to be something that rises up because common sense says you can't lose half your hospitals in the country all of a sudden, right? So. I would not. Okay, so I wanted to thank you actually for filling in the HCA's table on the commercial to Medicare reimbursement ratios. That's, I'll speak just for myself, but it was very much appreciated that you really tried to do both parts of the table and not all hospitals did both or even half. So it was really helpful. And you're inpatient, if we look at that, your inpatient reimbursement is pretty close to Medicare, 120% of Medicare, but your outpatient is 260% of Medicare. So there's a big difference in inpatient to outpatient in terms of the relative reimbursement ratios. And the 260 is on the higher side of what we typically, I think, see. And I'm wondering how you are thinking about the rate request that you're asking for, how it's gonna funnel down to those measures. If we come back this time next year, what does the inpatient look like and what does the outpatient look like in terms of the relative Medicare reimbursement rates? If that, if you're, how are you applying your rate request to those two component parts and then what would that look like that's coming back next year? And maybe that's as much math as I, but are you evenly, is outpatient, are you gonna be charging the 4.9% also to all your outpatient or is it gonna be disproportionately more on the inpatient side? So you're gonna bring up that commercial to Medicare ratio on the inpatient but try and keep that outpatient commercial reimbursement ratio closer to the, where it's at right now, which is already on the high side. That's my question. Okay, that's very helpful. Thank you. So when we apply a rate increase, we apply it across in and out, right? Besides with the exception of what I had said early in the presentation is we did not apply any rate increase to our medical group, to our physician practices, but on the hospital side, the amount will be applied equally through all our charges, whether they're in or out. So that relationship will basically stay the same. If that answers that question. And basically, and again, I hope I'm answering your question. The Medicaid on the inpatient side, obviously, all those payers pay basically the same way. They pay a lot of times on a per diem rate. So I think that's why you see that, that relationship is so close because they pay basically the same way in just a little different per per diem rate. And of course on the outpatient side, yeah, again, commercial is percent of charges, right? So we know there's the cost shift there and they are the ones that are going to bear the burden of the percent of charges in the cost shift versus Medicare does bear some of that burden because they do pay percent of charge on the critical access hospital, but Medicaid doesn't, they pay fee schedule. So there's no, the rate increase doesn't affect them. So, you know, they're gonna change accordingly, I guess, in the same way, but accordingly. Does that answer your question, Jessica? It does. I mean, it's been acknowledged that the cost shift exists, which we certainly, you know, part of our statutory mandate is to consider the extent to which the cost incurred by the hospital in connection with services and Medicaid beneficiaries are actually being charged to non-Medicaid beneficiaries, effectively quantifying the cost shift. And so to the degree that you're, you know, you can see it in your commercial rate request. You know, in some ways, I'm surprised, it doesn't break down in your commercial rate ask, you broke it down into inflation and the CERNR component, but clearly there's also gotta be, the cost shift is in there, embedded in there through the costs, right? Absolutely. And so that's another question around the 4.9%, you broke it down, you know, as my colleague, Maureen already alluded to, part of it was the CERNR component. And I had a similar question about why not use just day's cash on hand to cover that. But I know you already answered that question. The 3.3% that you're referring to in terms of inflation, when I look at the inflation worksheet that you all provided in the appendix, I don't see 3.3. So I, you know, there's very little that actually rises above 3%. Most of you are, it's 2% for medical staff, it's 3% for non-medical staff. There were a couple of areas where it was 5%, but the component of your overall expense budget was 1%, so it can't be driving too much of that overall inflationary trend. So I'm just wondering if you can speak to the 3.3 in relationship to the inflation worksheet that you all submitted, which to me it looks more like a 2% inflationary factor. Okay, so I guess I'm losing where the 3.3% came from. Jessica, I'm sorry. Oh, that's okay, it's on your slide. It's on slide. I'll have to pull it up now. It's on the slide where you break down the 4.9 into 3.3 for wages, insurance, inflation, and then the 1.6 for CERNR. So I'm just trying to understand. Yes. That's all in station basically, wages, employment, health insurance, which was broken down in that appendix, but it doesn't get me to 3.3. It gets me to something in the area of two under three. Okay, so Jessica, I think I'm gonna have to take that offline and look at that a little closer so that I can get to a real accurate answer because just on the fly right now, I wanna put all the pieces together so I can get you a good answer on that. Hugely helpful and I totally understand. I don't like doing math on the fly either. I just don't, totally, totally. I'm adding machines in my office, I get, you know. No worries, I appreciate it. I would be glad to do that. Yeah, I'd appreciate it just that, yeah, that'd be great. And I guess my last question really just revolves a little bit around some of the work that you, or some of the conversation that you just had with Maureen around the ED and analyses that you all are thinking about doing particularly thinking about the acute patients that really need to be there and then the patients that are coming in. I think Brian you referred to them as convenient encounters which I know every hospital sees convenient encounters and then the possibility of some of these walk-in clinics and the reason I wanna bring this up or expand upon this a little bit is as we are moving to value-based payment, right? You know, cost and quality are gonna matter and we did have a presentation last week from Mathematica that looked at hospital-by-hospital analyses of potentially avoidable utilizations and North country is actually at the highest as a proportion of Medicare fee-for-service revenue, 37% according to Mathematica's estimates. This is from 2019 only looking at the Medicare population but 37% of North country's inpatient and ED Medicare fee-for-service volume was characterized as potentially avoidable. That doesn't mean that people that come in don't need the care but had they had care in a different setting at a different time they may not have needed to come in. So I think some of the work that you already said that you're thinking about in terms of walk-in clinics and some of the population health reforms, my hope and I guess I'd love to hear you speak to that is hopefully gonna bring that down given that you're at the highest end of the state in terms of the types of encounters that are happening not only in the ED actually but also in the inpatient setting, patients who had their diabetes been controlled at an earlier stage wouldn't have ended up in inpatient and other things like that. So just wondering if you could speak a little bit to that and the plan going forward as we think about value-based care. Yeah, so I won't repeat on the walk-in clinic or the community care clinic. I will share just briefly that and I'm gonna actually have Megan Sergeant jump on here in a second to talk about something. I'll cue that up. We have had already discussions even before COVID. I did talk to one care about what's the opportunity for investing and there's no doubt that if we put the money in into a walk-in clinic it's gotta be seen as an investment. And when you looked at our rate increase and it's on the hospital side and we're not doing anything on the medical group side we're investing in our medical group by offsetting it with what we do on the hospital side. I choose to use the word investment. And so approaching on some sort of how do you get, how do you motivate an organization that is helping balance the bottom line on utilization and then say, well, take that book of business away and then invest in something that's gonna cost you money on the walk-in clinic and it either works or doesn't. So even if it works, you've lost the higher volume or the higher utilization dollars and that's the struggle with value-based, right? So we have had the conversation even with our medical staff to digest what has worked, what hasn't worked, what's the, you know, pushback if any. We have, I have had multiple conversations from Northern counties to continue to look at the model and how it's working at St. John'sbury. So I was pleased to see that they started one so we can look at that and evaluate the cost star. And again, did, I'm already repeating myself but talked about it in the channel. I do want Megan Sargent our VP of patient care services to talk a little about about what we're doing on the patient management side of things, cause I think that will help the utilization discussion. Go ahead, Megan. Great, good morning, everyone. So like Ryan said, regarding those, I'm gonna call them avoidable visits, especially in the ED, case management is where we are spending our time and energy. We have a dedicated case manager for our ED patients who works closely with our outpatient case management department in primary care. We meet on a regular basis with the inpatient outpatient team to discuss those high level patients. We monitor also our frequent ED visits. And again, our ED case manager is intimately involved with a warm handoff to primary care for those patients and helping identify any barriers to access outside of the ED, whether that is they aren't established with primary care. It could be transportation in this area. That's a huge one. Or just general knowledge of what's available to them as far as care. Regarding the patients on the inpatient side that could have been avoided, again, it put all my eggs in one basket, but it's care management. It's that care coordination and getting them involved on the outside in primary care, establishing those relationships and really that preventative care and helping people to access needs prior to being admitted. Our outpatient care management team will come in and do warm handoff as people are discharged so that we have that care continuum through across our organization. Additionally, the outpatient care management team is coming to the discharge planning meeting, interdisciplinary discharge planning meeting on a daily basis to help facilitate that. So those are some areas that we're working on and really, again, investing in our care management team and seeing that as a way to improve our standing with value-based care. And Maureen, I'm sorry, Jessica, just to share one more story to highlight the obstacles is, we had another patient come and we believed it's COVID positive and wanted to do the test. They met admission criteria and refused the test. After several hours of the staff working with this individual to try to advocate for getting the test so we could responsibly handle and the course of treatment, the patient said no and checked out AMA. So when that patient comes back, that's a, so we're dealing with the, all of us know this, we're dealing with a free will and free choice and the hospitals are that last point of accountability, but we can't control free will and free choice, we can only educate and seek to influence it. Thank you. Yeah, thank you. And I appreciate all the work that you're doing in these regards. Yeah, thank you. Yeah. Thank you, Jessica. Robin, Robin Lange. Thank you. I just have a couple of questions. I wanted to follow up on Tom and Jessica's questions around the Medicaid FPP shift in the care management conversation that you were just having. It seems like the increase in your attributed lives when Medicaid went to the geographic attribution or whatever their, I think they changed the name of it, but whatever they're calling it now, obviously that happened right before COVID and COVID was all consuming, but I'm wondering if you see that as an opportunity to maybe increase your outreach to some of those patients who maybe were not seeing primary care and thus weren't attributed. And so how you see that piece of it in relationship to your care management efforts? Yeah, I mean. Yeah. So with Megan Sargent's lead on this, we're seeking to build on the case management side of how we identify and reach out to these people and how they're identified to us. So I can't speak specifically about what that plan and approach is, but we definitely wanted to take that approach. I mean, that shift in Medicaid happened right before COVID. So you haven't really had an opportunity, but I hope, I guess I'll just say I really hope that you're thinking creatively there because I think part of the point of the FPP sort of financial structure is to allow for that creativity and thinking about how you can do care differently in primary care to avoid those later hospitalizations. So thank you, Beth. Yeah, Robin, we are using telehealth created an advantage too. So whether they were established or not, we were able to connect with people and even on the no shows, particularly around behavioral health, some were more comfortable on that setting than they were in person. And then some that missed their appointment, were able to call and still have the session. So that's an illustration of that creativity that we seek to continue. That's great. And I did notice in your, oh, I'm sorry, go ahead. Sorry, Robin. I just wanted to also highlight that our care management team, inpatient and outpatient, I mean, we're a pair agnostic. We're really striving to meet people who have the need. If they're screening in for case management services, then we're doing that regardless of what the payer may be. Who was that that just spoke? Megan. Oh, sorry. Yeah. Yeah, Megan Sargent's our VP of patient care services. Okay, it was coming through on a phone number instead of through hers on my computer. So, okay. Just wanted to make sure that it was someone who had been sworn in. I'm sorry. Sorry, Robin. No worries. I did notice also in your narrative that you talked about a telehealth grant that to help boost cell signal and with remote patient monitoring, could you talk a little bit about how that's gonna be integrated into the care management efforts? Into the care management. So it's a lot of infrastructure support. So, for example, boosting satellite and home signals, that alone connection allows for the telehealth. It's also boosting signal strength here on the campus. It's also, there's a lot of hardware. And that grant also benefits not only our hospital, but it benefits the local nursing homes for boosting their telehealth connections. It also, we have resources built in there for specifics that the V&A needs in our area. And also NKHS. So it's a broad reach. And, but I would say most of it is infrastructure. Well, anything, Brian, also that infrastructure allows us to do more home monitoring for our care management team. Increasing people's access to internet service and high speed allows us to have those home setups where we can monitor your heart failure patient. We can monitor your weight. We can monitor your pulse box. It can be sent in and one nurse can monitor that central station and then reach out based on what your reporting vital signs are and how you're reporting your symptoms that day. So expanding that internet access has huge implications on how we can manage patient panels more effectively. Great, that's terrific. So my other question had to do, hold on, let me just get to where I wrote it on one of the slides, I think. Had to do with the discussion that you had around the... So on slide 11, your compensation benefits in locums. It sounds like there's a bunch of different factors that are going into those costs. You've mentioned the increase of traveler needs in locums in a couple different areas. But you also mentioned that you had some furlough and salary cuts. Could you just unpack that for me a little bit more? I just wanna have a better understanding of what are the ups and downs related to your staffing. Okay, so I can start and then Brian can join or whatever. So the salary cuts and the furloughs happen during the time period of basically April-ish May of 21 till July-August of 21. So those show in our numbers there. We furloughed when our revenues went down, we furloughed the staff accordingly. So we did do a large furlough effort during that time. And also senior leadership, leadership and physicians took pay cuts during that timeframe in order to help that situation. They were returned to us at the end of the year because our volumes came back but during that time period we did that.  And again, that happened in that timeframe of the year. And as far as the locum and the benefit piece, health insurance had been running pretty steady and we'd seen in this last year into next year that the health insurance has gone really high. So that's in those numbers. And then of course in the locums, we put them basically flat. But again, that's something if I redid this graph today and looked at it, it would probably be a lot higher and unfortunately probably will be higher into next year. So there's a lot of different factors that are going in here with big dollars. So I think that's why you're, and if you add them all together, they basically come out that way. And we're self-insured too. We're self-insured as well, yeah. Yeah, so thank you, that's helpful. So the salary shifts in the furloughs were time limited related to COVID, they weren't, what I was trying to sort out was, did that have an impact on any sort of staffing vacancies and which then you have to fill with locums and how that all fit together, if at all. Yeah, no, we brought back basically all our staff from the furlough effort, unless there were some other reason why they didn't wanna return. So yes, we brought them back. Thank you. You're welcome, thank you. Thank you, Robin. I just have a few questions. I'll start with the certain or the better. In the past, you had told us that the reasons why you were with Athena were pretty much about price. And I'm curious if it's the same, your primary referring academic centers, UVM and Dartmouth are both with EPIC. What was it again, a price consideration or do you feel that you're gonna get some efficiencies out of CERNR that you would not have gotten out of, say an EPIC? So we definitely would get better efficiencies with CERNR then from, I think from EPIC just because of EPIC is EPIC. It's larger, I consider it the Cadillac of Systems, it costs far greater. So it wasn't that hard of a decision between the two. I'm sure EPIC could have worked for us, but it's not wired for hospitals our size. So we felt it was just overall, CERNR was a better fit for cost and quality for what we needed. Do you wanna add on to that? Yeah, we also looked in Meditech was the other player and Meditech is more appropriate for a hospital our size and clinically they came about the same, but the cost there was a very big difference differential and Meditech was much more expensive than CERNR was going to be for us. And CERNR did have a slight advantage as far as the clinicians and such preference for that first CERNR. Will they embed staff with you during the transition? Yes. Okay, great. You look at the millions of dollars that flowed in, you mentioned earlier in the presentation that you felt you were the beneficiaries of a population that you're serving that had confidence in your safety. And so that utilization came back to normal quicker than other hospitals experienced. And you're gonna finish this year with probably a likely projected 17% total margin. And yet you didn't choose to expand into the Medicare portion of the all payer model. I'm just curious if not now, will that ever be considered and what your considerations were? So first off, Chair Mullen, again, when we started the budget, February didn't look like what it does on a February project and didn't look like the trajectory it does today. So that's how quickly things can change in a matter of months. And it can also go back the other way. So we consider that. The only hospitals, and you can correct me if I'm wrong, but the only critical access hospitals that are in Medicare are part of systems. So that would be, they're part of Dartmouth or they're part of UVM. So there is a little, in my opinion, there's a little backup plan. I'm still not convinced that the risk outweighs the reward when it comes to Medicare understanding its impact on critical access hospitals and the critical access hospital method for reimbursement. And so I wanna make sure that we don't get kicked off a program that we can't get back on.  I think the risk and how much we have to book for reserves is great. And I think it's only gonna be, it's gotta be a matter of time and seeing closed out cost reports that are definitive. While we have our consultants that tell us, yeah, we think this will work or yes, we think this could be a benefit. But we don't have any hard evidence and cost reports take several years to, I mean, our latest outstanding cost report is 2019. So until we have some several cost reports, I think our hospital would be in jeopardy if it jumped to that. I did work with one hospital years ago that chose not to become a critical access hospital and they're in dire straits. So I don't want us to be in that situation and put that risk. It's just too great. Okay, you mentioned that as far as the farm in the 340B, there was a new player who dropped off. Who was that? Oh, darn. I'm gonna have to get you back that name. It was a pharmaceutical company that I wasn't real familiar with. So I have the name and notes from that meeting, but I can't recall it right now. I'm sorry. Yeah. Okay. And given that, you just said, Brian, that when you put forward your budget and started the work on it that things were different and you've seen increased volumes and such since then, given that what you've asked for and a change of charge is higher than what you have historically, and I don't want to infer too much based on the new federal transparency laws that were put in place, but because you really can't even compare, it needs so much work for hospitals to have true comparisons, but when you do take a look at it, and I think the Burlington Free Press article attempted to look at at least five different categories. And North country was high compared to their peers in most of that. So it appears that at least from a small look at what you're charging, you seem to be high compared to your peers. You have total cash on hand that's much higher than your peers, not only in Vermont, but throughout the Northeast significantly higher.  Would you reconsider what you've requested since that change in charge is higher than what you have typically requested in the past? No, we're talking about something that's happened over a few months. And like I said, there's all factors that come into how we manage that 2% to 3%, right now it's 3%. And we wanna stay on that path of a solid performance. And so we do have, we have CERNR costs, and a portion of those are one time, but we still have to look at what the market is in the environment with the locums and paying adequate wages. So I would just, if we had to redo this presentation, I would have flipped it and we would have taken out CERNR, we would still told the CERNR, but we would look at what the projected for locums is, which is now, we went again from nine to 15 and we're projecting at 22. And what scares me to death is the rates we're hearing about what those hourly rates are for the locums. So we're not talking, I don't even wanna call it out, but there's, in some cases, the rates that we would have been paying have increased almost double. So that's what scares me. That's the big recipe next year. Yeah. So at this point, I'm gonna turn the questioning over to the health care advocates office and Kaylee and Sam. Morning Chairman Mullen, good morning everyone. So this is Sam Paish, I'm a health policy analyst at the HCA. As was mentioned earlier, Kaylee and I are gonna be asking questions at the hearings. So I just wanted to open up with thanking North Country for all that you've done and continue to do for remoners during the COVID-19 pandemic, particularly given this recent services driven by the Delta variant. So in that vein, as you might be aware, the Department of Health and the VT Digger has reported on this, releasing new data showing that the ITO Steve Remoners are still disproportionately impacted by COVID-19 in the state. For example, black remoners have a case rate that's almost three times higher than white remoners. So in this realm, you probably saw that we submitted several pre-hearing questions that have a race equity focus. So those are gonna be the focus of our questions today. So our first question is, how much funding in your current and future budgets has been allocated to diversity, equity and inclusion or DEI and or racial equity focus projects, trainings or collaborations? Thank you for your question, Sam. So we unfortunately don't, we don't go that granular and carve out this specific expense. I can illustrate what we do. We do have, we try to use that as a component of how we operate. So we have leadership development Institute classes and also Elsevier classes that we now are onboarding that every employee will participate in as part of their annual in-service. We have within our medical groups side, we have a position that is our community wellness that seeks to influence and dialogue with community groups as diverse as they can be here in Newport. We're not a diverse, honestly we're not a very diverse. And that's not gonna change too quickly, but we seek to engage with the diverse groups through our community health needs assessment, which was just completed. And then we also, I would say we try to recruit diversity. Most recently over the last two years, we've recruited a number of nurses, international nurses that we have, I think almost we're approaching about 10 now that are from countries like Kenya, the Philippines and Jamaica. And those nurses have brought in some cases, families, which are now in our school system. We also, they've also helped recruit others, friends and family, and we're continuing on that platform. So we're pleased with that. And so I would say we're in a way, ironically, probably a little more diverse than we were a couple of years ago because of that focus. And any other thing I can answer in that regard, Sam? Thanks, so I appreciate it. Kind of building off of that. Do you have a sense of what percentage of staff and administrative leadership have received training and language access, implicit bias, cultural competency or related trainings like that? Well, I would say within the year it'd be 100% because of the courses that we brought on through Elsevier. Again, it's online that you, it's mandatory that you take it. Yeah. We also had, it wasn't this within this, well, it was within the last 18 months we had, we had someone that was going through a gender change. And so we had some classes that we offered here to leaders and to staff to support in which the individual was a part of as well. So we seek to embrace opportunities that come before us. Thank you. You're muted, Kylie. Thank you. You mentioned in your narrative that all patients receive a patient satisfaction survey. And can you tell us what languages those patient satisfaction surveys are available in? The, my understanding is the satisfaction survey is available on demand in Spanish. And then for right now, that's what we have. And we do have a capability, I guess, to do a service to put it into more languages. But again, like Brian noted before, we don't have that many people in our patient population that speak, you know, other languages. So we do have Spanish as the main one with English. Okay. And do you collect race or ethnicity data in your patient satisfaction surveys? I don't. Okay. We can find that out. I'm not sure. Thank you. I don't know if you can speak to this then. Can you tell me a little bit about how you assess what the needs are in your community as far as language access or diversity? How we assess it or identify it? Well, I mean, first of all, like coming to the hospital, we have to have, we have a system, all hospitals got this, but for when someone has some language needs, we have a certified interpreter system that we call it's not just someone that's on staff that may speak the dialect, unless they're certified, then we can use them. So that would be point of care. I think the other opportunity we'd have, again, is pointing back not to be overly redundant, but to more recently, our community focus groups that we engage with and in regards to our community health needs assessment. I just, I haven't had much surface as far as opportunity on that lately. I can think of the top of my head. Okay, thank you. And my final question is in regards to your financial assistance available to patients. I know that you mentioned in your written responses test that you have interpretation services available. Are those available for people applying for financial assistance? Can they access interpretation services to ask questions and get help filling out the surveys? When they, that would be available when they're working with our navigators that help them with their financial assistance because the navigators have access to that tool. So working with them, they would have access to that tool. Okay, thank you. And are the policies available in other languages? I mean, sorry, the applications available in other languages? I don't believe so. Okay, all right, thank you. That's my last question. Thank you. Thank you. Next, we're gonna turn to the public. Does any member of the public wish to offer comment on the North country hospital budget presentation? Does any member of the public wish to offer any comments on the North country presentation? Not seeing any hands, but I am seeing some blue around Dale. Dale, were you trying to offer a public comment? Go ahead. Yes, I lost connection for a minute and it came back. I'm curious on that last one where they said the only language that translation and the offer is Spanish, but they get doctors and nurses from Canada. Canada, wouldn't French be required as well? I mean, Quebec is mostly French. They are bilingual, but I'm just curious. It seems as though French would be required too. Yeah, Dale, that would be my first guess is the next language that we may, that we would bring online if there was a need. Unless there, again, we have interpretation services here at the hospital. So if Canadians come and access care, it's likely through the emergency department. We don't have them the staff and care through primary care because the Canadian system, well, there was a day and age where they did pay for services here, but they no longer do that. It's out of pocket. So we don't get as many Canadians that would come here that speak mainly French or French Canadian, I should say. One more question. Go ahead, Dale. When you say that the locum, if I use the term correctly, is from other countries, I am curious, do you know how they get their education before they are hired by you? I think there's an important conversation there that gets away from the hospitals, but nonetheless is important. So do you have any insight on that? Yeah, so Dale, good question. What we do is they have to meet acceptable board criteria to be able to work in the US. So it doesn't matter where the person of origin is, where they're coming from. It's a matter of if they pass the proper boards, whether it be for nursing for a medical degree, such as a doctor. So they have to pass those before they can even be licensed in Vermont to work. So, okay, and that has to be the Vermont exam or because I know like in Vermont, sometimes the test is on given every two years, things like that. So is this specifically for Vermont exam? So good question. So it depends on the origin of the individuals, not the origin, but what role that they're seeking to fill. So it's different for nursing. It's different for, again, a physician. There are national boards that are associated with say general surgeons. There's boards for nursing. And then it gets a little more detailed or fine tuned, I guess, when it depends on the state. I can't really speak more specifically of what Vermont may do to the same or different than a national board or a board coming from another state. There are programs, again, using as nursing as example, where Vermont is now participating in a nurse compact and that allows nurses to cross borders. If they meet a certain, if they're licensed within a certain state, they can cross borders and work within our hospital. And it works the other way around too. But internationally, if they're coming from an international across international borders, there's a little, there's more of a layer of complexity there. Thank you for letting me ask some questions and I listened to all of the board's questions. You did really well. Thank you. Thank you. Thank you, Dave. Thanks. Is there other public comment? Any other public comment? Hearing none, Brian, Tracy, Megan, thank you for the presentation. And we know these are tough times as everybody's facing that uptick with the COVID variant. And please pass on our gratitude to everyone at your institution for their work, not only for the last year and a half, but for their work for Vermonters all the time. So thank you very much. And with that, I'm going to place this meeting in recess for 10 minutes for a bio break. And we will come back at 10.35 and commence with the Rutland Regional Medical Center. Thank you.