I think what I'll do is, Jerry, if you could introduce each of the persons from NMC who are planning to testify today, and then we'll ask Joanne to swear you all in as a group. Okay, good. Thank you, Kevin. Good morning, everyone. My name is Jerry Barbini, and I'm the interim CEO here at Northwestern Medical Center. And in addition to myself, you'll be hearing from Dawn Bugby, our interim Chief Administrative Officer, Robin Alvis, our Chief Financial Officer, Stephanie Bro, our Director of Finance, Janet McCarthy, our Board Chair, Leon Berthium, our Treasurer, and Immediate Past Board Chair, Dr. Greg Brophy, our Executive Medical Director, and Dina Orfanitis, our Chief Nursing Officer. Great. Joanne, if you could swear them all in. Oh, I'm sorry, Kevin. I have one more. Devin Bestjelter, our budget manager, the brains of the operation. Sure. When everyone who's going to testify, please raise their right hand. Do you swear the testimony you're about to give will be the truth, the whole truth, and nothing but the truth will help you God. I do. Thank you. So Jerry, whenever you're ready to begin, take it away. All right. Thank you. And good morning, again, everyone, and thank you. Thank you for this opportunity. As I mentioned, I'm the interim CEO here at Northwestern Medical Center. I've been here since the end of March, and as you know, there's, you know, interviews going on here. There's a transition in the CEO position, and interviews are going on. So I expect that I'll be here another month or two. As far as my personal background, I bring 40 years of hospital leadership experience with me here to this engagement, the last 27 years as a hospital CEO in community hospitals in Massachusetts and in Michigan. So I think I bring a unique perspective to our discussion here today. I'm a fresh set of eyes. I'm brand new to the state of Vermont, brand new to St. Albans, and brand new to Northwestern Medical Center. And I can tell you that in the few months that I've been here so far, it's been a great experience. This is a great place. I'm sure most of you listening are probably long-term Vermonters. So, you know, you'll appreciate what I'm saying, but boy, this really is a great place. And again, it's been a great experience. It didn't take me long at NMC to discover that this is an outstanding organization and an incredible community resource. You know, at the time that I've been here, everywhere I turn, I see quality. As in most high-quality organizations, you know, that that starts with starts with the people and, you know, our constituent groups here, we have extremely strong commitment from all constituent groups, starts with the board includes the providers, all of our employees, our patients and the community is very strong community support for the hospital here. And all of that translates into very high-quality care being provided to our patients. This organization lives the mission to provide exceptional healthcare for our community. However, it also didn't take me long to determine that there are significant financial challenges here in the organization. For consecutive years of operating losses, we're in technical default on our bond covenants. And you know, as a new person coming in, I'd ask the obvious questions. Why? Now, my experience most times when there are financial difficulties in operating losses, it's because of expense control. Expenses are out of control, costs are too high. However, it didn't take long to determine that that's not the case here. And you're going to see some data later on in the presentation that will prove that. This is a low cost and a low charge provider. So that begs the question, what contributed to the financial decline? And I'll give you my opinion, the most significant factor is the compounding effect of the 8% rate decrease that took place in 2016. Prior to that, this was a financially strong organization with a consistent operating margin. And you know, from what I can determine, looking back, they got there one way and that's sound responsible management. And unfortunately, rather than being recognized and commended for that responsible management, they received the 8% decrease in 2016. So I want to make a few comments about the budget itself before I turn this over. First, I think it's important to note that NMC has met all of your stated criteria for the fiscal year 21 budget submission. Now, in my 40 years of doing this kind of work, I've seen a lot of annual budgets. And I will tell you this is an excellent budget. This budget represents a responsible balance of expense control, and you're going to hear a little bit more about what we've done to control and reduce expenses later in the presentation. Also includes investment and services to improve the hospital's financial sustainability and our ability to continue providing access to high quality care to this community. It's important that we not look at this budget in the context of one year. We need to look at it over a pattern of time, probably through a five year window. And this fiscal year 21 rate increase will help reverse the negative impact of the 2016 reduction. Since I've been in the state of Vermont, I've heard a lot of talk about hospital sustainability and I know you've got some work you're going to be doing here next year. And by then, I'll be long gone, but I will tell you that right now, today, NMC is at a crossroad. And this budget will be a significant step in restoring NMC as a sustainable community hospital. I encourage you to approve this budget as it is submitted. And again, I thank you again for the opportunity to speak this morning. And now it's my pleasure to turn the presentation over to our Interim Chief Administrative Officer, Dawn Bugby. I don't know if we lost Dawn or what. Dawn, are you there? Yep. Hold on a minute. She's back. I'm back. Good morning. My name is Dawn Bugby. As Jerry said, I'm on a temporary basis as the chief as the Interim Chief Administrative Officer. However, I'm not new to NMC. I spent 17 years here, with the last 10 of those being the Chief Financial Officer. Most recently, I spent 13 years as the VP of Finance at Green Mountain Power. I feel so fortunate to have the opportunity to come back home, though. NMC is special. This community is special. It represents what Vermont is all about, caring for your neighbor. The temporary role was intended to help NMC achieve financial stability, but the day I walked in the door in March, COVID was just beginning to take its toll. You've heard the pandemic stories from all the previous presenters. However, Vermont is strong. Vermont is strong. We are all in this together. We are thankful for our strong leadership from the governor's office, all the way down to our healthcare and essential workers working the front line. Many precious lives have changed forever. I, like so many others, lost a dear family member. He served as the community pharmacist. However, with this comes hope. This is a transformational moment in healthcare. We are now living in two parallel universes for the near future, maintaining business as usual, but moving rapidly into the new norm, finding the time to dedicate to prepare for the healthcare of the future. But to do all this, all hospitals are asking to first stabilize their current system so we can have the economic resources to invest in the future. With that, I want to thank you, Green Mountain Care Board and your staff, for all the tremendous amount of time and effort you dedicate to this process and for taking your role very seriously. We do appreciate that. And with that, we always welcome the opportunity to tell our story in NMC. I'm transferring my speech then to Robin, who is our Chief Financial Officer. Thank you and have a good day. Thank you. Thank you, Dawn. And thank you to the Green Mountain Care Board for the record. My name is Robin Alvis. I'm the CFO for Northwestern Medical Center. I've been here right out of year. And what a year it has been. You've heard over the last two weeks, all of our peers discussing really what unprecedented times we found ourselves in and taking care of our patients and responding to the pandemic. Those challenges, of course, aren't unique to NMC. And there's no words that can do justice to the response of our clinicians and the leadership of our physicians and really the support of the entire community and our community partners to care for our patients and to keep them safe as possible and to keep each other very safe. However, most of our presentation today will be focused on the non-COVID impact and where we were pre-COVID and what we need in a non-COVID environment to regain financial sustainability. What you'll see is a budget that produces a net patient revenue decrease of about 1.4 percent year over year. You'll also hear about our exhaustive efforts to continue to control costs to make the necessary investments, but also to make the necessary reductions. Our expenses year over year are down about 1.5 million, and that includes absorbing about a million dollars in medical inflation. Our budget, as Jerry said, complies with the benchmark established under the GMCB rule 3.202. To the left, we just went through the exercise to show under the budget order what we could come and ask for. Our adjusted budget to the left, you can see, was about 118 million dollars. Our adjusted budget was 117. If you were to apply that 3.5 percent allowable growth, that would allow for an increase of 4.1 million in NPR and a total NPR cap of 121 million. To ask for that, coming off of four years of not meeting our revenue cap would have been irresponsible. As we looked at our pricing, our costs, we're pleased to present a budget that comes in about 1.5 percent less than our 2020 NPR cap, and it represents a variance from our allowed cap of 5.2 million. To the right, you can see the columns that show our adjusted fiscal year 2020 budget and the changes between that budget and what we're asking in fiscal year 2021. You can see our net ask is to provide a rate increase that will return us to a positive operating margin and to give us an operating margin percent of 2.3 percent. Well below what the industry would recommend and say that our target should be. But we recognize that we're in unprecedented times. We recognize that there are financial decisions that have to be made affecting all Vermonters and hospitals in our community are no different. Maving to our vision, we feel, as Jerry mentioned, our community support is tremendous and we belong in this community. We have many, many years of high quality service and engagement with our community. Our service area of Franklin and Grand Isle County gives us the privilege of meeting those community needs for over 56,000 Vermonters. While we're growing, one of the few areas of the state that is large portions of our service area are rural and almost half of our patients live north of us and many would drive an hour or more for care at the next closest hospital if we weren't here to meet those needs. And that's on a sunny Friday afternoon and not during the winter months where transportation is even more problematic. Also, it's our strong belief that community hospitals play a vital role in providing access to care in Vermont, even for those hospitals that are adjacent or in close, somewhat close proximity to a tertiary care center. As the designated Seoul Community Hospital, NMC brings value to our region. If we did not exist and care provided here had to go elsewhere, Vermonters would pay significantly more and have to travel farther. We feel it is important to have a strong relationship with our tertiary partner and our community partners. We feel the right solution is to continue partnership where it makes sense and we're very proud to have helped support the dialysis center run by UVM that has been on our campus for more than 20 years. We also rely on our partnership with UVM for specialty care that we couldn't support independently in our community. We've also had to make decisions where statewide the scarcity of resources and certain specialties even make that relationship difficult to provide outside of Burlington. Which again brings me to the point and what you'll hear us speak to over the coming slides is the vital importance of the community hospital to provide care for our patients, close to home, close to their support network, and at a price point that makes sense freeing up those valuable resources and services that really only our tertiary partner can provide and who is trying to meet the needs for the entire state of Vermont. I'm going to ask Stephanie Bro, our director of finance to lead us through some of our financial and supporting data. Good morning everyone and thank you Robin. For the official record my name is Stephanie Bro and I'm going to keep us moving along here for a little bit. You asked us to provide a summary of our net patient revenue and a summary of our budget request and so you can see that here. As you've already heard this budget represents a decrease in our net patient revenue from the current year budget and that decrease is approximately 1.4 percent and it leaves about 5.2 million dollars in allowable net patient revenue growth on the table but we felt that that was really important not to just try to maximize our cap space even though that cap space is precious. We really wanted to build this budget from the ground up and looked at actual data from October through February in order to do that which is not unlike you know our regular process anyway so COVID was not horribly disruptive to that. Most of our volumes are assumed to be flat. There are some that are decreasing slightly just based on trends that we see and there are some changes related to programs and services that I'm going to talk about in a few slides. I've heard some of you ask about assumptions related to reimbursement from payers and so I thought this might be a good place to talk about that. We have assumed no increase or decrease from Medicaid and we have assumed a small increase from Medicare just based on the proposed rule that was available to us at the time. We did not include a three month reprieve from sequestration which for NMC would be worth approximately $75,000 so we want to calculate that for you and be transparent but you will see as we go through the rest of the presentation that we have unfavorable offsets to our budget as well that relate to information that we've received since submitting and that there are several areas of risk for NMC in this budget. Our plan moving off to the right of this slide is to implement a 25.37% increase on hospital based services and a 0% increase on physician professional services and that's been our strategy for a few years now and I want to explain the reason why. We feel really strongly that a 0% increase on the physician professional services is the best way to meet the need of our community because someone with a high deductible plan which so many people have that these days or someone who doesn't have insurance at all we want to make sure that those people can still make a trip to their primary care physician and to do it in an affordable way so we haven't touched those rates in quite a while. This is a summary of our P&L and our balance sheet. As mentioned earlier also this budget generates net income from operations of 2.8 million or 2.3% operating margin. We have also included some non-operating income here which is mainly interest and dividends from our investment portfolio. I thought this might be a good place to answer another question that I've been hearing which is around inflation assumptions. So we have assumed a 2% increase in wages for all staff. We have assumed 3.8% inflation on pharmaceuticals, 5.7% inflation specifically on surgical implants and 2% inflation on all other supplies and services. And so what we did was put that all together for you in a weighted average and the weighted average is 2.25% which for NMC equates to right around one million dollars. We are projecting a current year loss from operations of approximately 4 million and it will be the fourth consecutive year that NMC has experienced an operating loss and those operating losses total 18 million dollars and are not attributed to COVID. NMC has had to subsidize some of these losses with drawdowns from its investment portfolio and you know it's always our hope and our plan to use that investment's portfolio to pay for capital investments and to have that money available to us to make it through tough situations that we can't anticipate such as COVID. NMC has been fortunate enough to receive over 12 million dollars in stimulus funds and over five million dollars in advance payments from payers that will need to be repaid and we have submitted an application to the state for the healthcare stabilization grant but as you've heard already we're unsure if anything will be received that grant does not provide you with an ask or a dollar amount when you submit it. And yesterday we submitted our FEMA application as well and I expect to receive around 100,000 related to that FEMA application. We have applied for hazard pay for certain of our employees that qualify and we have also applied for smaller grants through VAS or through the emergency preparedness coalition so we really try to take advantage of everything that we can, everything that's appropriate and we will continue to do that but we know that our investment portfolio was needed early on right before help arrived and before the stimulus money arrived and we know that it may be needed again. Moving over to the balance sheet on the right hand side of this slide I want to focus on the ACO reserve of 1.6 million. Since putting this budget together we received communication that our risk reserve liability will actually be 2 million dollars so that is an unfavorable offset for us of 400,000. I do want to spend a couple of minutes going through ACO risk reserve activity because as you all know it's multi-year and it's complicated so I thought it might be worth the exercise. As of today NMC has just shy of three million dollars of ACO risk reserve on its balance sheet. NMC will be writing a check for over 1.5 million to the ACO for the 2019 program year which is a calendar year so that will leave us with about one and a half million of risk reserve but NMC's total risk for the 2020 program year the year we're in right now is 2.2 million so NMC will have to work with its auditors to determine if an additional 700,000 is needed in the current year to cover that risk and if so it represents an unbudgeted amount for NMC and it will have a direct impact on our bottom line. We're going to talk more about ACO participation and how it relates to our rate increase request for today in just a few slides but I wanted to provide you with that background. This is a look at our 2021 cash flow statement. The budget we have put together generates negative cash flow of 5.6 million but that is because of the maximum potential and I really want to emphasize the word potential capital spend that you see there of 14.75 million. We have put the maximum in here but there is no doubt whatsoever that we will have to be flexible with our capital spend because it's something that organizations can quote-unquote control pretty easily and deferring capital investments especially from multiple years in a row it has consequences it's not something any organization wants to do but it can provide short-term benefit and so it will be up to us to find the right balance and to use that capital money wisely. NMC does currently have an approved certificate of need for an emergency department renovation and that represents 7 million of the 14.75 that you see here and that 7 million would be funded with previously designated assets from our investment portfolio not through rate increase. As I mentioned earlier we do have some service line adjustments that have been incorporated into this budget and we have spent a lot of time in the current year looking at service lines and when we look at them and when we have those conversations we've really been putting them into three buckets. What do we want to invest in? What do we want to see if we can restructure or do it differently? What might need to be transitioned or even divested in? So what you see here is that we are continuing to invest in primary care and pediatrics we have new providers coming two new primary care providers will be joining us this fall as well as a pediatric app and we're recruiting for two more pediatric providers. We really feel that continuing to invest in primary care is crucial to population health and the triple aim and not only investing in it but really doing that work in accordance with patient-centered medical home team-based care standards. We're strengthening our ICU program and adding tele-ICU through Dartmouth and that's another example of NMC using partnership when appropriate to improve an existing and and needed service and this partnership will allow us to keep appropriate ICU level patients in our community and I'm going to talk more about that in just a couple of slides. We're also planning to provide sleep services within our existing pulmonology program to address the community need and we also see sleep services as a primary care type of investment as patients with untreated sleep apnea or other sleep disorders often develop additional chronic diseases. Moving into the category of restructured you see that we continue to provide lifestyle medicine and RISE Vermont services we have further integrated lifestyle medicine into primary care and we now see ourselves as a RISE Vermont spoke with the ACO acting as the RISE Vermont hub it's been exciting for us to start that program and to see that transition and lastly we're proud that we have worked with our community partner to maintain addiction and mental health services for our community and we have transitioned our patient neurology services back to UVM medical center where that care is most appropriate at this time. So now we're moving into the risks and opportunities section of our presentation and you'll you'll find out that we feel that there are many. First and foremost we want to revisit our mid-year rate increase request and the additional work that we have done since then to address your concerns. As you know we experienced a major impact of volumes in our physician practices after implementing a new electronic medical record in May of 2019. We estimated that impact to be worth approximately seven million dollars in the current year and the feedback we received was to cut expenses accordingly and to cover temporary losses with days cash on hand and NMC has done that. We have done the hard work of cutting expenses 1.8 million dollars within the physician services division alone across 11 practices and Robin's going to talk more about expense reductions elsewhere in a few slides. We have funded the temporary losses with days cash on hand and we have continued to optimize the system. We have worked tirelessly with the vendor with our staff with our providers and we have reduced the impact by about two million dollars and our current volumes are within MGMA standards but we're challenging ourselves to continue optimization and to cover another 1.7 million in 2021 and so this is a risk area in our budget and we think that the continued use of telemedicine is going to be crucial to mitigating that risk. Like many of our peers we began to use telemedicine heavily at the onset of COVID and it's really been a bright spot of the pandemic for us. Many of our patients have really embraced it. So between the expense reductions the ground that we've already made up and the ground that we are still challenging ourselves to make up we have come up with a five and a half million of the original seven million dollar ask if you will. Unfortunately there is still an impact and we can't implement further cuts in this area without jeopardizing quality care. I agree with anyone that there's always room for improvement and there's always opportunity to reduce expenses and so we're certainly going to keep at it but it would not be prudent to build additional expense cuts or additional volumes into our budget at this time. The other item that we discussed with you during our mid-year rate increase request was around temporary staffing and our ICU. Workforce recruitment and retention continues to be a challenge and we continue to need travelers. I've had the opportunity to listen to the other budget presentations and I'm really impressed and you know quite frankly I'm jealous that some of the other organizations have been able to reduce or altogether eliminate their use of travelers and so we're certainly going to be reaching out to them to make sure that we aren't missing something. But like our peers we have worked hard to revamp our orientation and our training programs. We have provided tuition reimbursement to try and grow our own and we continue to work on longer term solutions such as our partnership with Vermont Technical College. I've touched on that program in the past but I want to remind you of how it works it's called the Aspire program. We provide space we provide tuition and we provide guaranteed placement of up to 10 graduating nurses. This fall will be the first class of students for that program which has been nearly two years in the making so we're excited about the potential future benefit that that program can provide. The feedback that we received following the mid-year rate increase regarding our higher than budgeted traveler costs was to provide some detailed information about ICU services and whether the neighboring tertiary care facility had the capacity to more effectively treat those patients. It is important to note that not all of our traveler costs come from the ICU so that may have been a point of confusion when we did the mid-year but we certainly utilize travelers in the ICU and so we wanted to address your concerns. The tele-ICU addition results in 130 fewer patient transfers per year. UVM provided testimony during their budget presentation that they are at or near capacity and so we truly feel like keeping lower level acuity ICU patients here within the community is actually a way for community hospitals to support tertiary care providers and really ensure that Vermonters with high acuity cases have a bed and have the opportunity to receive the care that they need. Also the tele-ICU program provides a positive contribution margin for NMC because we receive sole community hospital reimbursement we're designated as a sole community hospital through Medicare and we receive low volume payments from Medicare and that program the payer mix for that program is highly Medicare so we really see this as a win-win. With all of that said NMC has significantly reduced its 2021 traveler budget from what our current year projected spend is and so once again we're pushing ourselves we're challenging ourselves to do better in this area and we're taking on risk in this budget. The largest risk and the largest opportunity for NMC relates to its pricing and so I'm going to spend a fair amount of time going through it if you can all bear with me. Before we dive into the data related to pricing we want to address some important issues and the first of which is affordability. Implementing rate increases impacts our community there's no doubt about that impacts the families that live here and that receive their care here and we do not take any rate increase lightly that is shown in our history. We fully understand that this is difficult and we still believe that the only thing more difficult would be if NMC does not exist to serve the community for years to come. This rate increase is needed for long-term sustainability and it makes sense within Vermont's overall system. And the next important issue I want to talk about is the cost shift. The cost shift is real and the cost shift is concerning. Nearly every hospital has had the chance to speak with you all about the cost shift and the fact that solving it you know requires solving some fundamental issues at the root of our health care system. What we're trying to say here on this slide is that this budget does not represent a cost shift for 2021 due to the fact that we are seeking a decrease in our net patient revenue and that the commercial payers have benefited by NMC not hitting its net patient revenue in the current year and quite frankly for the last several years in a row. And then lastly on this slide is the important issue of continuing to provide charity care to the individuals that need it. We had the opportunity to collaborate with the health care advocate this past fall and to expand our charity care eligibility. We increased the income level, we removed residency restrictions and we simplified both the policy and the plain language summary and so I want to give a shout out and really thank them for their hard work and their collaboration with us on that project. Also when talking about pricing it's important to remind folks that hospitals are not receiving the full contracted rate from commercial payers. So bad debts and denials from within the subscriber base can result in or doesn't can it does result in decreased reimbursement from the contracted amount. And you've already heard testimony that denials are up especially supply related denials and that has been our experience as well. Differences in payer mix must also be considered. NMC has one of the if not the highest Medicaid payer mix of any Vermont hospital. It creates a financial challenge for us that's true but it remains our privilege to serve this population in the same way that we serve the whole. And we need to talk about the impact of social admissions. Dimension patients and psychiatric patients they limit every hospital's ability to maximize revenue and to operate at the utmost efficiency. Keeping these patients safe until we have an appropriate place to discharge them is absolutely the right thing to do it's at the core of our mission it's what we all do. But we often cannot get paid for sub-acute patients and they can stay for weeks or months at a time. Fiscal year to date through July NMC's sub-acute patient days are up 26% compared to the prior year. And again this is not an issue unique to NMC it's a day-to-day balancing act for all. Now for some data to support our rate increase request and really to demonstrate the impact that it would have if implemented. So this first graph you see here this is an exploratory analysis only okay it cannot be used to draw conclusions on its own and we absolutely recognize that. Once again I want to give kudos to the healthcare advocate because they reached out to us and we've had the opportunity to take some good time to go through it with them and we're really grateful for them to take the time to do that with us.  One model for net patient revenue and one model for hospital expenses. And we used year-to-date volume statistics through February for each hospital to predict the levels of revenue and the levels of expense that you would expect to see given those volumes. Then we compared the actual revenue and the actual expense to the predicted revenue and the predicted expense. And we created the four quadrants that you see here. Points further to the left of this graph have actual revenue less than what was predicted and points toward the bottom of this graph have actual expenses less than what was predicted. And as you can see NMC falls in the lower left quadrant indicating that both revenue and expenses are less than what the model would have predicted. And again it's just a small piece of our presentation and we as we try to look at pricing and parity in a variety of different ways. Another way that you could look at it statistic that I think is much more familiar to all of us would be a cost per adjusted patient day statistic. So we looked at that as well and we feel we can compare favorably there too. This next graph is a graph you've seen before. We included it in our budget presentation last year and it shows the history of rate increases and where NMC falls within the range so that would be the gray shaded area and where NMC falls against the median for any given year. You can see that NMC is often below the peer group and if granted the rate increase that we have asked for NMC will still be below average over a span of 11 years. NMC would be at 3.9 percent with an average of 4.5 percent. And you can also see when you look at the last 10 years of actual data 2011 through 2020 NMC has been the lowest rate increase 50 percent of the time and we're only one out of 14 hospitals. You've heard us and others speak about the compounding impact of rate decreases. Jerry spoke about it at the beginning of our presentation and so we wanted to expand on that and turn it into dollars and cents. As some of you may recall NMC exceeded its net patient revenue budget by 2.9 million dollars from 2014 through 2016 and reduced rates by 8 percent in 2016 as a correction. The correction equated to 4.2 million dollars per year at the time and continues to compound. So nearly half of today's rate increase request is to close the gap that you see here to undo the compounding impact which we feel was never the original intent. And then this graph and the next two graphs that follow are to illustrate that NMC will remain a very cost effective option for Vermonters if the rate increase that we have requested is granted. We gathered data from the publicly available hospital report cards to obtain detailed pricing information. And then we looked at just the basket of services that NMC offers and we applied the prices to each organization on just that basket of services so that we would have a true comparison and so that we could demonstrate and see for ourselves that if we implemented this rate increase would we still be cost effective. And we understand that every organization has its own financial goals and its own unique challenges. This first graph focuses on inpatient stays. So the green bar that you see represents $1 of an inpatient stay today at NMC. And if granted the rate increase it would be $1.25. And you can see that it puts us much closer in line with some of our peers but still below average. Same idea here. This graph represents outpatient CPT codes. So lab tests or diagnostic imaging procedures for example. And you can see that if granted the rate increase our pricing will remain below average but more in line with our peers. And then lastly this graph represents outpatient procedures so that might be a colonoscopy for example. And you can see that if granted the rate increase our pricing will still be well below average in this case but closer to our peers. And with that I'm going to turn it back over to Robin. Thank you Stephanie. Continuing the theme of risks and opportunities we have to talk about the ACO. And our view is that it's both a risk and a tremendous opportunity. Speaking from a personal professional standpoint I'm a 30-year veteran in healthcare and I know that our payment system needs to be reformed and that incentives have to be aligned with quality and appropriate utilization and improving population health. It's what drew me to Vermont. It's what drew me to NMC in particular. What I've learned over the last year is that it costs a tremendous amount of money to participate and help support healthcare reform in the state of Vermont. For NMC that participation and Stephanie detailed that earlier represents 7.25 percentage points of our overall ask. It relates to dues of almost a million. The risk reserve funding that we originally projected at 1.6 that we now know is 2 million. And because of lack of scale represents a loss in our fixed when we compare our fixed perspective payments to what we would have received under fee for service. Attribution remains far below the level that we need to offset the decline in utilization in a fee for service model. The healthcare stabilization grant does not seem to yield a significant award that would help offset the risk of the ACO based on our understanding at this point in time. Regarding healthcare reform we have been a leader from day one as an organization. We have been all in from the very beginning and with all payers. We are struggling to continue to afford that investment and our board is constantly reviewing and asking and evaluating the value proposition of healthcare reform relative to the investment that NMC continues to make. One cares a lot of work to reduce the dues structure and to reduce the maximum risk in 2021 and we thank them for those efforts. But as you saw in their budget presentation some of the cuts that they had to make were in key program areas that are critical to improving population health. However we cannot afford to face the risk of COVID and the ACO and still be responsible in our rate request if we don't include it. Bottom line any attempt at healthcare reform without scale will fail. Attribution continues to remain our biggest risk and concern. It's also important to know that at our current level of attribution of around 35 percent we still have 65 to 70 percent of our patient population that receives the same focus and attention to improving the health in our community. NMC is the largest private employer in this community. For us to be successful we need to have a healthy workforce and they need to have healthy families. So we remain committed to the idea of healthcare reform but we are struggling to find a way to continue to bear the risk and at the current level of attribution we think all hospitals are being asked to bear that risk disproportionately. The next two slides attempt to illustrate simply a very complex issue and that is around scale. At this point in the program the original projections is that we would be in the area of attribution where the grant green line is and that also for NMC happens to be the level of attribution at about 55 percent that we need to thoroughly align population health investments, primary care health investments and reduce the focus and the dependence on fee for service. So you can see that when you look at the far right column as attribution increases our loss revenue associated with a typical fee for service declines and that is the total aim of an all-payer model and capitation as a whole is to provide a consistent revenue stream that hospitals and providers can plan their care around and can focus on investing in longer-term strategies that will continue to reduce utilization and ultimate health care costs. At 30 percent attribution we are not there to scale and we don't see a path forward to reaching it in the near future. The next slide shows the importance of attribution in a different way and what this represents is in general our 15 major service lines and at the lower end of the scale you can see these numbers of service lines and what this represents and you've heard other hospitals talk about contribution margin of various service lines that we have some that help support critical needs of our community that can't support itself financially. At lower levels we struggle to reach that balance of fixed payments relative to what we would lose in a fee-for-service world. As you progress to the right of the graph that correlates with attribution and you can see that we begin to reach that tipping point of around 50 to 60 percent where we have enough fixed payments to allow us to invest and consider the longer term strategies and not be so reliant in the acute impact in any given year of still having the majority of your patient population in a fee-for-service model. We'll turn our attention now to I think the biggest risk for for everyone and that is you know what will COVID look like this fall. Nobody knows that. We talked at length and we're thankful to have the opportunity to to speak with the Green Mountain Care Board about what should our budget guidance be in 2021 relative to COVID. What you can see here is literally anyone can show a projection that can't be attacked nor can it be defended. What we tried to show were some scenarios that were based on what our lived experience has been over the past few months. You can see that first row is what our COVID-19 free budget looks like in a perfect world with the work that we've done around controlling our expenses, setting in appropriate pricing and would return us to a positive operating margin of 2.8 million. Scenario A would assume what was our lived experience when we were in phase one and if phase one constituted three months of the year and phase two for nine months of the year. That would have generated for for NMC a loss of $30 million. However, in testament to the leadership really of Vermonters, the state leadership, our clinical leadership and really just the compliance and care of Vermonters for each other, we really think that that A is a worst case scenario that likely is not to happen based on us being ahead of schedule, I think, and close to phase three in terms of our capacity and productivity. Scenario B shows what it would look like if our first full month of recovery, which was June this year, would be our revenue level for an entire year. That would have generated under that scenario a loss of $18 million and that is what we would be looking at had we not had the help from the stimulus money. COVID-C to us represents something that's a little more realistic as we've continued since the time that we submitted the budget to see the impact on our revenue and recovery of operations in July and through the first part of August. We think that for NMC we could probably most realistically expect about a 10% ongoing decrease related to the COVID-19 impact. Then scenario D would be if Vermont was in a phase one for six months and then phase two for six months. Again, as you can see, there's a wide possible outcomes that could be considered and none of us have that crystal ball. What we chose to focus on really was what we know, and that is the impact on our expenses from COVID. We continue to learn more every day. As more about the disease and effective treatments are known, we'll continue to impact on our costs. The highlighted column here builds upon the column A which is the COVID-free budget. The Green Mountain Care Board asked us to give a COVID budget and that's what we've done and illustrated here in column B. But because of really the impossibility of predicting what future volume would be, we chose to focus on the expenses and knowing that that is a given. COVID has forever changed how we deliver health care and we quite honestly have challenges with our smaller footprint, with our antiquated ED that has curtains for walls instead of plaster and limited ability to minimize cross-contamination of patients through an aerosolized virus such as COVID. As you can see, we anticipate based on what we know now with the demands for curbside testing, for the cost of testing agents, for PPE, which you've heard from others that the costs are skyrocketing when those supplies are even available. For us, we expect over an annual basis that we're going to need another 18 employees just to support the safe delivery of care and the testing required and is necessary for not only treatment of COVID patients but also part of the recovery process as we look to return patients to the hospital in the return of elective yet needed procedures. Continuing on risk and opportunities, I mean financial sustainability. It's a risk, the struggles you've heard about the pricing and the compounding impact on our top-line revenue and you've also heard about some of our cost reduction strategies. I agree completely that any organization should always challenge themselves. Is there a better way to provide care that is more financially sustainable? And we've done the hard work pre-COVID as well as throughout COVID to continue to make those changes. We spoke to you about our service line adjustments that we felt were appropriate at this point in time and where we had partners who could provide that service to our community. We looked at our campus operations and utilization of our facilities to close some sites that were external to our main campus and that resulted in fewer lease expenses. We also looked at opportunities and worked with our benefit advisor to see how we could restructure our employee benefit program to reap some savings yet still have a benefit program that is crucial and competitive to our recruitment and retention. We also put our self-insured insurance plan. We put our third-party contract to bid and we were able to reap through a new vendor reduction in fees. The most painful decision that we had to make had to do with our staff. NMC has been here in the community for decades and on multi-generational employees. We have mothers and daughters that work here. We have sisters and cousins. We're a small community. NMC is the biggest private employer. To ask our employees to basically fall on the sword during a time of unprecedented loss of revenue, four years of sustained losses, opening up a voluntary exit plan that ultimately while we appreciated that commitment from those employees, many of which who had been here 30 and 40 years and still have so much to give to our organization and our community, it wasn't enough. We had to follow our voluntary reduction in staff with an involuntary reduction in force that built upon the cost-containment strategies that we had around furloughing employees. During the height of COVID, as we had to limit our footprint and had to limit the limitations of our physical plant, we did furlough employees. Some employees had to suffer low because of child care. What we found is that with the expansion, while we appreciated and we reaped some savings in our salaries and wages, we're self-insured from an unemployment compensation standpoint. And with the expansion, much needed expansion of an unemployment benefits, what we didn't pay in salary we were often paying in unemployment compensation. We also did have some areas where we could implement a better process or a different tool that reached some efficiencies and would lead to some permanent reductions in staff and we made those decisions. Again, some of those decisions impacted very long-term, very loyal members of our community and this organization felt it. In the midst of really trying to stay safe, trying to care for our patients in an unprecedented time of health emergency, we were also feeling the economic fallout and grief of losing members of the NMC family. And that's what this organization and this community is. Every community hospital is so vital to their community from an economic standpoint and from a quality of care and an access to care. All of that activity over the past year, pre-COVID, some of which included the reduction of we eliminated raises for leadership and managers, preserving that for our frontline employees. But the culminating impact of that is that we were able to reduce our expenses by over $4 million and we responsibly were able to contribute expected increase in revenue of $750,000 going forward. Our most concerning and my most concerning risk has to do with non-compliance of our bond covenant. We've been out of compliance for over a year. We have been in close communication weekly, if not sometimes daily, depending on the performance of the stock market with our bank and bond managers. Since the time that we submitted our budget and today, the bank asked to have a meeting with me, with Stephanie, with Jerry and Dawn, to talk about what was our plan in the next year to rectify this deficiency and to come into compliance. Of course, they understand the regulatory environment that we have in Vermont around our pricing. They are aware that we are meeting with you today. They're aware of what our ask is of you today. And they agreed to extend the timeline in which we have to provide them with the action plan to allow us 30 days post the rate decision that you will ultimately make for NMC. If the issue of our bond uses to call it, if we can't present a plan that gets us into compliance, that would have an immediate impact on our day's cash on hand, reducing it almost in half or 100 days. An opportunity that we are proud to continue to invest in. And as I mentioned earlier, we are nothing without our employees and we need them to be healthy. And our employees can't really provide the care and the quality care to our patients if their families aren't healthy. So we continue to make investments in patient-centered medical home. Northwestern Primary Care and Northwestern Georgia Health Center had already received the highest level of certification as a patient-centered medical home. This past year, due to the tremendous engagement and leadership of our pediatricians, we're pleased to announce that Northwestern Pediatrics is also certified as a patient-centered medical home. The amount of effort required to satisfy those requirements to build upon an in alignment with the ACO, a focus on care management, was a tremendous ask of our providers at a time that we were also implementing and working through new workflows with our EHR. We're very proud of the efforts around quality preventative care and have to definitely recognize Northwestern Georgia Health Center for having received the Vermont Department of Health as gold status for childhood vaccination levels. We continue to be actively engaged in the blueprint for health. NMC has been a driving local force in the blueprint. We are the fiduciary agent for the state for our health service area. We continue to partner with our community partners to improve both problems with chronic pain and with asthma COPD. As Stephanie spoke earlier, we continue to invest in Rise Vermont, but at an appropriate level respective of a community hospital. And then finally, we continue to be engaged along with Northwestern counseling as co-leaders of our regional clinical performance council. Finally, just a quick recap on our capital budget plans. This gives you a little more detail under what our expected investment would be should our finances allow. Most critically, we will move forward in our appreciative of the approval of our emergency department CON. And before we bring the presentation to a close again, I want to thank you. I want to remind you that we have met the stated criteria for our budget. We have made difficult decisions and we continue to challenge ourselves in the area of cost containment. We are requesting a rate increase that allows us to achieve parity and pricing with our peers and still provide a low-cost alternative for our Franklin and Grand Isle residents. At this point in time, before we entertain questions, I would like to allow our current board chair, Janet McCardy, to say a few things as well as our immediate past president and current treasurer, Leon Berthie. Good morning. Can you hear me okay? We can. Janet, you've disappeared from our screen now. Let's try that again. There you go. How's that? Testing? We can see you. We can hear you. Okay, very good. Thank you. Appreciate the man in the black shirt. Good morning. My name is Janet McCardy. I currently serve as the President of the Board of Trustees for Northwestern Medical Center. I come before you today as a longtime resident and health care professional of Franklin County. I've seen firsthand how critically important Northwestern Medical Center is to our rural community and leadership it has demonstrated to take risk, be innovative, and think beyond the traditional four walls of the hospital, not only in our small corner of Vermont, but also statewide and nationally as well. I'm currently serving in my ninth and final year as a member of the Board of the Northwestern Medical Center. Throughout the years, I've been witness to the intentional desire of the Board to assure access to high quality care in a cost-effective manner to our entire health service area through strategic programming, service optimization, and workforce development. It's been an extraordinarily challenging environment with our efforts to lead and participate in payment reform and population health while working to recover from considerable financial losses year after year. When faced with a leadership transition earlier this year, the Board of Trustees was deliberative in charging our transitional leadership team with a task of restoring financial stability, right-sizing our organization, and addressing workforce issues and turnover. Considerable progress has been achieved on all of these objectives all the while responding to one of the world's greatest challenges, the COVID pandemic. As you've heard this morning, difficult decisions have been and actions have been taken which address the Board's concerns and those that were expressed by the Green Mountain Care Board this spring. Our focus has never been sharper, the engagement of our leaders is unsurpassed, the desire of the people who live in our health service area to have access to a strong and healthy community hospital is unwavering. To be successful, we need approval of this rate increase to achieve the financial and operational sustainability to assure access to quality health care in our community. Paramount to this success, we need effective buy-in and partnership from other members of our health care system, the payers, the state of Vermont, the ACO, the Green Mountain Care Board to advance the ideals of health care reform. Thank you for the opportunities to present our support for the Northwestern Medical Center's budget request. I echo Don's earlier comments and words of appreciation for the work of the Green Mountain Care Board. It's my pleasure now to turn the presentation over to Leon Berthume who is currently serving as our Treasurer on the Board of Directors. Leon, are you there? Yes, good morning. There you go. Yes, I am Leon Berthume serving as the Treasurer of Northwestern Medical Center. First it's indeed a privilege but more importantly a responsibility as being part of the NMC Board. As you know, we are well served by a strong financial team that you witnessed this morning as well as in past years. In concert with the Board, this team has worked diligently to present a realistic budget that will allow NMC to move forward to advance our mission. Vermont is known to lead, the Green Mountain Care Board is known to lead, and NMC is known to lead and I will use the word lead as an acronym to really represent our presentation this morning. The L for lead, NMC is definitely leading an integral part of the health care reform that has been cost to our organization. We continue to lead by investing in our community to improve the population health that will have benefits on a long-term basis. We will also have again worked hard to be a low-cost low-charge hospital and believe that even with this rate request, we will continue to be one of the lower cost hospitals in Vermont. We will continue to lead by continuing to address both the short and the long-term financial position of our hospital. The E really stands for earned. Our fiduciary responsibility is to protect the financial viability of the organization for our community as well as for all Vermonters. We must earn a margin to provide the ability to continue to invest in our organization and our community and to look to the future. This is essential if we're going to maintain a viable community hospital. It is also essential if we're going to retain our medical and hospital staff as well again recruit new members when needed to our team. Our budget presents a net operating margin of 2.3 percent which is a reasonable margin growth given the prior year's performance results but also recognizing that there's still again risk to achieve this level of margin. The A is for abide. We have abided by your stated criteria for our fiscal year 2021 budget. We have demonstrated through our activities and decisions that we've worked through the Green Mountain Care Board's requests, guidelines and mid-year suggestions. Our net patient revenue is budgeted to decrease and under the growth limit of the three and a half percent. We provide our best budget COVID-19 free baseline budget and related COVID-19 scenarios. We have made the difficult decisions and we've looked at where investments can be made. We structured where there were opportunities and transitioned out of services were feasible. As been noted today expenses are down in one and a half million compared to the current year budget not including nearly one million in inflations that were incorporated into the budget. Lastly the D is for defend. We have presented a budget that we all can defend. Our rate increase is needed to maintain and support and protect the long-term viability NMC. The necessary rate increase incorporates the compounding impact of the fiscal year 2016 rate reduction of the eight percent. It incorporates the cost of investing in Vermont healthcare reform. It incorporates inflation and then considers our overall payer mix. This rate increase allows us to allow for a small net margin to reinvest in our hospital and community to sustain essential services to be effective in a viable community hospital to meet our bond covenants to remain competitive while being one of the lowest cost effective providers and to also ensure that we can meet the next challenge our community may face. When looking at this budget NMC is more than a hospital. It's part of our healthcare service and system. It's about serving our community our family our friends our neighbors and businesses and as a board member and a community member I can attest that they are asking us to ensure that this hospital continues to serve them. NMC knows how to lead and we're looking at working with you in the year ahead. Thank you for the opportunity to make our presentation this morning and we welcome your questions and your comments. Thank you Leon and thank you Janet. It's always good to have an informed and tuned in board really making sure that their institution is there for their community and you've just demonstrated that over the years. Leon I'd be a little bit worried that you have a Rutland girl replacing you at the helm but we wish her well. With that I also want to echo what Leon said about the strength of the financial team and you know I've said it in the past that I've always been impressed with Stephanie Brough and once again Stephanie clearly demonstrated that she was listening to all the questions that board members have been asking over the last two weeks and really tried to address those in the presentation. So kudos to Stephanie for being a step ahead and you know I also want to give my appreciation to Robin for the slide that showed all the different possible scenarios on COVID and again it's not all the different it's just some likely scenarios with COVID and we all know that budgets are precisely budgets and it makes me think about the research project that was done nearly a half century ago where monkeys were asked to throw darts at a list of stocks on a wall and the monkeys beat the professionals. So let's hope that we have better analytics today in that our budgets are much better and with that I'm going to turn it over to the first board member for questioning and that will be board member lunch Robin. Thank you everyone and I just wanted to start by saying thank you to all of the folks at your hospital including your frontline workers your leadership everyone for really stepping up during the pandemic and the resulting issues that we've all seen both financially and in terms of health care issues. So thank you very much for that we appreciate all of the work that you do for your community probably me in particular because I will tell you I have most of my extended family actually lives in Franklin County so I appreciate that you're there. I did have and again thank you Stephanie for anticipating a lot of the questions so I do have a couple of follow-up follow-up questions that I'll start with the first is in terms of your travelers could you talk a little bit more about how the travelers have kind of ebbed and flow pre-COVID into COVID and after COVID? Sure I can and I also have Dina or Fenina's here with us and she's our chief nursing officer so she might chime in as well but as you guys heard from us at our mid-year rate increase request travelers was a big issue back then right so it has been something that we needed just to stabilize the core staffing on the unit and the way that we have our unit structured is it's called a PCU it's a progressive care unit so it is the med surge this the step down the ICU and the subacute really all in one area of course recognizing that that certain nurses have specialties but just to you know get a core staff for that team we were having to utilize travelers much before COVID and that has actually just carried through COVID and at this point I think the most recent thing that I heard and then I'll turn it over to Dina was that we are actually at this point having a hard time finding travelers because a lot of the travelers are being utilized in areas of the country where COVID is still a major issue and where they're having you know hot spots if you will and so we have most recently to try to mitigate our use of travelers engaged with a company that will help us recruit and do kind of a nationwide search for us and so we're asking them to help us identify in place up to 10 RNs because we're certainly doing everything that we can think of here and we certainly have our HR team and our recruitment team here you know scouring all the different places they can to look for these folks but it's our health our hope that working with this new vendor that they may have some connections and some people that are truly ready to go and so that we can start to alleviate our need for travelers sooner rather than later we won't get 10 of them on day one but can we get a couple of them in a really short time period and then continue to chip away at that so I'll I'll see if Dina has anything she would like to add there. Hi good afternoon Stephanie actually did cover quite a bit of what I would add one of the things this is not new to the Green Mountain Care Board or the state of Vermont actively participating with the talent pipeline led by Marianne Sheehan across the state NMC is well poised to be doing all the right things for nurse recruitment and retention but as Stephanie articulated you know what we have learned is certain travelers in our region actually ended contracts early because they could go to the southern states where they really needed help and be financially benefited to break their contract here at NMC but when we look at recruitment and retention of nursing you know as others have articulated Stephanie communicated around our partnership with Vermont Technical College we have a joint faculty agreement one of our nurses is part of that we plan on increasing in that space to help partner with academics and supporting the nursing profession into the future for the state of Vermont understanding and appreciating that we are at a gap over the next four years 1800 RNs for our state so you know as the chief nursing officer here we're working both on recruitment and identifying those nurses that want to be here in our state of Vermont and having previous experience within the state and outside of the state I can say we are competitive in the space of loan forgiveness tuition reimbursement recognition of certifications and really wrapping around what I call that healthy working environment to have nurses come to NMC and see themselves as having an opportunity for professional development here so I can entertain any other follow-up questions if we haven't answered your traveler question thank you thank you now I appreciate that and I'm hopeful that your new program with VTC will help help grow some local talent for you because that that sounds like it's a working in other areas of the state absolutely we're not alone in that vision and strategy we're in good partnership with other hospitals across the state great I was hoping you could also speak a little more to telehealth in terms of I know everyone really had to stand up telehealth you know like that right very quickly and I was wondering what your experience was at the height in terms if you had a sensitive percentage of visits a lot of hospitals have been giving us that as a statistic and where that's now come down to we have seen quite a large variation depending on the area of the state in terms of continued use of telehealth so I'd love to hear your experience and some of the things that you felt were successes and can enter challenges yes I'll hand over to Robin Alvis she has the specific data and certainly if there's a clinical component we Dr. Brophy or myself can jump back on thank you for that question Robin I'll tell you we were really extremely pleased at how quickly we implemented telehealth through COVID as you've heard from others tele telemedicine is a platform that is very well suited in some instances and not so in others we were very proud to be able to leverage telehealth and pediatrics to strike the right balance of making sure that our pediatric patients came in stayed on schedule with their vaccinations with their well checks but also use telehealth to identify potentially acute or RSV patients to make a determination of where on campus they needed to arrive for their care primary care was a tremendous adopter and probably where we've had the greatest amount of success because it lends itself to chronic management disease etc in an interim basis specialists such as and I'll pick on Dr. Brophy being our executive medical director who's also an ophthalmologist the nature of of eye exams and etc that isn't a platform that that we certainly used it but that that was maybe around 10 percent of our visits whereas we really got to you know 80 and 90 percent for primary care in other areas ENT if you've heard mentioned it really was very situational in terms of the what the patient's needs were that that drove our the adoptability of that however it is important to note that while we appreciate that the reimbursement was preserved for telemedicine in all of its forms what we did see over that time period is it's not the same as an in-person visit and I think you you heard that from another hospital where yes you can provide the service with some of the relaxation around the review of systems in favor of face-to-face time you might could meet the needs of the patient in the moment but you weren't really generating any of the ancillary services that that they may need long term so while we certainly hope that telemedicine is here to stay that the reimbursement structure is here to stay it can't meet all the needs you still have to have a safe environment for patients to come on campus for things that can only be evaluated in person or when they need other ancillary services that makes a lot of sense would you say that you saw issues with connectivity or broadband did you see a lot of phone visits how did that play out yes absolutely we are plagued through different parts of our service area with connectivity again very grateful for the relaxation of the medium in which telemedicine was able to be performed high reliance on telephones in many instances where connectivity was a problem you know we'll definitely say that metatech I have to give a shout out to them in terms of their response to us and setting up our telemedicine and virtual visit capability immediately and so we were able to really resolve a lot of that connectivity because the patients could connect to us through the patient portal and oftentimes they could do that via their telephone if they didn't have and using cell coverage as opposed to a wi-fi access thank you that's very interesting to hear more about your we are getting a little bit of an echo so I think someone needs to probably mute thank you I noticed in your narrative that you talked about a reduction in health information management is that an IT position or is that like a data analytics position I'm asking because I'm curious to hear about me how you if that would impact your ability to do data analysis for the ACO program hi reman I missed the first part of your question oh sorry on page six of your narrative there is a discussion around a position called health information management and I was curious to learn more about that in terms of whether it was straight IT or or might have some impact on your ability yeah when we referred to health information management in our narrative we were referring to our medical records department thank you no problem okay so I wanted to turn to the rate increase and actually maybe it makes sense to actually reference the slide number and my apologies that I don't have that right here so on slide oh dear I don't see a slide number so it's the risk and opportunities a slide that has the compound pounding effect of the rate reduction whatever slide that is I don't sorry I don't have the number on my printout the so when I looked at your actual versus approved budgets for fiscal year 2013 through fiscal year 17 I do not get the same variance of 2.9 million now of course I did also look at fiscal year 13 which you did not include and that and so I'm hoping that you'll be able to follow up with more information for your calculation of the 2.9 million because when I look at actual versus approved I have a 5.6 million dollar overage of budget in 2013 a 3.4 million overage in 2014 a 7 million overage in 2015 and a 4.2 million overage in 2016 and then in 2017 you're at a little under budget at 800 and about we'll round it up to 826,000 so I think it's very important when discussing the rate reduction in 2016 to tell the full story and the full story is that from 2013 to 2016 this hospital was over its budget and I absolutely agree that the that a rate increase is a blunt instrument I think at the time I described it as a blunt instrument and not a scalpel as a way to address budget overages so I I definitely agree that you know it's certainly not a nuanced tool but quite frankly it is the tool that we have in this budget process so I this is really more not really a question it's more of a comment but I do think it's important to really tell both the full picture of that and why that rate increase was ordered in the first place but it would be helpful in understanding this slide to get your calculation of the 2.9 million and to also include fiscal year 13 so that's really the follow-up on that that I would ask and you're welcome to respond but you don't need to know I'll just say that we do have that calculation and so I will absolutely send it on to you I pulled it out pulled it out and kind of dusted it off in anticipation of this hearing and you know most of the difference which you'll see when you receive that schedule relates to the exceptions for physician transfers that go back to each of those years so those were really years that nmc took on a lot of employed physician practices it grew for us and it grew really quickly over exactly those years that you mentioned and so we will certainly send that to you because we have that ready to go great thank you I appreciate that. In terms of scale I am very appreciative of the analytical information that you provided related to scale and what would be a break even because Robin as you mentioned in your testimony like really scale is a key concept for a hospital that's trying to change its operations so that you're not you know that your revenues are matching your delivery system reform and that's the payment reform and delivery system reform go hand in hand. Related to scale I did have a couple of questions it's my understanding that at least as of May your employees were not participating in the ACO is that still the case with your new TPA? That is correct however we remain ready to participate at a point in time that the ACO is is ready for us to participate and that has been something that we revisit every year. Okay and do you revisit that with the ACO or with your TPA or both? Primarily with the ACO they that's their their job we did ask Blue Cross I think last year shortly after I arrived and I believe the intent and their focus on that point in time was to incorporate and I'm going to look to Stephanie UVM first and they wanted to see how that that went and and again we you know clearly are ready to have our employees join. Okay and who's your TPA currently? Blue Cross. Okay so I thought you said that you had switched uh for next year currently Blue Cross is our TPA we will be moving to Signal Agent for next year. Okay um have you also worked with the Chamber of Commerce or other local employers to talk about participation in the ACO? I mean at this point actually Blue Cross is participating in the ACO for its self-insured business. That does not relate to scale for us. I would love to talk to our area area businesses about participation and quite honestly that's one of the reasons that we did change TPAs. I did entertain a conversation with Blue Cross back last fall on how could we work within the network to to do two things. One for participants in the ACO we shouldn't be making money off of each other where could we generate a set fee schedule because obviously having a tertiary partner for all of us a lot of our spend every year is out of our service area and we take the risk for that. The other thing was to do exactly that Robin is to have flexibility in the network where we could approach our own local employers and to show and replicate an at-risk model but give them what that would look like in their community and what services we could provide to do that and that is definitely part of our strategic plan for next year. Great and did Signal seem open to those initiatives if you've spoken with them about it? Yes and I do want to be clear it's not a matter of openness but I think it is just a matter of structure and being able to accommodate that level of flexibility and yes we've been assured that that's not a barrier for us with with SIGNA to embark upon those individual conversations. Great that's good news. Then I had one other follow-up question in terms of the new primary care um and pediatric um practitioners or providers um and I'm wondering how that relates to cold hollow so um I know and if you could just speak to that a little bit but is this a net increase in primary care is it a replacement primary you know for folks that left and who might follow whether these were 100 new capacity or what? Yes for primary care is definitely a net new um and is net of cold hollow. For pediatrics it's a combination of replacement but also a net new in terms of the APP we definitely and appreciate the engagement of our pediatric group who met with us recently to really we're having challenges around preparing for the fall with RSV patients and so we think an APP can help in that regard so that's a net ad. Great okay thank you um I think that's all my questions. Okay next we're going to move to board member uh Pelham Tom. Well hello I uh am also impressed with your presentation both at the macro level of price variation among hospitals right down to the details of your particular budget all to essentially level fund your budget over the prior year so it's uh it's a huge amount of work for actually it's a $233,000 reduction NPR um so I I don't have much to ask I was worried when I first opened the binder in the narrative and I didn't see any reference to the EMR uh you know which we went through last spring but I noticed in the in the slide presentation when I finally got that um it was there I do I do want to understand that a little bit more um so last spring and today uh you were saying that the EMR impact on volumes was uh an impact of about $7 million and that um 1.8 of it uh you've worked out with the physicians reducing that cost of it um is that a permanent reduction uh with with those those um physician practices? Yes it is. Okay and so that leaves you um with a $5 million remainder and I'm just trying to understand what that is is that uh an embedded ongoing loss of revenue because of inefficiencies that are in in the the record exchange of the EMR system is just unrecoverable? Yeah so we actually had estimated a $7 million impact for the current year that we're in right now um and so we said okay well we can attack this two ways um it's a $7 million net patient revenue impact but we do have the ability to reduce expenses and we do have the ability to try to recover some of those revenues so we've tried to attack it from both sides so we did the $1.8 million of expense reductions but then we also attacked it from you know let's try to optimize the product and make some of these workflows more efficient um so that we can see more patients per day and that we can eat away from the number that way as well right rather than just accept that it is what it is um so we've made up $2 million worth of ground by doing that work by doing the optimization work we've made up the $1.8 million by doing the expense reductions and then we're challenging ourselves in 2021 to make up an additional $1.7 million and to have that come through the revenue side and we're going to do that um by implementing some changes to scheduling um so we've got a lot of work on our scheduling templates and we're going to continue to try to do as much telemedicine as we can as long as it's appropriate um because it is it can be quite an efficient way um to deliver care when it's when it's done appropriately so we feel like you know it's going to be it's going to be a challenge but we feel like we're up for it and we're going to you know use scheduling templates we're going to use telemedicine we're going to continue to have um our informatics team within IT working closely with um the actual MAs nurses and providers that are in those practices and say okay what's still holding you up what is still slow what is still clunky um to maximize it as much as possible i'm not sure we'll ever fully be able to close the $7 million gap all of the stuff i've just described closes it by five and a half million um so it leaves 1.5 million um but we're sure gonna try and you know i think that there is still benefit to having one EMR here at Northwestern which for us it's meta tech um because it makes things so much easier from a billing standpoint now there's only one patient portal that you have to go to so there is other benefits as well to having just that one EMR that we really you know we can't ignore really is much easier to do care management and care coordination when the record is all in one place so it sounds to me like what you're trying to do is make the best out of a bad situation that it might not be fully recoverable but uh you know you are hard at work as as to leveraging it the best you can absolutely and you know we're tracking the volumes really closely we have a you know a master schedule that we give to our finance committee and our board every month and it's broken down by provider and it says how many visits they started at you know and then you can see the progression and where they've come um so we're really watching it right down to the provider level um and we're not the only hospital um who has this EMR either in our physician practices we were a very early uh a doctor for this uh EMR on the physician practice side but um nvrh is that correct um uses this module as well and so the other thing we're trying to do sure that we um you know contact with them and what are their lessons learned what are our lessons learned so that we're not trying to just operate in a silo and and if there are stuff that can be fixed that we haven't figured out yet how to fix it but they have then we obviously want to know about that so um last summer when we uh came up to uh see your your RISE activities in action and I did that legendary dance um that uh was incredibly embarrassing because I didn't know that I was being filmed but we we took a tier tour um in downtown state offense there was a building that was being built there and I think that was where that was going to be kind of a link uh with your nurse training program is that has that always that building up and running did it uh work out as expected so uh that building the construction on that building has not quite finished um it's getting quite close um and obviously they had to take a bit of a pause with construction because of it um and you're right that building is going to be the location for the nursing partnership with the vermont technical college and the other um you know space within our third floor that we have in that building um was to have RISE Vermont and some you know lifestyle medicine services so we're focused on the nursing side first we've put a pause on opening up some RISE Vermont space or some lifestyle medicine space um because we think that we can actually accommodate that here um within our footprint of our main campus and on our our main hospital building so we're going to try to be as efficient as we can um with our main building first but you know we're certainly still doing a lot of RISE Vermont activities um and you know you guys are all well aware that that program was our baby and we kind of you know we feel like our baby's left for college a little bit the ACO gets to kind of act as like the hub and we get to be a spoke and we get to have you know a community RISE Vermont presence and we're certainly not going to give that up um I also want to talk just a little bit about the provider tax um I notice that your 2020 budget over 2019 is about 6% which is the the tax rate um on NPR FPP but you know with the uh where you are relative to your um 2020 projection you're at 4.9% so the delta between 4.9% and 6% is about a million dollars and is that a kind of a risk then that you see that when you chew up you know to pay that tax that's uh that's a um that that could be a risk in the risk category yep it is a risk so we all have to kind of pick a snapshot in time and say what's the projection as of that snapshot um for the current fiscal year and what is 6% of that number and so you're right it is going to be um a risk and we may have come in a little bit over and you know at that point it will be up to us to find that offset um I've heard a couple hospitals say that they actually have the amount um from the state and that it is what it is so I don't have that information it it kind of made me wonder why I don't so I've I've asked I've sent some emails I'm going to try to get my hands on it um but yeah we we certainly did pick a projection at the time and that's how we how we came up with that number well we're asking the same question I was uh I was a little confused on both of those as to whether or not they were talking about the 2020 amount over 2019 which is a no number um but uh we're tracking this one down um so that's it I would just like to applaud Robin on her travels with Charlie video uh I think that came out pretty well um flash in the pan but uh it was fun and it was nice to visit visit you all when we came up to film that so um for that I'll turn it back to Kevin thank you Tom next we're going to move to board member Yusuf or Maureen thank you and first um thank you for everything that you're doing up there you know particularly through this pandemic um you know it's a very difficult year for all the hospitals and you know for this hospital I think it's uh for me probably the most challenging budget to go through and you know we certainly want to make sure that you know the hospitals survive and that they're sustainable um and you know you've given a lot of support you've shown us a lot about the pricing details which is interesting because we're not always able to get that information in comparisons uh just want to clarify a few things you know one of the things we don't explicitly give is commercial rate increase guidance and that kind of gives us flexibility as we're going through the process and it also gives hospitals flexibility when they're putting their requests through um but I know for me personally by no means does that mean if you hit your NPR number with a high increase that it meets my expectations um you know as we still need to be looking to make sure that we're giving you know quality affordable care and your increase on the hospital charges is a 25 increase which which would would be going to the commercial payers uh your patients and um you know and I do want to talk about the class shift in a little minute but uh I think you know it's interesting because we all can't talk about our questioning and I'm going to go on the line similar to what Robin was doing and you know want to talk a little bit about history to just lay the groundwork a little bit because um maybe I'm taking it personally but it seems a bit like you know the board has put you in this position and I don't agree with that at all so I do want to go back through from 2015 to 2020 looking at some of your requests and I'm going to start with um NPR um in 2015 you would ask for 90.8 million in your budget you came in at 97.6 so quite an increase in 2016 you came in your request was 97 you came in about 99 again exceeding the numbers 2017 you're about right on 102 million to about 101 million it was really in 2018 you requested 106 you came in at 103 and then in 2019 you requested 113 and you came in at 106 in 2020 you requested 117 and prior to February you were down 7% so um the past several years you know part of the problem has been you're you're missing your top line and one of the things you know you've probably heard me repeatedly talk about in the hospitals is you missed the top line you can't make moves on your expenses you lose a lot of money and you know that's that's you know in essence part of what happened going to commercial just to talk about that a little bit you know um you requested in 2015 um 6.4 percent and you received 6.4 percent in 2016 you requested a negative 8 and you received a negative 8 in 2017 you requested 2.9 and you got zero so that was prior to you know that was looking back at all the overages you had had and we'll talk about profitability after 2018 you requested 6 you got 3.5 in 2019 you requested 2 you got to in 2020 you requested 5.9 and you got 5.9 so there were a couple years back there where you didn't get what you asked for but for the most part you have gotten what you asked for in your commercial rate ass going to possibly you know going the reason I always talk about cash is king right and you you have built your cash balances over the years because you're exceeding your bottom line in 2015 you're in your operating margin um net operating income not your total which is significantly higher you had budgeted 4.6 and you came in at 10 million in 2016 you had budgeted 2.1 you came in at 3.7 million in 2017 you had budgeted 3.3 and you came in at a negative 1.2 however your total operating margin you requested 3.8 and you came in 7.9 so up through 2017 the prior three years you were building cash you were you were adding to your funds in 2018 your budget was point uh was 800,000 for your operating margin when you came to us with your budget your projection at that time was staying flat with your top line 106 million and basically staying flat with what you expected for your operating margin that you had brought it down by 400,000 your actuals came in at missing the top line by 3 million to 103 although when you came in for your projection when you asked for your budget you were basically on plan and then losing 3.7 million so again you weren't able to cut expenses you missed the top line by 3 million that fell directly to the bottom line plus a little more um in 2008 2019 was obviously the big year where there was a big change you had 112 million on your forecast with a 2.7 million profit you came in 6 million short and you lost 8.9 million dollars so the full 6 million that you missed on the top line fell to the bottom line and um and you also had some higher expenses as well and then in 2020 we know that was continuing so I just want to lay some of that out there because yes you are in financial difficulty now as far as from your covenants as far as we lost the money um but a large portion of this is because you missed your forecast on top line for the past several years if you actually look at your actual to actual trend you've had relative you've had growth each year um you went from 97.6 and 15 to 99 and 16 to 101 and 17 to 103 and 18 to 106 and 19 and you would have been trending knew about 108 this year so every year you're growing slightly about one to two percent but your budget requests have been significantly higher than that year over year maybe even within the three and a half percent the caps that we gave you so it was approved you missed the top line you couldn't cut your expenses it all drops to the bottom line so I I just want to make sure that's out there a bit because there's been a lot of you know whether it's news articles different things pressuring like the green mountain care board has has you know basically done it in this hospital and has not approved things and and that's that's not the case at all um if you if you hit your forecast you would have hit more on the bottom line you missed your forecast you kept your expenses equal or higher as you went through the the electronic medical records and it's it's now all hitting you know the bottom line um but with that you have had well over 200 plus days in cash year over year because you were able to build that cash back in 1516 17 when you were exceeding the numbers and so that that that is one of the strengths that the hospital does have and I think you know we can't look that over as we're going through this um so I just wanted to lay that out there because you know I I know we now have to start with where are you now and what can we expect going forward um but I think trying to get a you know 25 increase on hospital charges um in my mind is going to be a stretch um now when we look at some of the increases that you're asking for you specifically um talked about the acl and I believe that's about 7 percent of your increase of the 19.9 I know it comes down and um you know that that's that's an issue we haven't particularly we haven't in the past let hospitals increase their commercial rate to cover the acl um I want and hope you will participate in the acl but I also don't want to be held hostage of you know if we don't approve this budget then you're not going to participate in the acl if if you know I'll be candid if that's what you do you know that's what you do but I don't think that's that's 7 percent right there is specifically tied to the acl I think we need to figure out how do we make that work and you brought up I think three pieces in there you know one being not not meeting your fee for service rates for the the coverage that you have the risk reserves that you have so um I think that's going to be a challenge you know that that piece in particular um and so let me get to a couple questions I'm adult I just you know I guess if you want to comment on that on on where you feel you know the history has been and and where you are right now sure a lot there but um no I agree with you I think that it is important to look at each component and to not just look at one year alone right we have to go back and we have to understand the history and I think that you know nobody is probably harder on themselves than we are within this organization and what could we have done differently and where do we need to course correct and you know where did we go wrong and as we've you know really dissected it and looked at it over the years we feel like we made so many investments really early on to acquire primary care practices um you'll remember that the the largest by far pediatric practice in our service area was um under the stress and we took ownership of that practice because we felt it was so important for the community to have that need um and then we invested in addiction services and we're so glad we were able to work with our community partner to maintain those services to our community so you're right that there has been a little bit of revenue growth and some of that is because we've generated business and some of that is because we've had rate increases but there's been a disproportionate amount of expense that goes along with providing some of those services and so I think we were so anxious and happy to be part of healthcare reform that maybe we went a little too hard too fast and so every time an organization adds a program or a service you know trying to figure out whether it has a controversy margin and whether it stands alone in terms of financial profitability is it's our responsibility it's something that we need to do but I think it's been part of our issue and I'll turn it over to Robin. Thank you Stephanie um definitely I would like to echo that obviously I've been here a year but still a very fresh set of eyes and asking the same questions as I'm getting up to speed on um you know uh what our history has been um I I think very much so our investments in primary care and and we can unpack all of that um and a follow-up if you would like but the investment in primary care the absorption of of a large pediatric practice with really um you combine that kind of investment with a lack of scale in reform and this is why I really and I appreciate your comment Maureen about um you know not wanting to feel like you're held hostage by highlighting you know what the cost of the ACO is that certainly isn't our intent but we do think it's very important we would not be having this conversation with you today if we were at the projected scale level of the ACO neither would any other hospital right now whose hospital leadership and their boards are questioning participation no hospital can deliver scale on a statewide basis and that was really the entire um desire was to educate around the challenges and the disproportionate risk that hospitals are bearing because scale has not offset what we've already experienced in terms of decline of utilization we're committed to patient-centered medical home which is very much aligned it's a government CMS program that also the reimbursement hasn't caught up with the investments that they ask us to make we need both that alignment of not just the governmental payers but all of the commercial payers in the state to move to this fpp system to be successful and that's why we went through the exercise of illustrating how important scale is we have to reach that tipping point to where we can continue to invest and be okay with the client you talk about missing the the top line revenue you're right but you have to have utilization also to hit that and when we're in participating all in and we're at 30 scale when we should be at 50 and a total goal of 70 um you have to take into the impact that that has on the on the top line and there is no replacement revenue for that the services still exist the activity still exists and we can't cut those costs in fact it costs more to provide that so it is very complicated and and and i get it and i understand that i can appreciate um you know in looking at data just in black and white and how you might be perceiving it but we're we're to crossroads here around payment reform in the state of vermont and you know what isn't going to look like we have been all in where we're still um pushing off our decision to to to see how as a state and as you know from the legislator to the green mountain care board to the hospitals to the aco and to our payers how can what is that road math to scale because we can't get there we can't get there without it okay can can you you qualify for me what you think the um electronic medical record bottom line in fact has been um you know 19 2021 you know from when you started the shift in both law sales and incremental expenses yeah we would have to we can definitely do that uh and follow you know that's a big piece of what changed right when you when you put in medical records and you had um you know which which i appreciate the the wanting to do that and the needs to do that it's just it had both the top line hit and an expense hit and i'd like to have you know quantified because again what we did try to press on you know in in your mid-year request was um which i know you would you know did uh take that into consideration but i'm not sure you're still quite there on you know if it's volume that's completely lost completely offsetting that or if it's expenses that are you know what's what's the net impact of this um still as we're going forward and you can you know put forward offsets there too yeah and absolutely and i'll tell you what's been been um of course not so much with the mid-year because um all the data even though we were in the middle of covid when we had our hearing you know all the data was pre-covid um but you you know what's difficult is um what's the impact of the EHR and i don't think there's any provider in the country or any hospital that can point to and say that an EHR made them more productive it doesn't you hear that from from from physicians and the most profitable uh practices are the ones that don't have an electronic medical record um but but that's where there are other um other reasons at play in terms of ultimately getting to that community health record to eliminate redundancy of services duplication of services etc but what makes and we will definitely give it um our best um estimate of that impact but we do what's difficult is is how much of it is directly related to the EHR but also declining utilization because between PCMH and our ACO efforts we are declining in utilization we are providing more services and care coordination and we're beginning to see you know i would point to our our results with rise vermont and childhood obesity it's unprecedented that we've reached for this community um a level a peak we're not rising we're not decreasing but but we're we should be several years out um of even reaching that that year over year static increase in childhood obesity and that again speaks to the impact of the that lack of scale is having in health care reform i believe in it i believe it's needed i believe it can happen and be successful um but we truly have to have the all-payer model and we need to have all vermonters in the all-payer model thank you for that question just on the car shift and i know trying to show that um i think maybe somebody needs to mute um maybe you could mute because i i do notice that when there's blue around you that marina echo so great thank you yeah i i think um you know i appreciate your your look at the cost shift piece um i don't agree with you that when there's a 25 increase in hospital charges that that doesn't create a cost shift and i can give you some numbers to that but you know part of the reason right is is part of the whole thing about the cost shift is because the government payers don't pay the full amount and so you need to increase your commercial and the commercial is you know exceeding um your cost of services and and that that's really kind of what the cost shift is and i think part of the reason you're not necessarily seeing that in some of your analysis is because you're going off of the 20 budget that you never were going to hit anyway so there is there is a growth of of um npr that's related to this commercial increase and that is adding to cost shift and if i go to 2019 which is kind of your fixed base you know 20 there's a lot going on when you're increasing by that amount what you do see is that um it does shift in how much your commercial is going up so in in 2019 for your um i think 42 percent of your net revenue gross revenue is coming from commercial and when you get to net it's 47 percent and when you go to 21 now skipping over 20 because 20 budget is not really relevant um you are at 42 percent still for commercial and it's going up to 51 percent of your total reimbursement so so that does show obviously that and the other payers are going down so there is a cost shift it's there is a cost shift it's continuing it it has to if you're if you're taking an increase and you really you know the fact that you had a budget of 116 million you weren't tracking to that budget you were going to tracking eight percent below that so it was 108 so you're really going now from you know like 108 to 117 and a large part of your growth is this commercial increase which is cost shift so um you know it's just not mathematically possible to take a 25 percent increase when the other payers aren't increasing that much and not say that that's that's not a cost shift so i just wanted to point that out um and you know i i do want to end with i do appreciate all of the praise stuff that you did put in there i do think some of the metrics that we do see on the reimbursement ratios um that you are lower than than other hospitals um you know you're you're closer from your commercial rates to the Medicaid and Medicare you know you're not you're not double what what um Medicaid or Medicare is for your hospital and so you know i definitely will consider that you know as i go through for what were to approve for commercial um i know i came off hard at the beginning i just really want to make sure that there is a message out there too that it is not the Rain Mountain Care Board that did this to this hospital um by not accepting rate increases in the past um for the most part you got what you asked for and then you exceeded those numbers and that is what ends up happening i think as robin brought out it may be more instrument but your commercial was coming down but the negative eight percent increase that you took you guys submitted that and that's what was approved so you know and then it does compound i agree with that so um i do respect all that you put into this and i i think you put a lot of hard work into this proposal um and you know i i will definitely strongly consider you know what you put put forward um it's a really challenging time um so thank you very much so thank you moraine at this time we'll move to board member homes jessica great um thank you uh thank you for the presentation and i really appreciated you anticipating some of our questions that was obviously did your homework stephanie so i appreciated that uh and also robin um and i also just want to appreciate you know the efforts that you've made to achieve efficiencies and cost savings i had no doubt that it was a challenge and caused painful cuts that impacted your community so you know i know that was not easy to do many of my most of my financial comments and questions actually have been already addressed so i'm going to go in a slightly different direction although it'll touch on some of that um one thing i would note is that you submitted a lot of very interesting um sets of analyses on it's clear you did a lot of hard work there and i appreciated you know the uniqueness of the approach and your efforts to tell your story and some of it was very compelling uh i just i will say i agree with moraine and robin i would like your story to at least acknowledge um and mc's historical budget overages and your own requested rate increases i think that's an important part of the story but i i think it's been discussed enough at length um one chart that i liked was on the risks and opportunities slide there was a slide that you had that had the service line financial alignment with the aco goals you know by attribution level and i'm wondering it would be really helpful to us i mean we can learn a lot from the analyses that you did particularly around scale if we want to make this thing work we need to understand some of the you know the obstacles and it would be really helpful if you could follow up with which service lines are in each category for example you know which two are aligned if you only have 10 which five are aligned if you only have 30 it looks like the work has already been done it'd be really helpful for us to understand that um and i appreciated that analysis so if you'd be willing to share that with the board yeah oh sorry we certainly can um we have like you said we have the data and i can tell you before we spend it to you that what you'll see is that the services that you would expect the higher prices like surgery for example right that's one where it's it's further down the line so the less expensive the more basic the service line the quicker you get the financial benefit from attribution the ones where there really is a high contribution margin that's being generated to the hospitals are the ones where you really need to get towards that 80 percent um attribution level until you're completely incentivized but yes we would be happy to send some of that to you great it was really interesting i appreciated that um and i'm not going to delve too much into my concerns with the regression analysis i think many of the points that an hdhca made i i agree with um i appreciate the effort but again in my mind 10 observations does not make a regression and um honestly if you're trying to explain differences in hospital revenue you really need to include you know things like payer mix and case mix index and hospital designation type right like those are all things that are going to influence revenue so then using the residuals from that anyway i won't go on but that was one area where i that was a bit of a stretch for me um it's completely fair um point to make and so i think what i've said all along is if you like that analysis great if you don't you can kind of throw it out all together um and still just look at the rest of our presentation but what we were really trying to do um was look at it like in a million different ways possible and as many different ways as we could because we wanted to know first and foremost um if we were missing something if this didn't quite hold together the way that we thought that it did um and i also want to point out you know not only um do i want to give that recognition to the green mountain care board because you guys have absolutely been partners with us through all of this i mean i remember um i was here back when that rate decrease took place and i i just remember you know talking to al gobe and being like can i can i write you a check is there something else we can do because you know we all knew at the time that you know it was going to create this compounding impact but i agree with robin that this is the tool that we have and so we just need to use it the best way that we can um and you guys have always been incredibly um thoughtful in your review of these budget submissions and in your conversations with us to really try to understand um and the healthcare advocate was great as well we had some great conversations with them this year about that analysis in particular and so i think everybody truly is on the same team um in trying to get to the same place with all of this and and none of the data that we put together none of it was to suggest that anybody else's prices were wrong right because like you said you have to look at case index case mix index you have to look at payor mix you have to look at hospital designations um so we're not in any way trying to say anyone else's prices are inappropriate um we're just we care so much about implementing a rate increase of this magnitude on our community that we had to do the deep dive and make sure that it was still you know these are subjective words but still reasonable or still cost effective right fair enough um i will say i found uh the cpt code evidence you know that you had the the reams of papers by every possible category uh compelling so thank you for submitting that i mean i think that was helpful for us you know and it's clear that at least at the charge level um that they do appear lower you know um an mc than at other hospitals and also as morin mentioned just looking at the average commercial reimbursement rate relative to medicare is also another helpful metric for us to compare across hospitals and sort of the relative pricing um so those are really helpful um so one thing just as an aside since i'm on that page um it's something struck me as i was looking through that because i literally looked through all of it i know you may not all believe that the board members all did that we do and i literally was reading all of these you know cpt codes and digesting it but um as an aside the first charge that was listed on there was uh this is going to be a little seen a little off topic but i'm actually curious about this was spinal fusion surgery and the reason this stood out to me was because spinal fusion is often shows up on those you know as a red flag on lists of low value care there was an article you know in jamma like last year that selected seven low value care procedures to assess to see whether the hospital acquired complication rates you know for those particular low value procedures led to more harm than good uh and so spinal fusion was actually one of the seven so the reason i was struck by that chart that you submitted was the fact that only three vermont hospitals actually even do the surgery and it was northwest rutherland and uvm and rutherland did 20 northwested 91 uvm did 229 so i'm just kind of curious if you can speak to or maybe somebody on the on the medical side could just speak to the high rate of spinal fusions given nmc size and where these patients are coming from because it just struck me as i was reading that yeah i can start and then i might ask uh dr rophy who's here to chime in as well but i think for a hospital our size it really is um literally one physician right so we're lucky enough to have um an orthopedic spine surgeon uh here on our team which isn't you know maybe super normal or typical for a small community hospital like us but um you know if one of those doctors really enjoys your organization and wants to practice there then of course they're welcome to do so so for us um you know i i can't get into the clinical side of it and and why those determinations are made to either go ahead and perform that procedure or not um but i'll say that you know for us we're just fortunate to have that physician here and um i'll turn it over to dr brophy for any actual clinical insights that he can help provide that's great thanks just it's a curiosity that struck me so i'm just curious thanks uh thanks for the question i wish i had been better prepared for that uh for the record i'm uh great brophy i'm an ophthalmologist i'm also the executive medical director of physician services here um so as an ophthalmologist i'm poorly uh equipped to answer that question i can tell you uh the surgeon doing those procedures here has been here uh in the community for about 12 years came from a uh larger community where he of course only did spinal surgery um i can just speak that uh a lot of patients from uh not just our our county but from the burlington greater burlington area and beyond would seek out dr barnum for second opinion and surgical consults um i can't speak to um your question about it being a low value surgery but i can tell you that all of our patients here in the orthopedic department are put through uh kind of an optimization program to ensure that they will receive value not only value from the surgery but that it will be safe and uh and it will be effective in their long-term care um so again i can't speak to specifics about that but i can't tell you dr barnum has a a wonderful reputation in the community and really in the state and i think people travel from uh uh from from far away to um seek his expertise medically and serenely okay fair i mean you know i you know i and it's my camera on because my my it is not jess it's not okay i can see you yes we see you okay try that again am i okay and you can see me okay perfect um as you know and i appreciate that was that you know you didn't know that question was coming and i you know i appreciate you may not have the answer but it just struck me as i was looking through all the materials um so maybe just in general i'm trying to get a handle or a little sense of why the volumes are lower that's the new normal um robin maybe you can answer this you know i i recognize that some of it was a temporary reduction due to emr but what is happening what what do you sense is it population decline is it what any more deep dive might be driving the new normal lower volume um it's a net we continue to try and crack and i think that um you know it's problematic because um it is multi-pronged and it's how much of it is related to our efforts into stephanie's point um early on fast and hard investing in physician services and primary care and um and i think all hospitals if you were to look at them their expenses have risen um exponentially uh higher um along that trend line of investment in and uh in primary care um and when you're a hospital that is burdened with the risk of the success um of of quality and outcomes um the all-pair model kind of creates that incentive if it's not the hospital employing primary care it it needs to be some central body to reach that standardization and have everyone rowing in the same direction with respect to care management coordination and and etc so you know i do think the volume and we are growing i mean i you know when jonathan gave me that statistic that we we are one of the fewer counties that are growing i'm like then where's the volume um and i really do think as i've um spent a tremendous amount of time this past year working with our primary care medical director um dr judy finger gut with the entire um primary care staff as i have um really become a student of what the requirements are for pc mh you're we're actively every day approaching care from the standpoint that it's absolutely the right thing to do our to for our patients that are a a direct detrimental impact on our revenue it's just plain and simple as we get diabetes under control we have less lab volume we have less um need for uh long term for dialysis and things like that and it's just a very complex exercise of how much of it is related to pc mh and aco activity um better coordination of care um also with that growth yes we're growing but do we look um are we beginning to look a little bit like burlington in that the growth we've had has been in younger healthier populations you know we've not seen when we get our reports back from the aco we've not seen a tremendous uh year over year rise in our um acuity level across our population so you know anecdotally that that that informs that we're doing something right and either we're improving the health of our population or our population is is younger and and some of our risk is offset in that regard okay okay something to unpack i guess we're fine maybe if you mute for okay sure no no speak though go ahead no i said i think that that's just you know it's such a complex exercise again um it'd be an easy question to answer if we were um at optimal attribution or not in at all you know it's really trying to pull two different payment methodologies and making some kind of sense out of that it's an educated guess got it okay um can we just turn to the icu for a little bit uh because that's been you know obviously it came up in the in the spring and it's you chatted a bit about it here in this presentation and i really want to understand it a little bit more um so it sounds like moving to tana health to get to a positive contribution margin on that moving to it doesn't tana icu doesn't move to a positive contribution margin you're still going to lose money even though it's no it's it's already profitable okay it's already already profitable strengthening that profitability and positive contribution margin okay um so do you have is it six beds is that what you have there six icu beds what is the number of beds we have uh 10 10 we want for 10 okay and so what is the average occupancy rate of those beds like on a weekly basis or daily average daily occupancy those 10 beds like one per day true i see you one per day using the other nine but we use the other nine i mean again as yeah as stefanie said it's a progressive care unit and so as patients um improve during their stay then they're in different classifications okay so you have a truly critical care patient that maybe only be one a day but you'll use the other nine beds for alternative uses progressions they're they're staging their their care yeah okay step down step down okay um i you know there was a i mean i guess i'm the quality person today um question you know actually all probably all week but i the reason i ask a little bit about this is because there was a recent article that came out on if any of you saw but it was in the news about um it was in jamma but then it was picked up by the news that covid patients i don't know if you saw this that were admitted to hospitals that had fewer than 50 icu beds so that's what they determined by the study was a small icu was fewer than 50 icu beds but patients who were admitted to those hospitals had a more than three fold higher risk of death than patients who were admitted to larger hospitals and so i think about you know do you know i know you've got travelers in there i know you have you know do you have an in um a critical care internist in there our physician in there how do we make sure that the quality given the small volume is going to be maintained um at an icu of that size and i think about this in reference to porter porter hospital had a small icu they decided to shut it down a few years ago it was i think largely a financial decision but they were even farther away from from uvm um and they still made that decision it was a better decision for them obviously every hospital is different but i'm wondering how quality factors into your decision about the ability to maintain an icu sounds like the finances are working um i will say my understanding is that uvm has they operated 80 occupancy so there is capacity at uvm to take additional patients but and that we heard directly from uvm so anyway maybe that would be helpful sure sure i'm gonna um turn it over in just a second to to our cno but you know i will say that um uh we do have um a hospitalist and hospital-based medicine here um we uh do provide very high quality services this will only strengthen that and i think that capacity rate um i didn't hear 80 percent i heard more that they were at like over 90 percent um utilization um but i'll let dina speak to to those care coordination activities and the times in which we um which there isn't a bed available so dina if you could answer that question thank you yeah uh thank you i think you really bring up some very valid points and i would say that um i've been in my role as the chief nursing officer into my second year so coming and uh having a fresh set of eyes as the chief nurse here really looked at the services in which we provided um here at nmc and absolutely did the analysis with my cmo partner john minandayo who also at that point um had oversight for the hospitalist service um did an analysis to understand because i i agree either in the business or you're out of the business for quality of care high risk low uh low volume um doing that collaboration with dartmouth hitchcock with understanding the service that they are um able to provide the patients here at nmc what we did understand although there are certainly our partnership it's not to take patients from the tertiary center they absolutely there's a subset that has to absolutely go to the medical center but appreciating that although we could potentially transfer all critical care their capacity to take all those patients um would likely not be able to meet the need um in for for our patients here in franklin county uh having said that the partnership with dartmouth really will realize uh an increased um uh collaboration in regards to the quality of care as a nursing leader uh appreciating nurses new nurses coming into the environment not having the expertise and experience and at the other end of delivering a standard of care that would have an expert nurse looking at that patient with a new newer less years of experience we will only increase our competence and and um and our delivery of care for our patients in addition having also intensivist critical care trained docs at the other end of the of the collaboration really working with us in that clinical integration breast evidence-based practice policy and procedure will enhance our ability not only for critical care patients but we do have an average daily census and i'm looking to my finance colleagues of about uh 10.2 i believe of step down level care in which we also are waiting beds for uvm for those stemmys for that we're not able to get over to the cath lab because they need that intervention we're unable to provide so um you know i think recognizing i hear what you're saying as a clinical leader but feel really excited and confident in our uh work in this space uh to support the care of the patient we anticipate that we'll be going live with tele ICU and it's not like we're going to turn it on and have droves of critical care it's really to enhance the care that we're already required to deliver um and we anticipate that to launch in november december time frame so i hope i um added some value to uh what we're trying to accomplish here no i really appreciated that answer thank you very much you know i just it's something i've been thinking about and i appreciate your answer and your attention to the quality you know that's helpful yeah and just to also um inform certainly myself having conversation as well as dr menendaya with our colleagues at uvm um both peg gagney and her interim chief nurse role as well as um ryan clauser who has oversight of critical care to talk through here's what we're doing and um you know they're they're supportive and appreciate and value that that partnership um with dartmouth and dartmouth will also collaborate with uvm in terms of our transfers to get patients to the medical center so i i think um we're heading in a really good direction for region for the region for uh care of our monitors uh in particular in franklin county thank you i appreciate that uh my final question actually is um you know nmc has always had incredibly strong community support you know we we witnessed that firsthand when we have our mobile board meetings and we've gone to st albin's and tom has danced which is always fun we hope we get to see that again uh but typically during in-person hearings you know um usually there's a lot of community members and i suspect maybe there are some on the call but in person we always have a lot tom don't give me a thumbs down um but uh but so i'm wondering you know and we've actually received public comments from your community members uh i don't think we've received public comments from other hospitals at least not at the at the frequency of nmc so i'm wondering you know about fundraising as another revenue source you have such incredible support in your community um and grace cottage i know has tapped into this and it's helped them financially become more stable uh so i'm just wondering if you can talk a little bit this my last question about nmc's fundraising efforts trends over time particularly now are you seeing an outpouring of financial support from your community to help get you through some of the current issues how's that looking for you as a revenue source thank you uh for that question i'll tackle it and and we have jonathan billings here our vice president of planning who can also chime in um if we need him to but you are 100 correct that we have an incredible community and that we have incredible community support um and we have done the fundraising um in the past we uh did a major capital campaign um back when we built the medical office building and we renovated our pcu and um we had great response from our community and from our employees and so i think every hospital tries to strike the balance of you know how often do you ask and what are you asking for we had the community come uh in droves at the onset of coveted because they just wanted to make cloth masks for us so badly and they wanted to provide whatever ppe that they had available and i've heard similar stories in the other budget presentations so i know that you know all the communities around vermont love their community hospital and you know the hospital really does act as kind of this center point for the community and so you're absolutely right and we continue to evaluate fundraising efforts look at fundraising efforts we have talked about the idea um for emergency department renovation uh you might remember that that was part of our certificate of need at this point we have um you know really relied on that as a tactic to help with capital investments and not so much just to sustain operations this rate increase will be enough of an ask for our community um and so we don't have i just want to be transparent we don't have any formal um fundraising campaign plans at at this time um that are just to sustain day-to-day operations so i hope that answers your question yeah although i guess what you just raised was an interesting point that the rate increase is a lot so i'm just wondering do you offset some of that rate increase with a with a fundraising campaign and therefore get some of the revenue from people who can afford to pay it versus a blanketed you know 20 percent on everybody i mean is there is what was there any thought to doing that to increasing fundraising and offsetting the commercial rate ask yeah i mean it's an interesting idea and concept i haven't had any specific conversations but i'm sure donathan has has certainly will probably wants to yell at me from across the table right now with a perfect answer um about what we have done but um you know i think that we've i i know i touched on affordability during my presentation but there's just no way to do it justice right when we have an hour to give a presentation i wanted to address the elephant in the room um but there's just no way to to truly do it justice so you know i heard mike um from the hca i think it was you know before you know during uvm's uh budget presentation i heard him say you know i think it's possible for us to really show our gratitude and our appreciation for everything that hospitals did during cobin but i think it's also possible for us to go through this process and to really ask the tough questions and and those things don't necessarily necessarily conflict with one another right i think he said something along those lines and it really struck a cord with me because it's been a struggle uh internally putting this budget together and submitting it and so i