Can everybody hear me? It seems like, is this loud enough? Do I need my outdoor voice? Everybody's good? OK, we'll get started. For those that don't know me, my name's Art Matheson. I'm the CEO of Coughly Hospital. I just want to take a few seconds to do some housekeeping. I want to thank our board members. I'm not going to go by name, but thank them for taking time out of their schedule to be here in support of us today, as well as many colleagues and also family and friends of Coughly Hospital. Thank you for your unwavering support. Board, I'd like to thank your administrative team for their great collaboration and working hand in hand with our team in getting us to this point today. So thank you very much. And then last but not least, I want to thank my team members here to my right and to my left for all their hard work and preparation for a budget that we feel is real, transparent, and a budget that we feel that we can live with. So before we go any further, as usual, I forgot to ask the court reporter to swear you all in. I think you all have this true what he said. Yes. You all have a strange right hand. It's going to be this group, too. OK. All right. Do you all swear that the testimony you're about to give and have given shall be the truth, the whole truth, and that we've got the truth to help you go on? Thank you. OK. So I already messed this up, too. So this is on me. Let's see if I can. Got to be smarter than the controller. Is it the? It's the top two. The top two. OK. Great. Go up. OK. Great. Thank you. So as our presenters speak to their slides, they'll let you know who they are so you know their jobs at Cochle. I want the board also to know that we follow the slide agenda that was presented to us. And it's pretty much in order of what we were provided. So hospital issues. We were thinking of changing this, but we wanted to stay in line with what we provided as hospital challenges. It may be semantics, but we feel that these are challenges that can be worked on and in a positive way can be overcome in many instances. So I want to say that with these challenges, not in order of importance here, but one of the issues or challenges that we are having is trying to get to one fully integrated health information system. I talked to some of you. Many of you know that at Cochle we have three electronic medical records. One inpatient, one outpatient, and then one in our ED. Not to mention just staff frustration at times with having to go into two systems or three systems where they're trying to take care of you, but also the biggest thing that keeps me up at night is safety. And one of my big jobs is mitigating risk in what's the risk of doing something or what's the risk of not doing something. And usually the latter is the one that worries me the most. And so as we go into our second year of our strategic plan, which we talked about last year at this hearing, three key areas that we're focusing on. One is getting an EMR across the full continuum of care is very important to us. Then also focusing on our building and then also focusing on our orthopedic center of excellence. I'll talk more about that later. Recruitment and retention. I was here a number of months ago, board members talking about the challenges of recruitment. If you remember, we talked about our general surgeon, happy to say she should be arriving in a couple of weeks. She did buy a house in Morrisville, so we're pretty confident that she's still coming. We are going to continue to be challenged by this. And this is not a Vermont thing in my belief. If you remember, last year there was a study done by the state that I talked about through 2030 what our challenges would be and various specialties. And we are going to have many shortages. We are going to have to find creative ways of trying to get physicians and other highly skilled professionals to come to our beautiful state. Facility, medical equipment, always going to be a challenge. Most of our hospitals are pretty antiquated. I think ours is well over 50 years old and then medical equipment to assess our patients as they come through the door. It's just expensive and it's always going to be expensive but it's necessary. Financial challenges, I'll leave that to the guy on my right to get into the weeds on that with future slides and my other right. Thank you. Thank you. The last thing that I wanted to put on here was addressing the determinants of health. And this is a challenge. I'm not trying, and we are not trying to be negative with this but we just feel it's a reality. When we sit around our table as a senior team or key leaders in the hospital, this is something that we're challenged with daily, weekly, monthly. And the reason why is we have like most areas of the state like other states, finite resources and so many needs. And the question is how can we put those resources to one area for the best, for the biggest number of people, you know, biggest bang for your buck. And that's not easy. And as I was talking to the healthcare advocates that are here a few minutes ago, this is the long game. This is a marathon and it's something that we just have to get after every day. So as you can see, many of our areas of risk are also challenges on the previous slide. Finances and capital requirements, something that I say to our staff is no money, no mission. It's just the bottom line. With a new EMR selection, there's one piece of getting a new EMR for your hospital where you want to select the right one, you want to get buy-in from your staff. And that's a process in and of itself. But the thing that scares us the most that COPLI is the implementation of a new electronic medical record. And this is why. You can predict the cost of a new EMR, right? So there's a startup cost and then there's a cost over, let's say a seven-year period. And say that's $3 million. It's a lot of money, without a doubt, but it's predictable. But where a lot of hospitals, particularly small hospitals, go wrong is not that side, but it's the revenue cycle side.  And that's not a good enough reason for us now to move forward, but it definitely is a concern. I talked about recruitment and retention already, healthcare reform. I really like some of the things that we are doing with population health. We have the Rise Vermont platform. We're gonna talk to you today about a number of things that we're doing at COPLI that I think are helping with population health, preventing disease, et cetera. The other piece of that is payment reform. And I wanna say that last week we had a presentation from OneCare and I told them afterwards, and I mean this, it was by far the best presentation I have heard in three years. It really gave us the numbers, the data for our board, our FQHC, who was also at that meeting with us to really make a decision about going risk for Medicaid for the upcoming calendar year. And I was asked, and right now my answer is we're on the fence, but we're strongly considering it. Areas of opportunity, I taught strategic plan, general surgeons coming in, and I think it's important to understand the challenges although this is an area of opportunity, but I'll talk the challenge. When you have one general surgeon at your hospital, Don Duque, he and I arrived here at about the same time. We had been trying to recruit a general surgeon long before our arrival. And what Don has been doing and he's been a great sport is essentially pulling call two, three weeks a month for three years. And we finally have a great partner that's joining him, but if you're looking just from the business side of cost, it actually costs a great deal more money to have a temporary surgeon allow Don to take a few days off every month. It's an incredible amount of money and that money really is a challenge for our hospital, not only in that area, but other areas as well. But we're excited. I'll talk more rise for a month in further slides. Day to day operations, I'll cover that and then I'll move on. Some of the board members were part of our certificate of need process. I'm glad to have closed that one out. And if you remember, one of the big questions was utilization of our OR rooms and then our procedure room. That was one of the big key things that you were looking at, the key metrics. Now with the number of surgeons and other providers that we have on board, we are having to become very efficient in the utilization of our ORs as we should. As of one September, we are making monumental changes in the usage of our ORs in procedure room where essentially almost every minute of every day of every OR room in our procedure room is going to be utilized because we don't have any more room in the house, so to speak. So it's number of surgeons and other staff are going to fill those four rooms almost completely each and every day. And it remains to be seen in the future what we're going to do, but that all comes down to access and a number of other things. A lot of collaboration is going on, has been going on and will continue with other hospitals, the FQACs, and we have had great relations going on with academic institutions where we're trying to build our own bench. And then we'll talk more about our community health needs assessment and follow-on slides. So wait times. I want to let the board know that we decided to update the data on this as of August 15th. So last Thursday, we just felt that was the most up-to-date information. The one thing that really stands out there, the one real change is 107 days for new patients into cardiology. Adam's here, he wanted me to remind you he has patients at one o'clock so we can help decrease that number. And I think you know this, we use third next available appointment to look at access, usually first in second appointments are anomalies and don't give you a good look at what true access is. This may be an anomaly, we certainly hope it is, but I know that right now, Adam is at least in the 50 to 60 days out for new patients. Adam does just about everything that a cardiologist, a general cardiologist can do works hard every day, but those are the numbers. I'm here with my co-achieve medical officers, Don Ducree, our surgeon, and Adam Kudin, our cardiologist, I'm Lori Grafati, I'm Chief Nursing Officer, and I hope that we together can inform you about our quality work that we're doing at Conflict. Access, access to primary care, access to transportation to and from the hospital, access to local services, housing, dental care, food, and counseling. In May of this year, we had a patient come to our emergency department by ambulance six times in a short period of time. Once we were able to drill down and meet the patient where they were at, we were able to identify that with some food, with safe housing, with transportation assistance, a companionship that we could help this individual stay at home and in their community. We continue to collaborate with our community partners to provide timely access to safe, effective quality health care. We continue to engage in prevention strategies to keep our patients out of the hospital and helping. Our health service area continues to meet and exceed five of these eight, APM quality metrics. Although several of these are mostly closely aligned primary care, we're committed to our community partnerships to having a positive influence in our primary care outcomes. In FY19, we'll continue to build on our strengths, our social worker in the emergency department, which you will hear wonderful data and stories about today. In that role, a shared position with our community health partners that has grown to a permanent position in our hospital this year, this position is handling over 500 referrals in the last two years to patients seeking primary care. It has identified 77 complex care patients and high utilizers in our emergency department, connecting them with our community resources early at a time of discharge from the emergency department. We will continue with our shared position of the social worker in the women's center. We're enhanced screening in connection to state agencies, community resources, improved health outcomes, and our mothers, our newborns, and our families. And in FY19, we will focus on our strengths. And our opportunities in areas where we can make an impact. For patients access our health care, our health care teams. Our surgical center, our specialty clinics, our acute care setting in our emergency department. In FY19, our goal is to improve our screening by connecting early with targeted patients and improve quality and health care outcomes. We are expanding our partnerships with the Moio County Mental Health, setting staff to be trained in suicide assessment so that we can fully support and participate in the zero suicide program. We continue our focus on chronic health conditions through enhanced blood pressure screening and education with targeted populations and early identification of remission risk prior to discharge in our acute care patient setting. In FY19, our partnership with Cheslow will continue as we add an additional shared resource who will work with a social worker in the ED and our care management team. The objective is to enhance the screening of substance abuse, mental health, social determinants of health, and ACEs. Follow-up and monitoring of our high utilizers. Mental health is substance dependent patients. Our goal is to connect early to patients after discharge from treatment in acute care and to participate in our community shared care plans. Thanks, Lori, and good morning. My name is Don Lufui, I'm one of the co-chief medical officers at Copley. My primary task as a CMO at Copley is to both track and foster the high quality of healthcare that we at Copley, I think, are rightly very proud of. Whenever someone starts talking about the quality of healthcare, really the first question that anyone asks could immediately be, how do you know? And at least when we're talking about the quality of surgical care, that by far the best answer is the National Surgical Quality Improvement Program or Nesquik. At Copley, we have been engaged in the program for a little over a year and we have about a year's worth of data in the database at this point. We are just now reaching the point where we can draw meaningful conclusions from the data. The first task on it is very, very encouraging. Our observed complication rate from our operations is less than a quarter of what the national average is for observed complications rate amongst Nesquik hospitals, which are for the most part, the hospitals that you all think of when you think of really great hospitals in America. The data for readmissions and return to the ORF re-operations are essentially similarly favorable. This data really is so encouraging that our initial prime thrust is to maintain this high quality while we increase the efficiency of our operating units. The second program that we're very excited about is the antibiotic stewardship program which we're partnered with UBM with. The ASP is a concept that the Center for Disease Control came up with quite some time ago and CMS has recently included as a condition of participation. The concept is that antibiotic usage can be optimized to improve outcomes while decreasing side effects, decreasing development of resistance and where applicable, decreasing costs. In Vermont, there's a program that allows community hospitals to partner with and gain the expertise of the specialists at UBM. And I know I can say that at COP we've really enjoyed our collaboration with Dr. Zahirn and Dr. Smith. I think we have a productive partnership. Our initial idea was to take three antibiotics as targeted antibiotics and try to optimize their use. We recently compared the usage for the last six months to the six months that preceded the development of the ASP program at COPLE and we compared them. And happy to be able to tell you that their usage decreased by anywhere from a third to three quarters while producing essentially the same outcomes. And I certainly, it's certainly my opinion that this is really a model for how the expertise of the medical center can be used by community hospitals to get the best possible medical care for our local communities. In a slightly more local collaboration, we meet regularly with our primary nursing home and rehab facility, the Morrisville Manor, to review re-admissions from the manor to a few care facilities. We've met three times and what we basically do is look for patterns or opportunities to improve the system to keep the people at the manor when appropriate. We certainly want them to re-admit their patients when they need it, but if we can apply resources in an intelligent and timely fashion, we can decrease these re-admissions. And so far the manor, I'm also happy to say, is well within their target and well below national benchmarks. Finally, we continuously and concurrently review our own re-admission data, with the idea being that we're gonna look for patterns and opportunities to decrease these re-admissions. The problem with this is that it's essentially backward-looking, the re-admission is already happening. And so we can maybe learn something about it, but what we really want is a forward-looking tool that will allow us at the time of discharge to have some idea of who is at risk and what resources can be marshaled to keep the patients healthier and at home rather than less healthy and back in the hospital. Toward that end, we have adapted a tool with the acronym LACE toward our local idiosyncratic situation. And we're really in the last phase of data collection. We'll soon start the analysis and the desirable that this will be in its initial trial phase, at least by ski season. Hopefully, I've painted a picture here that really shows pretty clearly that community hospitals can really deliver effective and extraordinarily high levels of care and at the local level, which I know is where my patients want to receive their care. So now I'll turn this over to Adam. Good morning. Everybody hear me? Yes. I'm Adam Cunin and a cardiologist, as you heard, and also the co-chief medical officer along with Dr. Don McCwee. I'm gonna go a little bit out of order. First, I wanna talk about shared decision-making. Some of you may be familiar with it, but I'm gonna explain it a little bit. I've been involved with shared decision-making off and on, really since the years 1993 to 1996 when I was a resident at Mass General, working with Michael Barry, who's a really well-known researcher in this area. He continued to be my mentor. Primarily, I've been a user of the shared decision-making tools, but now I'm actually involved in investigation as well. We worked in conjunction with HealthWise to make this project, which is the organization that does most of the national research in shared decision-making, so it's spread around quite a bit now. So what is shared decision-making? You get a structured evidence-based process which helps patients evaluate the risks and benefits of various treatment options, and it's unique in that it elicits the patient's own values and preferences, specifically when there's choices to be made. And the research is pretty clear that investing more time in shared decision-making usually results in a reduction in invasive treatments and cost savings. I think it's a good antidote to some of the ills of moderate medicine. Sometimes people think more is better. And specifically with these treatment-sensitive and preference-sensitive decisions that can be really useful. Starting in 2013, Copley has been participating in shared decision-making for orthopedic surgery, and a couple of years into that project, one of your previous board members, Alan Ramsey, came and visited this very enthusiastic and encouraged us to look into other opportunities to expand shared decision-making, and that's what I undertook with, again, the help of Michael Barry. So we chose a disease called atrial fibrillation. This is a very, very briefly defined disease. It's a disease of the heart rhythm. It's the cause of about 40% of the strokes in the United States. Many of these strokes are preventable using guideline-directed therapy, primarily anticoagulants, you may have heard of some of them, warfarin, coumadins, zarellto, just to name a few. And nationwide, only about 50% of patients with atrial fibrillation are actually on guideline-directed medical therapy, which is an embarrassment that I'd like to see improved. So the purpose of this study was an intervention of essentially education intervention to look at a group of patients before and then after the intervention to see if a program education worked. It was a pretty intensive education that they went through with a lot of program questions and answers and assessment of the process as well. And we proved what we wanted to prove. In, I have the study, if you wanna look at it later, it's still in a draft and we're getting ready for submission to publications. You can't reveal it to the press. But it's gonna be a blockbuster. We proved that patient knowledge regarding both the risk of bleeding if they take the anticoagulants and the decrease in stroke, increased dramatically with the educational intervention. And even more important than that, the intervention group reported having a better process of shared decision-making meaning they understood the risks and benefits. They felt it was a balanced presentation. This study is somewhat of a pilot study but it has great applicability, not necessary to cardiology but for primary care population where most of these patients are seen. I participated in a grant application so that we could roll this out to all primary care practices at Mass General. Unfortunately, that grant has not been funded but we're still working on a way that would be tens of thousands of patients if we can get that going. In Vermont, I can see this being rolled out via one care to large numbers of patients. It's very applicable, it's not very expensive. So this has been a great success and it's been an education for me in terms of my foray in mid-career research. Moving on to the next study in the Unified Community Collaborative, I have the privilege of co-chairing the UCC along with Floyd Neese who's also the Director of the Memorial Family Center which is a great place if you ever want to visit and it's currently inspiring place to visit and to work at. We've expanded in the last year of the framework of an accountable community for health. Working directly with the Department of Health we've established a new mission and a new charter. We have several initiatives some of which Lori has already touched on an emergency room and in the Women's Center at a very minimum going to these monthly meetings interacting with folks in other areas like mental health, substance abuse. I've learned a lot about restorative justice. I've learned a lot about the hard work that these people do and when you look at their budgets it's unbelievable how much they produce with very small amounts of money. So our initiatives involve for one reaching outside of the providers' offices for adolescent well-trialed screenings that's a health system wide initiative. Continuing what we've been doing for several years which is developmental screenings for each of the 33-month-olds. UCC also brings together what's called a Memorial Care Management Team which is a team that focuses on the highest risk groups. Oftentimes there's only 30 or 40 individuals who are being focused on it. It's usually not their medical needs. It's social determinants of health. Folks who have mental health issues, they have had abuse issues in housing and food security. You go to these meetings and you get a sense how much work is done in the background to keep people out of the hospital. In summary, these are the investments that we've made to improving care to patients that are robust and that are on their own. Thank you. Good morning. This is Dr. Rangelich. I'm the Chief Financial Officer for Kashi Hospital. Pleasure to be here with August as well. What I'm going to go over is that briefly over the financial overview of the copy and discuss some about cost-containment efforts and what are the major expense riders for the hospital as well as capital needs and also a longer range of outward for time. So in this free income statement, you can see our 2018 budget versus 2019. 19 net patient revenue growth is about 5.9% about $4 million. Expenses grown roughly $2.5 million, 3.5%. And this would give us about 2% operating margin. As you look at the 2018 budget, you pretty much have no operating margin, it was 0.1%. You look at the MPR breakdown, there is multiple components. Obviously, we are asking for rate increase in 2019, which is 7.9%. We had over 11% of rate reduction in the last three years. And the investment increase of $2 million. Primarily, the way we agree, critical access hospitals work as your cost growth outpaces your volume, your utilization. You are getting better reimbursement, so as you are supposed to get cost-based reimbursement, so that's why you see major increase in our reimbursement dollars. Not all Medicaid, but that's pretty much the majority of that is from that $2 million. About a million and a half is a Medicaid. Our bad debt and charity care, there's no real significant difference as far as our experience as a percentage of our operations. So there is no materially impacted our MPR. Obviously, we've had a low utilization of 19, so we are carrying some of those low utilization through the 19 budget. That's why you see about a million dollar reduction of our MPR associated with that utilization. We also had a dish payment cut, but close to $300,000 that impacted MPR. On the expense side, we have grouped in the major categories, whatever the expense tribes. We will be talking about that a little bit further. Our labor cost is doing about 2.5%, about a million dollars. Pharmaceutical cost associated with the inflation as well as the utilization is going up close to 28%. Our supplies primarily are in-plan because OTP is a big service line for coffee, that's going about close to 7%. And rest of the cost of the organization is in the state plan. So that's a great amount of about 2.5% or about 2.5 million. So we selected certain ratios here to kind of show in coffee's plans, which is improved compared to system as a whole. So if you restart the rate changes, so this is a coffee's rate changes over the last few years. You can see on 2015, we had no rate change. In 2016, we reduced our rates by 4%. In 2017, 3.7% reduction. In 2018, about 3.4% reduction. And in 2019, we are looking at a 7.9% increase. Even with that increase in 2019, our average community for five years will be still a decrease of 3% prices compared to system which is going up about 18%. So this is about, in our calculation, about millions of dollars going back to the saving to the healthcare system as well as our rate reduction over the last several years. Then we look at the operating budget. I think the last time we had operating budget was in 2015. Since then, we've had losses from operation, not as much in 2016, but 2017, and obviously this year as well. So we are hoping to have a 2% for 2019. That's our budget we submitted. So if you look at cumulative for coffee hospital for five years, we have less than a penny on a dollar from operation. We have the product market cumulative compared to system offering marginal over 3%. Obviously all of this impact at the end of the day are days cash on hand. Our days are cash on hand. We don't have the system for the last couple of years, but you can see the gap between where the copy is versus the system average. So we have lost about 42 days cash on hand since 2015. And it costs us about $200,000 a day to run the business in our coffee. So that trend is roughly about $8 million reduction in value of a cash. This slide is very simple slide. You were asked to break down our business based on in-state versus out-of-state. 95% of our business is for Vermont resident and 5% is outside the state. You are simple. Over the last three years we have targeted close to $3 million in cost containment for coffee hospital. In 2017, about $760,000, $18,000,000 and $19,770,000. So far today we have achieved about 61% of those targeted cost containment. And the next slide that I'll go through, we'll look at the big piece of that. Targeted area was the labor component. We are about halfway there. We selected certain, we put the details in here, some of those areas that we're looking at. Primarily is about stacking mix in those area. We also looked at the travel cost and also we changed our health insurance plan over the last couple of years for savings associated with that. We still have some work to do. We're obviously halfway there but it's got a big piece of the work that we need to figure out how we can reduce our travel. Because we do budget for travel because that is the cost of doing the business but seems to be for the last two or three years we've been about 50 to 70% above what the budget. So that obviously is impacting our expenses. The next category of cost containment is supply chain. And that's pretty much includes both drugs as well as the supplies primarily in-plant. So we have aggressive price negotiation with our in-plant vendors, about $500,000 savings there, from around 20 to 35% reduction. We have fully implemented our 340B in our drugs which is about $170,000 savings there. And we also manage and manage our waste as in-group supplies and food and drugs. And we have pretty much about 91% of that. So we have pretty much there as well at that time. Next topic that we were encouraged to talk about what is your expense driver for the hospital? So we have identified three major categories which is probably will be a common theme amongst most hospitals. One is labor. So if you look at labor costs for coffee, the historic increase we've had, traveler, even the budget for over the traveler budget significantly year after year, we've made close to $2 million in market adjustment for various positions in the organization which is both clinical and non-clinical area. We also made some investment in our, in a workforce drive to grow some of the positions within the organization. So with that said, three year average for that, that category of the cost has grown not up about 4.7% for coffee. We budgeted in 19 to be 2.5%. The big risk in that budget for 2019 is that tried to live with a budgeted trap because we know that it hasn't been successful but there's a lot of initiatives that we are hoping that will pay out. On the second bucket, drug costs, obviously drug costs, it's inflation, it's been double-digit in the pharmaceutical costs. On colleges, the utilization is grown at coffee and then there's this shows of drugs that you have to pay as what the members build. So that growth has been 11% on average for coffee for the last three years. We are budgeted about 28% increase in that category. That's a combination of inflation, which is double-digit plus we are seeing uptake in our oncology program which requires us to find one for us. Last category here is the supply pack that primarily for us is internet has grown about 6.8% combination of price as well as the types of surgery we do. Even though we may not increase the surgery at an older period, but the service mix has changed, the face mix has changed in that so we are doing more surgery that requires a prime standard in the previous years. And then in budget, we still have 6.8% much in line with the store going on increase. Here's the snapshot of year today performance for 2018. Compared to budget, we are down about 2.3% MPR. Oh, we are projecting to be down 2.3% in 2018. And from that, utilization is in the world some parts of, you know, most parts of the service that we provide. And the expense pressure, obviously, is an expensive or higher combination of, as I said, about the travelers and paying for the drugs and then mix up their services in our each time to solve that sort of problem. So at this point, we are seeing a loss on operation a lot. We're projecting to be over $2 million for 2018. Okay, just a quick update on our community health needs assessment. We are right at the point with our new community health needs assessment to get more approval next month. We had quorum health resources come in and help facilitate this process. The thing that the staff here is really thankful for is we were part of this process with creating our needs assessment. When we came in in 15 and 16, we had a very big learning curve with our needs assessment because we weren't part of making the needs assessment. We were just there to implement. And so we all said to each other, wow, it was nice that we could be part of putting this together. What quorum told us, and a couple of the quorum staff members have years of experience said that they hadn't seen a process quite like the one that we had at Copley. And what they were talking about is the input and the participation from our community. We actually had 78 local experts from the community take part in making this plan and providing feedback. We had two different surveys that went out with over 172 responses. And then we had a two or three hour meeting where we had our first draft of the needs assessment at the table. And most of the community members that we know were there. And what we did together is essentially try to figure out where we would put our effort and our resources. Not that we won't focus on other needs because we certainly will. But as far as our needs assessment, these are the top needs identified. You can see preventative care and chronic health are from the 2015. I think we all could agree that both the worthy of continuing in our 2018 needs assessment and then also mental health and substance abuse. Something that all the hospitals are quite familiar with. Now, some of the things that we're going to do as far as primary and secondary prevention, this is not all inclusive. Certainly it helps with cost avoidance and bending the cost curve. But most importantly, with the patient being the center of all we do, this helps to keep the patient out of the emergency department, out of our inpatient floor. It helps them to remain healthy and enjoy their life. And that's really our goal. So one of the key things that we found over the last couple of years that we've been trying to work on this is that screening, identifying what the patient needs and then having and knowing about the resources through adequate case management is really where it's at. And we've seen great success. Lori talked about it on the next slide. But we're really excited about that. One of the other things here that I haven't talked about that I won't talk anymore about because it's not in our presentation. And it seems like a small thing, but it actually is a pretty significant. We're putting in our first medication drop box into Covley. And sometimes change is tough and some people have some concerns about is somebody going to come in and rip it out and take the drop box. Which has happened not in Vermont, but is a possibility. But again, it's about mitigating risk and saying that's pretty low risk. And we want our patients to have another place in concert with Sheriff Marku and what he's done to be able to drop off their medications and get rid of them the right way. I looked under my, my, as we go through this process there's a lot of regulation that takes place in order to get this done, believe it or not and make Morris, our director of the pharmacy has been great. I think we actually had it at the hospital now. But I was in my bathroom and looking for something under the sink and I realized, gosh, I have over 100 pills that I've been carrying with me probably my last two Army duty stations and just never got rid of them because I was like, I don't want to pour this into the system and into our water. And I think I'll be one of the first persons to partake and use this drop box. This partnership with the blueprint for health and Cheslove with a shared position in the emergency department of a social worker is an excellent investment for all of us for health care reform. Many of you in this room may know Dominique and this is a great example of right person in the right role at the right time. And what we believe we've experienced this year in our emergency department is a bit of the Dominique effect. Her commitment to this work of connecting patients, screening for social determinants of health and getting patients access to period resources has really propelled us forward and we've seen a decrease in the ED utilization and volumes. However, 6% of all emergency department patients were screened or evaluated by our ED social worker. 608 total referrals, including 422 unique patients. 157 of those were complex with chronic health conditions and required a face-to-face evaluation. 241 patients were successfully connected with primary care and 77 high utilizers, again, chronic conditions were identified and connected. In the second quarter of FY18, we committed to this position becoming a full-time employee at Coffey and created a shared vision to start working towards a second role to support this work, which will be the community referral specialist. The work and learnings related to high utilizers have transferred to a acute care inpatient unit where this social worker has identified opportunities to enhance early follow-up and monitoring of our patients after discharge. In FY19, this new shared position, the referral specialist will help us to be better community partners through advanced screening, early intervention, timely follow-up and more frequent monitoring. Our goals are to get these patients back in the community due just-in-time care management, specifically where we see our mental health patients, our substance-dependent patients, leaving treatments or acute care settings and coming back and being able to make that connection with the care management team from those facilities so that we know when they're back in our community and we can be there to give them the phone call and make sure they've got the resources they need. Okay, in the interest of the time, I'm not going to go over each of my remaining slides in detail, so I'll pick it up a bit if that's okay with the board. It is. So rise for more. Two years ago, Jill Mary Bowen, I think she's sitting in the crowd. Jill, thank you for being here. Talked to my staff, my senior team, she came to Copley and talked to us about Rise Vermont. Now, she's sending me Rise Vermont stuff to wear in the mail. I got something late last week, Cycling Jersey, which I'm going to wear in the near future. I think this is a great platform for the ACO and for the hospitals to follow. The big thing for us is it was a tad bit of risk where we were not part of the risk hospital pool when we decided to go forward with this program and we're excited to be part of it. I looked at our calendar for this month. We had exercise classes, story time for kids at the library, childbirth education classes, and we're doing some training for the 5K on a regular basis with those that can get out late afternoon and do that. So we're excited about this program. So last year, I talked briefly about our blog that was nationally recognized. It's grown even more. You can see the FY18 results. 22 households in the Laurel County have been touched by the blog or have gone to the blog. You see some of the past topics. I specifically enjoyed the building resilience and hope we all need resilience. We all need to find ways to cope with life itself sometimes because it can be tough. 753 impressions for Facebook and Twitter, you can see the numbers. We're excited. Our community is actually excited about this. I've had a few members say thanks for that article. So I didn't write the article, but you're welcome because it's being read and it's helping us and our community think about ways that we can improve our health and live quality lives. So on this slide here, what I really wanted to highlight is the investments, not just in the action grants that we're gonna work with the UCC to decide where those dollars would go to, but also on our social worker, our Rise for Long coordinator, our community action grants as I just talked about, but some of the other things that we've invested in reform, which are not within the parameters necessarily of the guidelines for the 0.4%, but are maybe one or two steps away to help us get there in many instances. We had Quorum do a wonderful job with our needs assessment. I mean, just a terrific job facilitating that. As I said, we're excited. Nesquit is a cost of thousands of dollars yearly to be part of that program, but I think long-term, this is the long game, right? I think long-term that's gonna more than pay for itself with all the things we're now learning, which you heard me talk about three years ago. We think we're good, but we don't really know. And now we're starting to know that, hey, we've got some things to work on, but we overall provide great surgical care and that Nesquit program is providing that. Shared decision-making, not cheap, upfront. There's a huge upfront cost of $20,000 to $30,000, but we felt it was that important to include our patients in the process of deciding what kind of care they should get with their physician or other provider. And you heard the results from Adam that he's so excited about. And then also on a yearly basis with our survey company that we work with to get our patient feedback on how we're providing care to them and then using that feedback to sustain what we're doing and then also improve what we're doing if there are areas of improvement. Capital spending for capital. For 2019, we had about $3 million capital spending budgeted. Those are primarily routine capital. That's a number that we normally have somewhere on that to just routine replacement for equipment. There's not no major item over $500,000. However, for the following years, we have planned close to $19 million. And that includes both routine replacement of capital spending. Also, there are some placeholders for two major area, one being electronic medical record. We're still in the process. We have a group that work on it that will have options laid out for senior management board members to discuss sometime in fall. And then second group, we have a placeholder we have a facility need for the organization. That also needs to be part of the planning process. We have some dollars in different buckets in those following years, but we don't have the details yet how what options we're gonna take because the groups are working on it. What would be the funding cells? How are we gonna achieve those investments? This is just for you guys to see what the future capital needs are probably and made those plans. This is a slide was probably the one that took a little while to pull together. So it's brief, but it's not, it's complex at the same time. So in order to figure out what would be a top line growth or company may look like in the future, obviously you need to know what the factors going below the top line. So top line meaning that I think that section 10 was related old player model of 3.5%. I think that was the question that I mean that much. So there are certain parts of these factors that you can quantify some degree and others on that. So cost pressure. So this is the conversation we just had earlier what is a cost pressure? So we think for future, we probably sum around 3% to 5% cost increase. Different buckets of cost category may be higher, some might be lower, but that's a range we see that based on historically and what we see coming down the top. Second, we need somewhere around 2% to 4% operating margin to be able to fund our routine capital spending along with the funded depreciation that we have. Also, start building our cash reserve. As I know this earlier, we have lost over 40 days of cash on hand last year. Then there are other factors that goes along knowing what will be the utilization trend for COPD. COPD is one of the companies that population is growing and also there's a patient choice they come for our services, especially for our competing. What will be our service mix? This is very important for small hospitals. COPD hospital is about 50%, all services use fixed cost, no question about it. But COPD hospitals, about 50% of our business, including downstream revenue, are related to oncology and OTP. Obviously, if you have oncology, chemo's, you need drugs, which is the variable cost. Obviously, if you have most of the OTP procedures that we have requires implant. So we can charge for the chemo and drugs and we can charge for implant. But that puts a pressure on the cap on the top line because in order for us to capture those variable costs, we have to get the revenue associated with those variable costs. And that goes against the top line cap. So I just want to make it clear, this is very important. As big as the hospitals are, this is less important because you change, the law of averages takes over. But in our case, when you have 50% of our business, it is important. Then we also have a major capital investment that we talked about earlier that we need to figure out how we're going to fund. So that has to be factored, what the future outlook for COPD financial center will be. And obviously, we're going to continue our effort on cost containment because we, but the thing is that there's a diminishing value for small hospitals. We've already put $3 million in dollars. The counter is 61% of that. We are hoping to get the remaining down, at least most of them down, or we'll continue that. What we see as an all-payer connection is that, perhaps as a system level, it might be achievable on the state level. And I think if you look at the budget submission on system level, it pretty much comes within the range of the cap that we talked about. However, hospital to hospital becomes case by case needs to be evaluated. There are factors such as utilization rate. Basically, there are hospital areas that population is shrinking, certain areas growing, demographic is changing. You've got servicemen. So obviously, a smaller U.R. and you got the services that are high on the variable cost, high on the pressure, size of the organization. There is a reason for the Cleveland Access Hospital designation because there's a huge, fixed cost that has to be carried to the small hospital. So it's a pressure there as well. Capital needs. Not every hospital is on the same capital spending site. Every hospital has different parts. Their needs has to be evaluated and reacted to. And also, overall, health and the financial health of the organization. So goal, I think as far as goal came out, I think it's pre-attainable on the high level, but it might be problematic in the individual hospital unless they look at the case like that. And then, this tour called, Section 11, we want us to see how we're, as far as it's applying to the MPR in our, we look at 16, 17, 18. We were way up on MPR in 16, 17, too much on target. This year, way below what the target is. So over those three years, we had reduced our rates by 11%, roughly $5 million a year back to the system. We exceeded the cap on a combined basis by 400,000, less than 42%. I've essentially covered everything on this slide. And so I will turn this over to the board. Thank you, our, we'll start with Robin. First of all, I wanted to thank you for what to me seemed like this year, a more balanced presentation between your understood focus on surgical procedures and investment and focus on the community as a whole. So I really appreciate that. I particularly appreciate your focus on shared physician making, given that your hospital does have a focus on surgical procedures that, to me, seems like a very necessary component. I, my first question around the Rise Vermont program is my understanding of how the program works is that there is also some reporting that happens related to the one care helps participate in around cost and utilization. And I'm curious if you choose not to join one care next year for at least the Medicaid program, how that will impact your Rise Vermont participation and how you get that data. And you're welcome to follow up. If later, if that would be helpful. I'll have to say that I don't know the answer to that question. We have not crossed that bridge yet, but I think we'll know what we're going to do in the next couple of weeks and we can get back to you once we're past that point. Great, thank you. You're welcome. The other question I had relating to your rate increases, could you talk a little bit about your major commercial payers and are they all reimbursing as a percentage of charges or how does that kind of work with your payer contracts? Roughly speaking, half of our business is government pay and other half are commercial payers. And most of our contracts are percentage of charges for all of them. And Medicare is based on a pre-pill access and information payment. And Medicaid is a percentage of charges which is very significant. Sure, thank you. You're welcome. And then my last, I have two more quick questions. One is that in, that we get a chart that talks about areas of utilization that vary from year to year. And I was noticing that your physician office visits from your 18 budget to 18 projected were down a little over 25%. But I didn't specifically notice a description of that in your utilization narrative on page 10 of your narrative. Could you talk a little bit about how that interacts? Absolutely. I think if you look at it beyond, even if you go past, there are, I think we maybe discussed the last year was that we had a hospital-based urology practice that went on private, so nobody was countered in our position. Then this year, I think over there, we had sleep clinic that no longer done a copy so that would be impacted. We had some subspecialists that was coming to the coffee. We lost those as well, so those are not major procedure-driven, but those are what used to be counted in the hospital as a physician visit is no longer being counted. But there is an effort that's going on primarily telemedicine that we try to substitute those subspecialties of coffee. So there is that effort underway. But what you see is basically going from in-hospital practice to outside hospital, either by other hospitals or to private practice. Thank you. And then lastly, in your health paper, Monarch 2020 profile for your county, I noticed that there was just a strangely high rate for new cases of end-stage renal disease per million population in the 500s as opposed to the statewide average of 188. And that could be a data issue, I don't know, but I just wanted to ask about that because it was such an outlier. And again, if you need to get back to me, that's totally fine. Yeah, I don't personally have any information on it, but it didn't give me a reference. I could try to dig it up and speak to some of the, your own neurologic colleagues. That would be great. It's that healthy for Monarch 2020 for a file that's done by the Department of Health and we can send you a little bit, although I'm sure you can find any cases. Yeah, no, I will dig it up. Thank you. Thank you. Okay, Tom. Thank you. And again, thank you for hosting for Maureen and I, I think about one time over this year with a very healthy lunch. Thank you for coming. It was healthy. Listening any healthy lunches, sometimes not that compatible, but it was nice to see you in your facility. I have a two or three questions here. One is I see you in some kind of a mini version of what we went through with Gifford, which is looking for 2019 to be a year to get back on track, so to speak. And so you're kind of looking to increase revenues at a rate higher than trend at over 8% and squeeze expenses below trend, which the trend was 4.72 since 2015 to 2.8%. And then kind of flip the bottom line from a $1.8 million loss due to a $1.8 million excess in revenues. And I note on the revenue side that you're looking for a rate increase that will yield you about 3.1 million. And that all comes on the commercial side. There's no rate increase associated with Medicaid or Medicare. And so the commercial rate increase combined would be 11.3% and your Medicaid increase would be 3.3% and your Medicare increase would be 6%. So is it fair to assume that that 6% increase in Medicare will be associated with the fact that you're an access hospital? Yes, basically the way it works is that they pay us based on a lot of the costs, 101% of a lot of the costs. So certain costs are deducted because they don't recognize those costs and there are certain costs that they can't but ultimately it's based on the cost. So we have areas that when we have low volume we got less money from Medicare because your unit cost drops. Therefore you get less money. So the utilization is down and you can cost and not give more money. So that's why we see that $2 million in reimbursements kind of a fact. There's some other pieces there but not the majority. So the 6% Medicare is a combination of utilization and cost and Medicaid. What's behind your assumption about a 3% increase in Medicaid revenues? We put some 2% increase in that because I think there was some discussion at some point that they may increase that. That was a combination of I believe for utilization and cost. I think that was the raw back in it and we used it as a premiering number and there's other stuff that goes back on. Thank you. I know in a number of instances to mention and then your presentation dimension of travelers. Clearly I can come to learn that travelers are about two X times the cost of having a staff member on board. So I'm looking at the utilization data in the budget presentation and it had travelers for budgeted for 2018 at 10 and for 20, you're running at about a 14-bund rate and then hoping your budget for 2019 to get back to 10 again. But I couldn't find any in the documents any financials associated with that. And in my senses it's probably a big number with your travelers up at that level. So that's my question is that if you're looking for savings out of travelers in 2019 which I think was the presentation but you have the same number of travelers budgeted in 2019 as you had for 2018, I'm looking for the savings. Well, 2018, if you do a budget to budget comparison which is this variance talks about if you look at what we budgeted for 18 for traveler, what we budgeted for 19, I don't think there's an increase. So basically we are seeing more in projected line for travelers than we budgeted. Therefore, we are working at least to get that to the budget. So that's why you won't be able to see since all the comparisons done budget to budget, you won't be able to see that savings according. But the budgeted budget is basically a budget. Basically. Two more quick questions here. You said during your presentation that I think you called in your procedure room or wanting it 100%. So does that mean that you're more upside associated with them? Tom, when you say upside, are you saying that there's no additional capacity that you can use to bring in more revenue? So first of all, I wanted to step back and say that 100% in ORs and procedure rooms, it's more of a percentage in the high 60s, low 70s. And so we don't have our high speed director of the surgical center here. She's out of country. But what we have preliminary starting in a couple of weeks is essentially utilization in that fall park for both our three ORs and one procedure room. And from a person perspective, when you have physicians and other providers, surgeons and other types of specialties that have been practicing for decades one way. In other words, they had the procedure room three days every week for years because there were no other physicians that needed that space. And why I say this is a monumental change is we're changing those habits, not that they're bad habits or behaviors, but we're changing those behaviors to allow a number of the procedures that are currently in the ORs go to the procedure room to open up more space in the surgical center, the three ORs, where those cases need to be. So basically we want the cases at the level that they should be at, either the procedure room or the ORs. And what's happening is we, Joe McLaughlin, Dr. McLaughlin is our hand surgeon. He can do a lot of his cases in the procedure room. It's just as safe. It's the right place to do it. He's willing to do it. And what that does is it opens up space for our new foot and ankle surgeon that didn't have OR type. So everybody that needs a procedure room that needs OR time and the amount of days that they truly need will have it starting in September. You know, give or take, we'll see, we'll assess and make adjustments. But that's, it's a good new story, right, because we're being efficient as possible, but our physicians and our nurses and our other staff really have had to make some changes to how they work each and every day for the betterment of Cochle and our patients. And finally, just to put it one, I know that you initiated a 340B program, but in your budget document, there's no revenue on your income statement associated with that. And so I'm just wondering if maybe, not now, but in some of the way you can just give us. We don't have detailed pharmacy in Cochle. There is a difference between, we just do inpatient, there are hospitals that they have retail pharmacy and they do show some 340B savings that will be under their other revenue. And because- That's $170,000. No, in our case, that's $170,000 a cosset, not the revenue. So revenue stays the same, but you buy the drugs cheaper, therefore that's the savings comes from. But there are hospitals that you probably turn to that they have other revenue in their income and that is related to their retail side of the pharmacy. You won't count as a patient revenue, it will be a other revenue. You're welcome. Reminds me, I have just a little quick thought. Jed Durant, hi, Director of Verde Cycle. In our community, our local FQHC has a 340B, full 340B program. And so the members of our community are able to access those cheaper drugs of the pharmacy through their primary care practices. And we don't have primary care coupling. We've actually looked at the possibility of doing the retail side of the 340B program twice, I think actually in our last five years. And we don't attribute enough volume for any of those members to things if that's something that is viable for us. But fortunately, at least for our community, they're going through the RFQHC to get those savings. So that helps clear that. You agree? I want to talk a little bit about your cost structure relative to your revenue. And really looking, I'm going to start in 2016, 17, and 18. And the concern is in 2016, you exceeded your top line from your forecast by a little over a million, but on the bottom line, you missed by a million. And you were negative 872 in non-operating, I'm sorry, operating revenue. In 2017, you slightly exceeded your top line, but again, missed the bottom line by about 600,000. And now in 2018, you're missing your top line by about 1.6 million, but missing the bottom line by over 2.3 million. So the trend keeps concerned about your balance sheet is weakening, your cash position is weakening. But when you look at your forecast now for 2019, there still seems to be some optimism on the top line to grow off of where you're currently trending at 8.5%. And a real reliance on rate, at an 8% rate increase, to potentially turn around to a million five in operating profit. There seems to be, A, a lot of risk in that. And again, reliance on an 8% rate increase where it seems you really need to look at your entire cost structure and be shifting away from, you know, I know you talked about about 50% of your revenue comes from the orthopedic oncology. What's been going on with the rest of the revenue in the past three years? And you know, where do you see that going forward? Because it's just, you know, it's not sustainable how you're running it now, but I don't think it's also gonna be sustainable to expect to get an 8% rate increase. And I'm also concerned, if I look back at 18 specifically, your budget request when you came in was for over 7%, but I think a 0% rate increase. And it was knocked down to a 5% revenue and a negative 3.5% rate increase. And you're not even getting there, you're at 2.2%. So I'm a little concerned a couple things. One, you're probably, you may be doing yourself a disservice and saying that you need an 8.5% increase on your top line, because I don't know that you're necessarily gonna get that. And again, the reliance on the 8% in rate where it may need to be the cost structure, we need more cost savings.  And it's just, I guess, if you could talk about the financial strength of shifting that. Absolutely. I think what makes it hard, because I think you are kind of a unique hustle of that. I know where you are going with that conversation because you've got areas that perhaps is not going or volume-wise, which primarily uses our fixed cost. Then we have areas that grow in, besides using the fixed cost, also using the variable cost. So, for example, so we have, you know, 25 bed hospitals, so we kind of stack according to them. So we need on the medical side, you know, those are fixed costs. So if you need to travel in order to provide that care and on that side of our service line, we have to accommodate that. So that kind of puts a pressure on the fixed side of the cost that we are struggling. Then we have an area that it's grown and every time we do more or to be surgery, we have to do by more input. Every time we do more oncology, we have to buy drugs. So we are in that it's 50% of our business. It's a unique situation. I absolutely get what you are saying and that's what the challenging part, what the financial outlay look for the hospital outside. And only area, because we did look at possibly, you know, reducing the services, but it's not enough to reduce services that you can really reduce the fixed cost. And if you want to reduce the services that has a variable cost, but that's in people coming for that services because we have backlog for the services that it has a high variable meaning orthopedic. So if we have to choose, let's say cost saving associated maybe reducing the services in some part, then you have to offset that the fixed cost with the rating increase because you don't have the revenue associated that longing for you to happen. So it's that I'm not quite sure if I took away what you're looking for, but that's basically what our challenge is. So we have a combination of service line and for a small hospital especially, then you've got half of your business grows both fixed cost usage as well as the variable cost. It's a pressure on that. That's what you see on this year, for example, our surgery on orthopedic is doing fine, but other parts of the hospital is not doing as well as far as in patients stay. But that cost of incline is not going down, but the fixed cost, it is what it is for the hospital ourselves. So that's a challenge. So I actually really understand what you're saying. And we are trying, unless we do something with our variable side of our business, there's a minimal statin that we have to do in certain parts of our business. We have the MRI tape, regardless of you do eight or nine or 10, you have to have the MRI tape. When you have two nursing obstetrics, regardless of how many babies born there, you have to have two nurses around the clock. So it's complex and I try to make that clear. That's why I said that page looks simple at the same time, very complex. And that's why it makes sense to look at the hospitals case by case, understand the full picture of the service is that we provide. And that's what I'm saying.  I think what happened in the 2018 is that we always use the free year of moving average for utilization. So we, since we've been going up, we try not to exceed the MPR again, so we may have to overshoot that utilization more than we normally do. Second piece was that we had a new position cover more and we projected faster than they could ramp up. And that's one of the reason I can often describe in looking at block time. We have the positions on board, but not necessarily have the block time for those physicians to be able to use our Oana procedure rooms. So that's combination. Then 2019, we are going back to using free year average for our utilization. We also had significant amount of discussion with our director of orthopedic as well as OAAF to make sure that, to validate all of those procedures for different specialties that we have. So we make sure that our 2019 volume as solid as possible. But only see on 2019 that I've already mentioned was perhaps our labor costs, our travel, because we're still budgeting pretty much flat budget from 2018 to 2019, and we still see the pressure that we may need travel, but we are working hard not to use it as more than budget. Okay, Jess. How are you? Good, how are you? So I'll preface all of them about to say with genuinely wanting to see COPD succeed, I really do, and I want you to continue to provide high quality, affordable care to your community. I think you can incredibly engage community and I want you to be financially strong. And I too worry about your case and cash on hand and some of the trends we're seeing. But I really do appreciate all the efforts you're doing and shared decision making and some of the quality initiatives and real things about Medicaid for the welfare model. These are all really great things that are here. Here's my conundrum and I'm sure you're not surprised with my conundrum, so sorry. I'm sure I'm not. Sure you're not, all right, this is our annual dance. That's right. But let's do it. Let's do it. So last year, you would like that wouldn't you? We told you. All right, so last year, you know, if my memory serves that it may not. But you know, to get properly into compliance with NPR and with CON promises that were made, it was about a $3.3 million over which that would have required a 6.8% rate reduction, right? So the board decided actually not to impose a 6.8% rate reduction, but instead to cut that in half and impose a 3.4% rate reduction with the idea that the new leadership team do, you know, come into compliance over two years, cut costs, get expenses under control. And the idea was that let, you know, properly go over in 2018 and then by 2019 be more like coming in under the budget guidance so that over the two-year period we're all in compliance. And in the end, I think as Maureen said, we allowed a 5.6% increase in NPR, which was the highest of any hospital and really still exceeded our target, as I said. And so this year, I was genuinely surprised to see, you know, with our hospital budget guidance of a 2.8%, a 0.4% HRI from investments to see an ask for 5.9% NPR or an 8% commercial HRI. And in terms of, you know, the health performance investments, it was only about 0.1% of that in VR was for health performance investments. A little surprising too, because as I looked at where the hospital service area that you're in, so not properly in particular, but the hospital service area that you're in, a lot of those all pair model metrics actually for that service area were below the targets, more than some of the many other hospitals. So I thought, well, there needs to be more improvement on health reform, and we're not seeing a lot of it with a big ask. And so I fully understand that COVID needs to get a positive margin. And I fully appreciate that, and I agree with that. But I'm not convinced that I want to explore with you other ways to get to that positive margin in light of declining utilization that doesn't necessarily ask commercial ratepayers to pay 8% more. And so the way I look at it is, well, we can look at either increasing revenue or decreasing costs. So if we start thinking about the increasing revenue side, I was surprised that it actually was part of my question that was answered by Tom's question, but I looked through a copy in Springfield where the only two hospitals that don't report any 340D revenue, which surprised me actually, to realize there were only two hospitals because I realized there was a retail pharmacy and I couldn't put it to it. But that's millions of dollars that other hospitals are getting that you're not getting. And I guess I would just, I'm gonna go through my list and you can answer the ones that won't go through my list, but is there an opportunity to explore that retail pharmacy piece again, given that it seems to me that other hospitals are benefiting in order of magnitude of millions of dollars on that 340B side. The other piece that I noticed on the revenue side is most other hospitals seem to have some granting and I looked through and not a lot, actually zero grand income coming in to properly over the past few years. And it's not a lot of money, but some hospitals brought over a million dollars, now it's got me 540, North Country 175, and it is money coming in. To the extent that it offsets commercial rate increases would be really helpful. So on the revenue side, I'm thinking more grants than what is the possibility of 340B? When we go to the expense side, we've been talking about expenses for a while, but I do appreciate the cost reductions that your team has undertaken in the past year or so. But I still look at some things that were red flags to me. So for example, your cost per adjusted admission is the highest of any hospital presenting today. But so it's 13,900, Giffords is 10,000, North Country is 10,000, so Northeast is 12,700. So still significantly high cost per adjusted admission. Your FTE per adjusted occupied bed is 10, the state average is six. So I'm thinking about labor. Is that a reasonable FTE count when the rest of the state seems to be managing it at six and you're at 10? So is that, I don't know, but is that a place where there could be some movement? Your utilization is falling, your project of fewer admission, the shorter length of stay, fewer OR visits, yet we're seeing these supply costs and these drug costs that are really high and these increases are higher than we're seeing from other hospitals. So I'm wondering, are there opportunities here for supply chain management improvements or getting into some consortium of buying, affiliate, associating with some other buying groups, things with purchasing groups? Because those increases also seem high. And then the last one that really struck me was remarketing budget. So your marketing budget is about $437,000. To put that into perspective, I'm gonna try to look at other hospitals. Quarter allocated 36,000, North East allocated 55,000, North Country is 132, Bralboro 75,000 and different is zero. So your marketing budget is extremely high relative to other hospitals put in your size. So that seems to me another place to be looking. So I guess my overall question is, what can you do on the revenue side with this respect for the two things that I mentioned? And then can you help me understand why the cost for adjusted admission is so high, the FTE for adjusted bed is high, your drug costs are rising while utilization is falling and why your marketing budget seems out of line with other hospitals when you are pure good at it. A lot of questions I have. I figured I'd throw them all out at you and. So on the revenue side, just a brief thing. First of all, they may have millions of dollars in the revenue on the post-crucifolding deed, but if you go down that road if there is a possibility, you would have a cost associated with that as well. So that revenue line that you see is not net of cost. So just two for that. Second thing is that we do have grants, but it comes through a company assistance the parent organization normally probably runs around $5,200,000 range. The problem with grants is that you have a revenue associated grant. You also have the expense going along with that grant. You get grant, but you have to spend that dollar for the grant purposes. So as far as the bottom line with that post will be zero because you show as a revenue, let's say $50,000, and what you are gonna spend that grant will be a $50,000. So, so I, so. What if it offsets some other expenditures elsewhere that would have shown? If the grant potentially offsets something else, but most likely most of the grant is for new initiatives that you have to have, or the donors that sometimes restrict for certain things. So not for routine operations. So if you have a routine operation that's supported by grant, of course you get more revenue, but most of the grants we have for specific purpose, emergency preparedness grant, to call improvement plan, different things that there's a cost associated. So there's a net impact in that offering margin pretty much non-existent. So that's on the revenue side. On the cost per justification and FTEs, I wish for a small household that was adjusted for the serviceness, because if my services that I've been providing talking primarily about medical cases, we probably won't have the compensation that I have in today, as far as cost per person mission. We probably won't have a compensation by the FTEs because the complexity of care, they can get out there, surgery, after therapist, you know, you have to have a certain level of notice of different kind of specialty. So by not adjusting for, as I said, the big hospital may not be important, but the small hospital, not adjusted for that kind of severe service makes discrepancy amongst small hospitals, makes a big difference on those calculations. So if I'm adding the cost of the oncology to cost for just admission, and if I didn't have oncology programs, trust me, then those costs won't be there. If I didn't have orthopedic service, we won't have any kind of cost associated for that calculation. So that's why it's important to dive down by service by some of those metrics especially this small hospital because there's just wide range of types of services makes a big difference in those calculations. Marketing? Validation. Marketing? I don't know. Marketing, I thought. Well, that's certainly not me, but I'm gonna follow the guidance that I gave to my staff. I don't necessarily know the answer to that question because I can't compare us to the other hospitals and the costs of what they are doing versus what they're not. So I'll have to get back to you on that to talk to my marketing focus. Okay, one other actual question about that. I noticed that one of the expense lines is four to seven percent inflationary adjustment for health insurance for your employees. And so I'm assuming are you self-insured? Yes. So has there been any consideration of talking to your carrier or your TPA about attributing those lives to one care and getting under a self-insured attribution through your carrier? We have Don at this point in the time. Thank you. So a couple quick questions. First was for Adam and Don. You talked about 107 days for the first appointment on cardiology. Yet one of our travel board meetings heard from another hospital that in addition to experiencing wait times for mental health related issues, they've also experienced wait times in referring patients to tertiary hospitals on cardio. Have you experienced that same thing at Copwood? Yeah, it's hard to get into C specialists almost everywhere in Vermont and cardiology is no exception.  But I think this is what you're seeing as a reflection of the increasing complexity of medicines back 20 years ago when I was in primary care. I could take care of a lot of these problems by myself. I didn't need the cardiologist. Now I'm taking care of diseases and treatments and the primary care doctors have much less familiarity with them. So it's a combination of the increased complexity of care procedures that were never invented before like period valve replacement without open heart surgery. And of course the demographic shift as well. And there's a few, I work with a cardiology fellows at UVM. None of them are interested in rural cardiology. So it's a combination of factors that's I think putting pressure on all hospitals both within the university and outside the university. So Adam, what I really was trying to get to is when the patient really needs to be sent to that tertiary hospital, are you experiencing any problem with getting them there then? Right, well cardiology is usually an emergency. So they get in the door, something like an ENT evaluation that could potentially wait for weeks or months is sitting with cardiology is a little bit different. We get them in the door because it's an emergency. Okay, great. Okay, I'll just ask one more because I see we're really way behind on time. But our last year there was some discussion about moving lab from the hospital to the FQAC. Did you proceed with that plan? Actually that did not happen. That was a repetitive plan and I can't really speak to the FQAC side on their building, their new building and what they were planning to do. But I can tell you this, we've already met with their interim leadership and what we're looking to do, I'm not sure how they're exactly gonna move forward but one thing that we're trying to do which I think both sides are excited about is we are planning to send a phlebotomist over across the street to do the phlebotomy work over there so patients aren't having to cross the street. Now to you and me, that 50 yards is nothing but to a lot of our patients, that's a big deal. And so it's a small thing, we're already doing the work but why not bring the work to where it actually needs to be. So that's all I can tell you right now. Okay, Pat. Thank you. The board has addressed most of my financial questions but I do have one observation. On your slide six, where you highlight performance on quality measures, I just wanna point out that a higher number is better for the number for 10,000 population accessing medication assisted treatment. We're really looking to get people into treatment. So your county actually exceeds both the 8 p.m. target and the statewide green. So I just want to point that out. Thank you. Thank you, Pat. This time we turn it over to Julia and Eric from healthcare advocates. Hi, I think it's Julia Shaw for the Office of the Healthcare Advocate, which is part of the Mont Blay. So our office advocates for reminders of healthcare policies and also we serve reminders who have issues accessing healthcare. So we hear about really from people who can't afford care to be. And we're wondering if you agree that healthcare is a major challenge for healthcare. Oh, did you say affordable? Yeah, we're working here on healthcare as a major challenge for reminders of healthcare. I think it's a challenge throughout the country. And it's something that we've been talking about for years. So absolutely, we feel it's a challenge. I think if you look at our mission, that's one thing that we're proud of is the fact that we care for everybody regardless of their ability to pack.  And that's something that we're glad that we can do. So whenever you can describe some of the affordability challenges, there's five patients. Do we speak to them? Sure. I see it every day and a lot of it has to do with pharmacy costs and when you choose a drug, you have to take the patient's insurance account, which is frankly awkward. Patients who have the bronze plan, oftentimes they'll want to lump all their expenses into one calendar a year and includes planning for elective surgeries so they're all clumped into one year. We, for example, the medical director of cardiac rehab, we found out that having every cardiac rehab patient go to the financial office. We cut their co-pays in half because many of them qualify for free or reduced care. So I think it takes a lot of time. It's a very awkward discussion sometimes because you just want to give the right care to the patient. But we do have the good resources available to us to try to get the best of the situation. But if you sit in my office for an afternoon, you'll deal with most cost conversations that are coming up all the time. And I don't have a great solution here. We work with the system that we have. We do the best we can. Thank you. So hospital is often qualified for care as something that's provided for patients who can't pay them. And I thought that as qualified as whether that's not qualified for patients who could they pay but choose not to. And what if you agree with that characterization? I just want to do this one.  Some people, you know, pay our employees and some people will be able to pay and really empower people. And they really want to pay their bills. But we encourage them to, because at the end of the day, I prefer my staff and bill them to not to chase the dollars that people cannot really afford to pay and go after the people that have good potential to pay their bills. So we encourage people really to look at our financial system policy and meet the financial counselor meeting the office and people that willing to do that. And we have across the hospitals that we probably have one of the generous, you know, some around people up to 400% of the federal poverty income guideline. They could get some sort of reduced payment. I mean, discount from us, so it depends on the people. So, but we, but people they don't pay, we do follow it, we do a credit before it, we have to collect on them. So, so we go as far as we could, because Medicaid also wants us to do that because they don't want to sit in the money to be left on the table. So that's part of the requirement, we have to do it to diligence to collect. Have you assessed the mother's ability to pay one setting their prices for a different way? I think we, as I said in my presentation, about co-oply, it's when you look at price setting, when you look at top line, go to the combination of revenue and the price. We have to look at the cost structure. So if you look at our margin, so we are putting in the revenue. And if you, even if you have pricing which is almost 8% as mentioned, we have to put in the context that we had 11% plus reduction last three years. So we really have reduced our rate over 3% last five years. So we've done our piece because that 11% reduction counted for $5 million that went from co-oply to the system as a discount. So we did as much as we could. Our balance sheet doesn't show it. Of course it did not hurt in process taking those deductions, but we did our piece to give back to the rate payers directly by reducing our rates in the previous years and combining the increase that's coming up, we still will be on the negative side compared to the state average. When the board gives you a free commercial rate in your budget order, do you see that as a ceiling or as a stat rate that you'll apply? The rate that you get increased is not necessarily the amount you're gonna collect. So basically that rate goes in there and also MPR is not just the rate how much you're gonna collect because we also have a huge risk making sure those patients come through the door. At the end of the day utilization is a big piece as well. So this year the utilization is down and then we also have a certain year of price reduction that we gave back. So we gave back the, basically rate is more certain than the utilization. So last three years we had a certain rate reduction in the hope that we have utilization and we don't have that. So next year we have a little bit less utilization but the rate increase overall is still the reduction. So when you, so say the board approved the 7.9 that you asked, do you at that point then negotiate with the private insurance companies or do you just apply that rate and expect that insurance will do that? I'm sorry, didn't hear the end of that. I expect that the insurers will pay that, thanks. Insurance not necessarily pay that rate because we just apply for our prices. Right, so you're gonna apply that. So we get a price. When we do negotiate like pay it we are negotiating a discount from our charges. So we are not like getting up to have a fixed payment method. So most of our, so we apply that rate across our business and then they sign an insurance company or the discount rate is that discount applies to that. So that's why 7.9% price which would translate some of our 5.9% ampere because you lose some of that increase along the discount that you get by two payers. So you've heard from a few people in your community that Copley has, I've been out a lot of providers to provide MAT or not encourage providers to provide MAT. Is there any, I'm wondering if that's an accurate characterization and you can just describe your, that might be it. So let me just make sure that I'm clear that on what you're asking. So you're saying that a couple community members in the Morel County said that we would not allow providers to become MAT providers. Right. But that's absolutely not true. I actually will tell you against a number of staff recommending otherwise, I was truly considering a specialty provider, non-primary care provider, to become an MAT certified and provide that care in our building because I believe it works and I was willing to do that and then that provider decided to go private as a provider. I'm wondering if you can talk about what hard reductions services are available in your community to minimize risk for people who are actively in the first range of the channel. We are currently working with the state regulations around pharmacy and our licensure for American distribution from our emergency department and working with our providers to see if we can provide that service, how we look and how we would educate the patients and kind of discharge to ensure safe usage and give it out to the community. We partnered with community programs to support people exchange in our community and are working to bring that service in as well and our drop-ups that we are putting in and ready to be wearable to have implementation on that this fall is coming as well. Oh, so I just have one final question. Sorry, did you want to say that as well? I did, but I can talk to you more. No, go ahead. I'm fine. You saw it on my face. In addition to those things that Dory just talked about, Don Ducuy, one of his roles has been to work collaboratively with primary care, Sheriff McCoo, they meet on a regular basis to talk about ways that we can better combat what you're talking about. But another thing that I think is very worthy of discussion or is to let you know is we have done a training program for de-escalation, which you're gonna often deal with, right, with mental health patients, with patients coming in on certain types of drugs. We send 10 people to Burlington to get that, to become certified for that de-escalation training, which they are bringing back. And we're looking to try to get everybody trained by the end of this year. I may have made that too lofty of a goal, but basically we have 10 people geographically throughout the hospital that are gonna train their folks. So everybody at Cobley is trained in how to help people not harm themselves. I just have one final question that's kind of a clarifying question. So you responded to the first and answered the one addressable one of these questions, but my understanding was that your FTs are adjusted by having increased over the past year, so it's, and you responded by, it's due to your service points. So has your service points changed over those years and that's caused the increase? Yeah, definitely, I think that part of it, I think that the patient stays down, he doesn't make the cases that he thought he could, than he assumes, and there's different level of, currently, from our clinicians, as soon around me, so when we go through the budget process, we stress on FTs and I, you know, they're noticing the types of, when you have that, when you're able to get surgery in oral, you probably need a radiology tech in the room so you, so there's a lot of pieces there that it's very complex, that above my level of thinking, I know not to be dangerous, but there's a lot more staffing needs to change it with that kind of services, with purely just medical cases on the low Q. So that's why two points on those metrics should be service links adjusted, should be QD adjusted, should be adjusted by, you know, sizes of the hospital, I mean, all of that stuff matters, and it's following you on it. And I have a lot of questions. Thank you. Thank you very much. This will open up to the public for any comments or questions. Hamilton, chairman, this is sort of a question and a comment. And my name is Hamilton Davis. Oh, thank you. The, in slide five, they're talking about quality measures and they talk about the National Surgical Quality and Puget Program, and it seems that both doctors, we and students are very interested in that. So my question is this. In the all payer, in the one care quality measures, they look at re-admission to the hospital, but in Vermont, which has two head, two tertiary centers, but then 12 smaller hospitals, the, it seems to me that one of the most important quality measures is not re-admission to the hospital, but revision surgery, that is to say, surgery fails in one place and they go to another place to get it fixed, okay? And my question is, and this is not any kind of a knock on, this is not any kind of a knock on Mansfield Orthopedics, it's one of, I've got anecdotal information about all kinds of places, but not none from there, so. But I'm very curious whether, A, doctors to Puy and Cunin agree that that is an important issue. Number one, number two, do they think they can do it and do they think it should be done across the state? So I guess the answer to the first part is that, yeah, absolutely, a return to the operator is important really no matter what hospital it's happening in, and yeah, that is absolutely tracked as well, so that doesn't escape us. As to whether a particular type of revision surgery is done by a particular surgeon or practice, that's really made as an ad hoc basis and it's highly dependent on the specific doctor. And I don't want to speak to the orthopedists that can speak themselves, but I do a great deal of hernias and I have a lot of experience with revision hernias, so it would be unusual for me to refer what I would consider a standard revision to someone else because they're in perfectly good hands at the company. That's not my question. Okay. My question is this, let's say that a person has a hip replacement at a community hospital, the surgery fails. The likelihood is, the likelihood is in my experience that that person is not gonna get a redo of the surgery in that hospital, that person's go to another hospital almost certainly, not definitely, almost certainly an academic medical center and not only that, they can switch between academic medical centers. I've seen that too. You get something failed at UVM, goes to Dartmouth, fails at Dartmouth, goes to UVM. So my question is, that seems to me a huge quality marker in our system and I don't think we're planning to collect it at this point. So my question for you and Adam is, do you think it ought to be kind of collected? I believe it is collected. As a matter of fact, I'm quite sure of it. What's that? Yes, it's collected. It is collected. Yes, sir. Somebody's gotta tell one care about that because they haven't heard it. I'd also like to address that question. I'm sorry, sir, but can you join me? John, I see. Thank you. You're at your work, Peters. We do a lot of revision surgery at Coblin Hospital. We do a lot of revision joint replacement surgery and it's actually the opposite of what you speak of. We take care of our own revisions. We take care of revision surgery from all around the state. Burlington and Dartmouth folks come to us for revision surgery. Well, if you heard my caveat, I said what I was speaking about had nothing to do with Mansfield North of Peters. I understand that. What I'm talking about is other community hospitals. I mean, if you think that that kind of revision surgery isn't going on a lot, then you'll make a mistake. It is going on. We are seeing it and I would agree with you. So all I'm saying is it should be collected. I think we are.  But that's my question. You're doing revision surgery, you're one of the sources and I don't doubt that. All I'm saying is that if you've got somebody doing in some hospital that's getting a lot of revision surgeries and have to be redone, okay, that's a quality problem. Do you disagree with that? No, I agree with you. And that's why we track it. Okay, any other public comments and questions? Dale. I think it's just a clarification question. I did not hear them mention having workforce issues, which I thought was kind of curious. Do you have recruitment issues versus high tech and recruitment in general because your deal was some really very specialist type recruitment. Great question and your point at the end about specialist is spot on. I did have it on my slide, but I didn't go over it too much primarily because I've discussed this with the board many times. But I'll tell you, hospitals are very dynamic organizations in many ways. And I've always said in one way is because if you look at all of our workforce and the various specialties, a majority of them are highly trained, highly educated, highly skilled, and we call for a fairly high salary because of that. And that's going to continue to be a challenge. And we're doing pretty well at COMPLY as far as recruitment and retention, but it's something that we talk about every other week at a meeting that we have scheduled. And because it's that important without good people, any organization is dead in the water, in my opinion. Okay, other questions or comments from Paula? I see one person with their hand kind of up, but this gentleman has his hand all the way up, so go ahead, sir. My name is Carl Schlehetka. This is just a housekeeping issue. I didn't get the last name. Schlehetka. Can you spell it? I can, it's S-Z-L-A-C-H-E-T-K-A. Thank you. This is more of a housekeeping issue. It's very, very difficult to hear some of your folks, particularly the healthcare advocate, so that for future hearings, I would ask that she actually speak directly into the microphone because we couldn't hear a word she said back here. And then some of your board members also, if they could just more directly speak into the microphone, it would be very helpful to the public out here. Thank you for that feedback. Try to make sure that everybody gets close to the microphone, but we're all going to do it at any time. So anyone else? If not, my apologies to the people from North Country. We are already past the time that we were supposed to start on their hearing, but we are going to take a 20 minute break for lunch. So thank you, team Copley. Thank you, sir. Thank you. We'll start again in 20 minutes.