 So welcome back, it's 1.30. For those of you who don't know me, my name is Jessica Holmes and I'm serving as the interim board chair for the Green Mountain Care Board. So a warm welcome to the whole Brattleboro team there. I see you're all in your conference room, that's great. We know there've been a lot of changes at Brattleboro over the last few months. So we look forward to meeting everybody. And it might be helpful as we, as you all start if you could introduce yourselves to the board and the staff, it'll also help our court reporter with names. And so I'm gonna kick it over to all of you now for your presentation. Knowing that we have a tight schedule this afternoon, I'm gonna hold all of the board and staff questions until the end of the presentation and you, Brattleboro team, you have until about 2.45 for your presentation. So Ross, could you please square in the Brattleboro witnesses who are going to be speaking today and presenting? Of course, happy to. If everyone can hear me from the Brattleboro team, if you could identify who is going to be speaking this afternoon. Certainly. I'm Rhonda Calhoun. I'm chair of the board. And who will also be here with me today is Chief Financial Officer Jennifer Griffey and Andre Bissene, our controller Laura Bruno, Chief Medical Officer Kathleen McGraw, Chief Operating Officer and Chief Nursing Officer Jody Stack, Director of Development and Marketing Gina Patterson and our President and Chief Executive Officer Christority. All right, terrific. Excuse me, please. May I ask request one more time for those names a little slower, please? Of course. So I'm the chair of the board. My name is Rhonda Calhoun. Chief Financial Officers are Jennifer Griffey and Andre Bissene, our controller, Ms. Laura Bruno, Chief Medical Officer is Dr. Kathleen McGraw, Chief Operating Officer and Chief Nursing Officer Jody Stack, Director of Development and Marketing Gina Patterson and our new president and Chief Executive Officer Christority. Thank you. Thank you. And I think the first time everybody speaks, if you could identify yourself by name too, that would be very helpful for us and for the court reporter. Absolutely. Are you ready for us to begin? I'm ready to swear you in. If everybody could, who will be speaking, raise your right hand. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth so I'll help you, God. I do. Great, thanks very much. I will turn it back to you, Chair Holmes who are over to the Brattleboro team. Yeah, great. I think I'll just turn it right over to the Brattleboro team. So whoever's kicking us off and if you could share your slides with us, that would be fantastic. Thank you. Thank you very much. My name is Rhonda Calhoun. Again, I'm the chair of the board of directors. I've been chair and I've been on the board of directors for the last five years but have been involved with Brattleboro Memorial Hospital since 2012. So 10 years of volunteer service and also serving on various committees as well. So I have definitely seen this hospital at its best and definitely during some of its struggles. The challenges of the past two and a half years have definitely put our hospital as well as probably every other hospital in the United States in a very, very difficult time with our shutdowns of operating rooms and routine care, the inflation, the cost of medicine, the cost of medical equipment, the cost of staffing has just overwhelmed us all tremendously. We're very concerned about Brattleboro Memorial Hospital. No entity can withstand millions and millions of dollars of losses and we're hoping that there will be reasonableness in discussions with regard to our budget. There are definitely opportunities for a turnaround. We're starting, as you know, very well. We had to shut down in the beginning for several months, tried to start getting back up. We were doing well and then again, we had to shut down again for another period of time which has certainly crimped our, any opportunities we had at that point. Our hospital is very vital to this community. We sit at the gateway to the state of Vermont. We serve as an excellent healthcare medical facility. We're a wonderful community partner with programs and outreach to all of our populations within our local community and we're a major employer. This budget has been developed with the input of pretty much every single stakeholder possible. Every department has had a say in this budget. Even medical staff, physicians, our doctor groups, everyone has played a part in developing this budget which is a very responsible budget. And as I said, the input was gathered from everyone. So at that, I will just lead you off that my leadership team, our leadership team, dedicated and committed people that are behind me today and who are in every department in this hospital, they're gonna present the details of this budget, where we are today, which is very important as to where we're gonna be going and what we intend to do about our future. So I thank you for listening. You can go one more, Laura, please. Good afternoon, I'm Chris Stardy. I am the new president and CEO here and I'd like to thank Rhonda for her comments and I'd also like to thank you for your incredible leadership through these turbulent times. We really appreciate it. I have had the immense pleasure of being the president and CEO of Rattleboro Memorial Hospital for all of three months now. Even in that short time, I've been able to comprehend how vital a role this health system plays for this community. I remember my first images of Vermont were of the gorgeous trees that surround us here. And it's very fitting that the BMH logo is a tree. As I've pondered the tree as our logo, I found that there is a very deep meaning of this logo. I see BMH as very much like a tree. I draw the correlation based on a book which was a bestseller called The Hidden Life of Trees. I offer just a few of the similarities between BMH and trees. First, trees serve as our planet's lungs. They give off life-giving oxygen. Similarly, BMH serves as the lungs of our community here in Brattleboro. We strive to be the hub of hope and healing for the entire community. I believe the COVID pandemic and the role of BHF, the BMH is a perfect example of being the lungs for this community. In the book, we find that trees can sense danger and learn and adapt. Right now, BMH is sensing danger as we were in a very fragile position due to a lot of complex issues. You're gonna hear more about it, the very high inflation that we're facing, workforce shortages, et cetera, and the talented team here will talk about those things. I'd like to take just a moment to give a very real-life example of the challenges of mental health and workplace violence and how they converge here in a place like BMH. This morning, this Monday morning, a gentleman was released from prison. Historically, this gentleman has called 911, has been brought to our ED and carried out assaults 10 times, including throwing a coffee mug at one of our employees and punching a nurse in our ED in the face. This gentleman is not allowed to go to the homeless shelter. They have gotten a no trespass against him. He knows that if he calls 911, he will be brought here and we will have to assess his medical needs. We have, in fact, put him on a safety plan so that when he shows up and he will, we assess him in the parking lot. This takes multiple staff members out of our ED for a very extensive period of time, every time he comes in and we have no idea when he's going to come in. We are sensing danger in our financial performance since we have done everything we can to develop a responsible, reasonable budget. Finally, we learned that trees help one another. Likewise, BMH exists for that sole purpose of serving the wonderful community in which we reside. We seek approval of a reasonable, responsible budget so that we can serve and hopefully prevent any further degradation of service levels and access to essential services. I'm very fond of a quote from Winston Churchill. He once said, "'To improve is to change, to be perfect is to change often." We do not sit here before you professing perfection, not in the very least. We do want to emphasize how committed to constantly improving we are and how much we embrace the need for constant change in healthcare. Unfortunately, not all change leads to improvement in every area. The tough environment that we are in has created change as has had some negative impact on our service levels and access to our services as our capacity becomes more and more constrained. We seek to stop any further degradation and truly become the hub of hope, health and healing for our entire community. Gonna turn it over to Dr. McGraw, our Chief Medical Officer to talk about that hub of hope, health and healing. Thank you, Chris. I wanna give a little details about the way in which we are a hub of hope, health and healing. And to start with really is looking at what our community impact is. BMAH is an essential part of the fabric of this community. We identify the needs and bring in the needed resources to address issues to allow for hope, health and healing. We recognize the importance of getting ahead of these issues as well to provide actual impact on change and not just crisis response. And each of these changes we also recognize brings financial responsibility to the hospital. So some of the ways that we have had health and healing more recently in our organization includes things such as the dental program. We noted on several of our community health needs assessment that dental need was high and referral options for those patients was slim to none. So we partnered with the United Way of Wyndham County and we now have a fully functional dental clinic. We recognize that births were trending down in not just our local community but the region and the state as a whole. And that Springfield was financially stressed and closing their birthing center. And so we invested and brought births to BMAH keeping the numbers up for patient safety, patient, our clinician skill as well as convenience for those patients. We also invested in prenatal care up at Springfield for patients convenience and brought in Dartmouth Hitchcock providers to assist in the support for neonatal nursery coverage. With respect to mental health which we know as an ongoing issue in Vermont more so than in some other places we've worked together with our local organizations such as Groundworks Collective which is the local homeless services organization, HCRS which is our designated agency for mental health and the Brattle World Retreat. And between the four of us we've been working to eliminate barriers to both medical and mental health care for folks who are experiencing homelessness or insecurity for their housing and also have simultaneously a mental health diagnosis which we know is really a recipe for a very, very difficult situation for them. And I would say that the work that we're doing with that is really groundbreaking. We are a major employer in our community. We take this responsibility very seriously. We've been here since 1904 as a hub and recognize that every position we have is important to those in our community. And so we evaluate every expanded position with that gravity to ensure stability for the long-term health of our community. We recognize the pay and the benefits that we bring to this community provide the baseline for our community's wellbeing. And in addition, we have strong educational relationships and affiliations and Jody Stack, our Chief Nursing Officer, Chief Operating Officer will speak a little bit more specifically about some of those programs. But I want to say that we are a resource for careers, internships, education and clinical experiences for folks. And we see that not just as a benefit for ourselves as a way of creating future employees, but also as a hub of education resources for our community because it really helps ensure their future. We are committed to the quadruple aim of improved population health, reduced cost, improved patient experience and improved provider experience. And our work with value-based care plans and OneCare Vermont and our investments in population health really align with that. And among other things, gives us great data to use for ongoing quality improvements. And we have had substantial investments in quality to ensure that our health and handling can continue. And so the other key about this is ensuring access. So the access to care, as I know Jessica Holmes will certainly agree is really the key. And one of those keys is having it be local enough that people can actually get to it. And so this is why for the past 10 years, we have transitioned to a largely employed medical group model. And we have had a whole community of clinicians who have been here for really decades who have come to retirement age and stepped away from medical care. And we have had to put together an employed medical group to ensure that we have ongoing access for our community. And at this point, most of primary care is actually, not all, but most of primary care is through VMH as a result. We also have telehealth, another reason, another important part of ensuring access. Telastrope, telasyte, tel-ICU and more. And it lets us provide what a small community hospital has barriers to otherwise providing in a cost-effective manner. We have local oncology and orthopedics so that those who are least able to travel, elders and those in pain, don't actually have to travel. And we have wound care in partnership with Helogix and HIV care in partnership with UVMMC because we recognize that there were no comprehensive services for miles in any direction in for those communities. We also created a post-acute care program to ensure that there was continuity of care for our patients who are entering the hospital and leaving to go to some skilled nursing facilities in the area. It's helped with our throughput ability, but as you've heard already today, and I'm sure we'll continue to hear over the next few weeks that the throughput ability within our hospitals is quite difficult. But this post-acute care team has also been able to provide attention to care to ensure that we can have successfully decreased readmissions for those patients who have been discharged. And then lastly, I want to remark that our strategic partnership with Dartmouth Health has been really essential for achieving all of this. It means that every time that we see a need, we look at it from a regional perspective, think about how to more broadly leverage resources in the region to get patients what they need. And this has meant many collaborations with Dartmouth Health. Our ED clinicians are cardiologists and many more. We're a hub for hope health inhaling, but that can't be without the resources necessary to ensure that. Vermont communities depend on us hospitals to manage issues that don't have other solutions. And so we have continually leveraged our relationships to provide a community with what it needs. But we've stretched every dollar to make opportunities for our meeting our patients needs. And we continually work as partners with others and look forward to working with the state as a partner as well in order for us to have the resources we need to do this work. Good afternoon. My name is Laura Burnone. I'm the controller at BMH. We will begin the financial section of our presentation with a walk through our financial projection for the remainder of fiscal 22. We enter these hearings in a difficult financial position with our projected operating margin estimated at a loss of $3.5 million. As of May 22, we have reported a cumulative operating loss of $2.3 million or a negative 3.5% margin for projecting a $3.5 million operating loss for the full fiscal year FY22. There are two key drivers of the operating loss that we're projecting. The first is the inflationary impact. Contract labor expenses, which include the impact of traveling and contracted nursing staff have exceeded our budget by $3.8 million from a budget in FY22 of $200,000 to actuals now approaching $4 million on that line alone. Pharmacy and drug expenses are another area where we've seen expenses increase dramatically and we're projecting a $930,000 overspend versus budget FY22. This is partly volume-based but also due to new drugs coming online such as some of the specialty oncology drugs that have not yet transitioned onto the 340B program pricing. The second main area of impact is service access. As Dr. McGraw had mentioned, we partner with Dartmouth Health and Cheshire Medical Center on critical areas where we need to provide access to our patient face but do not have our own providers. In expanding access to our community on these services, we have overspent on this line by $584,000. This next slide is a visual chart of our performance through year-to-date May 22. As you can see, our first quarter was relatively strong with above-the-line operating gains reported. That was followed by a sharp decline in performance due to the surge in the Omicron variant which led to BMH discontinuing all elective procedures for a period of time during the months of January and February. Since that low point, we've been working towards establishing positive operating margins while facing significant headwinds from inflationary pressures and service access concerns as outlined on the previous slide. One of the most significant pressures we are facing financially is our cash position and usage of reserves. This chart shows a significant decline in our cash reserve between the start of our fiscal year in October 21 through June 22. Our cash reserves declined by $3.7 million over this relatively short period of time due to the fact that we have needed to fund critical operational projects with cash. Our days cash on hand have also significantly declined from 206 to 138 days over this period. Here's the breakdown of our requested fee increase. Overall, we are requesting a 14.9% increase to gross charges which breaks down as a 1% fee increase for the medical group, pharmacy and supplies and a 20% increase for hospital areas. When translated to net patient revenue and fixed perspective payments, this fee increase nets down to a blended 13.3%. We modeled the fee increase request which produces a modest $727,000 operating gain for the year and a 0.67% operating margin. It is worth noting that this operating margin we are proposing is very close to our proposal from last year which was a $669,000 operating gain and a 0.69% operating margin. As part of our budget request for FY23, we are planning for volume increases to particular segments of the hospital. We will see increased volumes in our inpatient services overall. We will also see increases in our hospital outpatient areas specifically within pharmacy, OR and chargeable supplies. One area where we are anticipating decreased volumes is in births and all other areas should remain relatively flat to the FY22 budget. Inflation will have a quantifiable effect on our FY23 budget and financial performance. In FY22, we put in place $2.2 million in wage increases at BMH which will carry over and continue to be in effect for FY23. Given labor market pressures, we're planning to enact a similar sized additive wage increase in FY23 estimated at $1.6 million. We're working to reduce our reliance on contract temp labor and have budgeted a reduction in that line from actuals at $4 million in FY22 to $3 million for FY23. We expect to still need a significant investment in this area given the continuing labor pressures. Contract medical specialists will be up by $52,000 for FY23. We've estimated our fuel increase and exposure at $700,000 for FY23. And the healthcare provider tax rate which on a rate basis has remained at 6% for BMH but with our volume increase, our tax bill will actually increase on a dollar basis by $860,000. So the total inflationary impact has been estimated at $8.2 million for the year. This next slide is a year over year income statement. I'd like to draw your attention to a few key lines. First, as mentioned on the previous slide, the wages will increase budget to budget by $2.2 million. Contract temps will increase budget to budget by $2.8 million. Drugs and other supplies which are volume driven expenses will increase our expenses by $3 million when they're combined year over year. And the healthcare provider tax burden will increase by 860,000 pounds. This next slide is the budget balance sheet. I'd like to focus on a few critical lines here. First, we're expecting a cash decline of 18.7%. We're $1.2 million year over year. Total board designated assets is decreasing from $38 million to $32 million year over year due in part to negative performance in our overall investment portfolio. But this decline can also be attributed to the fact that we have had to pull $3 million for the continued Ron Reed Pavilion project. The $32 million is also a conservative estimate for FY23 as we have since had to pull an additional $2 million out of short-term investments in the month of July to fund critical operating expenses. The land buildings and improvements and major movable equipment lines have increased due to the CON construction project and build. As for the capital budget, over the past several years in our capital budgeting process, we've endeavored to keep our non-CON capital spend within a band of about $2.5 to $3 million. This year we're proposing $3 million for critical projects. Our spend will fall within the following categories, patient care equipment replacements, diagnostic department equipment, plant services and IS projects and infrastructure upgrades. The CON project to construct the Ron Reed Pavilion is progressing well. We're happy to report. We have completed phase one of the project which is the boiler plant upgrade. We expect to occupy the new building in mid-September which will mark the completion of phase two. At that point, the renovation phase of the project for the third phase on the existing space will begin. Given our unsustainable current financial state and the continued pressures we experienced as a hospital, we have committed to a series of savings initiatives to begin now in fiscal 22 and to continue throughout fiscal 23. We're enacting a series of enhancements and optimizations to our revenue cycle procedures that will improve our AR and net patient revenue. We've targeted certain areas of non-essential spend that we can reduce or eliminate. We've met and decided on certain capital projects to eliminate or carry over from FY22. We're enacting plans for position control and organizational design with a focus on productivity goals and staffing optimization. We're also conducting a review and rationalization of all existing contracts to determine whether they are necessary, discontinuing any unnecessary spend. We have begun to put these savings initiatives into action already at this point in FY22 and we'll continue the rollout of our action plans into FY23. Gonna hand it over to Jody. Good afternoon, I'm Jody Stack, Chief Operating Officer, Chief Nursing Officer. So when we presented in 2021, we were just starting to feel the impacts of what's being called the bid quit or the great resignation. This is a national trend not limited to healthcare, but we're certainly feeling the impacts here in healthcare. COVID-19 is being framed as a life quake experience and this is twofold for healthcare workers. Healthcare workers are caring for patients at hospitals and ambulatory care settings and they're also dealing with COVID at home, with family members, children who are displaced from childcare and the same social isolation that others are feeling. There's also generational differences and lack of pipelines that contribute to workforce challenges. All of this started to trickle in the spring and summer of 2021. After a year of having no contact temps for nursing, we brought that contact temps in July of 2021. That trickle started to create a staffing problem that was compounded with hospital capacity issues. So hospitals in the region were surging with COVID and non-COVID patients. Beds are being closed or taken offline, largely due to the nursing shortage. We found ourselves in a position where we are unable to transfer patients to higher acuity, so both for medical and psychiatric care and for lower acuity. So patients who had been admitted inpatient that need to go home with health services or to a skilled facility. Once you find a bed in either a higher or lower acuity setting, transportation becomes a challenge, specifically with critical care. And we have our inpatient beds full and boarding in the emergency department. So that staffing challenge, that started as a trickle after a year of making some huge strides, combined with the capacity being limited, combined with multiple surges and bumps in COVID, created some really adverse conditions for our staff. This led to rapid turnover. So the numbers that you see below are a quick snapshot. We have almost 700 employees. You see a slow growth rate over the past year. This is from October 1st, 2021, with a turnover rate cumulative of 22.3%. If you looked at this turnover rate, it has slowed in the last couple months. We've implemented a lot of things. We continue to push forward with some of our initiatives, but we're still feeling the impacts from 2021 in this high turnover. And as you've heard and as you're aware, the cost of turnover is really high. The next slide, if you want to put through, is one indicator of that. So what you're looking at is our contract labor spend year over year. If you look at fiscal year 2019, that 1.7 million was our biggest budget expense item at that time. We put a lot of things in place to decrease that spend, investing in our own employees. We created the nurse residency program. The blue is RN, contract temps, and the orange is other allied health. So lab techs, respiratory therapists, echo techs. You could see the results of those initiatives in FY20, where we had a spend of 891,000. And when we came to you last year, we had been a whole year without contract temps. We projected the 242,000, and that was in the last quarter of 2021. So July to September was the 242,000. We were starting to feel the impacts. We had staff going from regular positions to per diem, reducing their hours significantly, and it really started to spiral. This year we're projecting $4.1 million. We have anywhere from 16 to 20 contract temps on site at any given time, which is not much more than we had in FY19. The biggest difference is the bill rate. We're more than double the cost for those contract temps in specialty area. And we're seeing a bigger increase in allied health professionals, not just nursing. Next slide. And these are some of the things that we're using as solutions. And these are things that we've done before and we know will have an impact. So compensation, we're committed to maintaining internal and external equity. We don't want people to have to leave their community to get a fair wage. We're nurturing our clinical collaborations and pipelines. So throughout the pandemic, we were committed to letting students on our facility safely supporting them, knowing that that's our future. So that's both for nursing, allied health, an MA program. We've doubled the size of our nurse residency program through the pandemic, environmental services, and ongoing education and professional development opportunities for our leadership and all of our staff. Below, you'll see some of the schools or clinical collaborations that we have from high school to Keynes State College, Vermont Tech, CCB, and Great Hill Community College. One of the big impacts is going to come from the culture that we create and maintain here at BMH. That includes trauma-informed consistent leadership. There's been a lot of change in the past couple of years and stability is important. Trauma-informed, recognizing what our community has been through and what our staff have been through. Frequent transparent communication. Taking action against instability and violence is a big one. Our staff need to feel supported and heard and kept safe as you heard Chris say earlier. People need flexibility to thrive in spite of the COVID-19 lifequake recognition, evaluating staffing models, exit and stay interviews, and employee engagement surveys are going to look different and they're important. We need to ask people as they're leaving what it would take for them to re-enter healthcare because a lot of the people that we see leaving are leaving to go to another hospital. They're leaving the profession. Support for wellness programs that include mental health and we need to create a diverse, equitable and inclusive work environment for everybody. Again, I'm Chris Starty, president and CEO and I'd like to just highlight a few of the risks. You can see what's on the screen but let me highlight some of the high risk areas that we have in terms of trying to actually obtain this very razor thin operational gain next year. One big risk for us is the status of Medicare dependent hospitals and low volume designated institutions. We are the only one in the entire state of Vermont that is set to sunset, September 30th of this year. We're very hopeful that a new US bill that is in the house and Senate right now will be approved and that will actually make the Medicare dependent hospitals and low volume status a permanent designation. We're working very actively and arduously with a lobbying firm to try and push that forward at this point in time. We may have done this incorrectly but we did not budget for a resurgence of COVID-19. We have no idea what the future holds as much as we think of Dr. McGraw's incredible clinical expertise. I don't think she could predict what COVID-19 is gonna look like this fall, this winter or whenever. So we did not budget anything if there is a resurgence. So that's risky that there could be a resurgence and could send us into some difficult situations if we again have to stop doing elective procedures and other issues that we may have to contend with. We did in our budget put in for the ongoing expenses of dealing with COVID additional PPE. We've had to hire additional personnel for screening and other types of activities at our entrances. Those expenses are carried over from year to year at this point in time. But if there is a resurgence, we have a vulnerability and a risk there as well. Again, I may have made a big mistake by not budgeting something there but we didn't. And then again, I'll say what was happening here this morning. Jody and several members of our nursing leadership team have been involved in active union negotiations with our nursing staff. And again, that's certainly a risk depending on how those negotiations go. We've only budgeted a very razor thin margin and we're hopeful that these negotiations will go favorably and well for all parties and that that won't jeopardize this razor thin margin. Next slide, please, Laura. But there are great opportunities as well and we look forward to a very exciting future after we get stabilized. We do see opportunities in continued revenue cycle improvements, as Laura mentioned. And we're looking at those aggressively and trying to find different ways to really optimize every dime owed to us by the insurance companies. We will be continuing our collaboration with Dartmouth Health and Cheshire Medical Center. As Dr. McGraw said, we have a very strong strategic partnership with them. That is the only way this area would have access to the types of subspecialty care that we've been able to bring only through Dartmouth Health and we'll continue to work with them on trying to bring additional subspecialties. We have a joint operating agreement with them and we've been talking with them about other subspecialties that on a rotational basis may provide better care to this community. And as Jody mentioned, we really are rekindling our efforts in justice, equity, diversity, and inclusion. I am not a Star Wars fan, but that comes out to Jedi. So we are on a Jedi journey to actually really infuse into our culture into everything we do, justice, equity, diversity, and inclusion. We're working with some tremendous community leaders in that regard. We look forward to learning from some of our colleagues. We've been reaching out to Dartmouth Health that has a tremendous equity, diversity, and inclusion program. And also the University of Vermont Medical Center has a wonderful one and we're looking at best practices from across the country and trying to get those incorporated here so that we can be more just, equitable, diverse, and inclusive. And then finally, we're also excited about pursuing such population health management activities as creating a mobile health integrated network. Our local EMS team is actually getting a very large grant. They received a very large grant to create a program here in the Brattleboro area. And we started to talk to them about how community paramedics may be able to help us with chronically ill patients and to more proactively manage the ongoing health of patients who we know have a chronicity that needs to be dealt with. Next slide, please. So in summary, again, we do come before you asking for a large rate increase comparatively to anything we've done in the past. It's not our desire to do that but it is the only way we see of trying to create a stable future and to really generate a very razor thin operating margin of 0.67% and about $727,000. So we ask for that approval and Laura, you can go to the next slide, please. And we really don't fear the future. We know we just need to get strong right now and we need to be able to tackle the future in a very positive, strong way and create an ideal future. We truly applaud you all for the vitally important charge that you all have undertaken and accepted to reduce the rate of healthcare costs in Vermont while ensuring that the state of Vermont maintains a high quality, accessible healthcare system. We stand here today to partner with you in that noble mission that you have accepted. We have done all that we can to keep our request for a rate increase as low as possible. We implore you to approve these rates so that we can stop the degradation of the quality of care, service levels degradation and also degradation to access to essential health services for our beloved community. We ask you to approve our budget and to allow us to go on the road to becoming the hub of hope, health and healing for our entire community. We thank you for your time and attention and we look forward to your questions, guidance and opportunities to partner together. Nate, thank you so much for the presentation. It's nice to see you all and to meet some new faces. And I recognize that for some of you coming before the Green Mountain Care Board is a new experience and we appreciate your efforts in preparing the materials for this unique process that we have in Vermont. With that, wow, and we are, thank you also for your timeliness. We are actually a little bit ahead of schedule so we appreciate that. I will open it up to questions from the board again starting with Robin. Great, thank you. And nice to meet all of you from Brattleboro. I grew up in Brattleboro so I always look forward to hearing about your budget and how things are going. So my first question is, I just wanna walk through some of the appendix tables. So we use the appendix tables typically to kind of understand some of the assumptions that are outlined in the budget. And some of your appendix tables were not fully filled out. So I just wanted to talk to you a little bit about that and I understand you're new and this is a new process so I'm sure it's challenging. But I wanted, so in appendix one, which is the reconciliation tables, it looks to me in looking over your budget generally that you're asking for essentially a 10 million increase in MPR from projected to next year's budget. And of that about 8 million is from the price increase. Am I understanding that correctly from the materials? And I can't see you by the way, so I'm sorry. I'm not sure if you have your camera on, but. I think we have the camera on. It's just not. Do you have the video on? No, I don't. And that's okay. No worries. Here we come. Sorry. Oh, great. Sorry about that. No, no, no problems. It's just nice to see you when I'm asking questions. Hi, Rob, and this is Andre, this and that, the. Hi, Andre. Good to see you. Good to see you guys outgoing CFO. So we're kind of tag teaming this. I don't have the appendix in front of me, but that's pretty close. I think to the numbers that I recall, majority of it is in the fee increase. Okay. So could we talk a little bit about the utilization assumption? So appendix three wasn't completed. And so I usually use that to, and compare it to the information from adaptive, which also, quite frankly, looks wonky. It has like your total average daily census as one, which I'm sure is an error. So could we just talk a little bit about the utilization assumptions? It sounds like you're assuming sort of, I think your narrative said January year to date is what you were using. Is that right? That's what we built the budget with. Yeah, it was January year to date. And then as we got closer to submission, as Laura talked about earlier, those volumes have definitely changed since January. But that's not reflected in the budget assumptions at this point, right? No, not a hundred percent. We reflected January year to date with some decrease, because we knew what February and what March was potentially gonna look like, but we weren't to a point with April and June to lock those into a budget assumption. Yeah, okay, thank you. And certainly understanding, it sounds like the Omicron surge in earlier this year really hit the hospital hard and you had to shut down services, but setting that particular piece aside for a moment, can you speak a little bit to where you think you are compared to 2019 in terms of utilization? And the reason I ask is that in the data that we saw during the rate review process, it looked like there's a pretty good correlation between COVID surges and ED utilization, meaning the opposite ED fell and urgent care fell when COVID came up, but at least statewide, there might be some delays that the care was catching up within the same year. So I'm just wondering if that's a trend you've seen if you for some reason are not kind of consistent with that statewide trend, and if you could speak to that a little bit. Thank you, yeah. I think it has some correlation with the statewide trend. I know when we reduce some services because of the second round in January and February, the ER really wasn't much less busy. During the first round of COVID, it definitely dropped. With us and I think all the other hospitals, we were trying to get patients not to come into the ER if possible, just for all around safety reasons. When the second time came around, none of that was out there. So we really didn't see that much of a change in the ER volume, where we did see volume issues were in our ORs because we had to reduce the OR down. We had almost 60 staff out on what I call COVID protocol and some of the, yeah, we just could not staff the OR. Some of the clinics were the same way. So those are two of the areas that we saw the decrease. We've seen those bounce back since February. And our inpatient has actually been really busy all through this. So those are the areas kind of what Laura highlighted with the areas that we saw some volume increases from budget to budget compared to 19. I didn't go back and compare it to 19, but there probably are a little bit, those areas are a little higher than what 19 was. Okay, great, thank you. And the other area Robin that we've seen are really two areas of a big increase. One is our orthopedic surgery area with our total joint program. We've seen a significant increase in that. So if you look at our supply line, that's you see that going up, that's part of the chargeable supplies. And the other area is in our drugs, which is our infusion program. Two things have happened there. One, we've seen some pretty significant volume increases there, unfortunately. And two, as Laura stated, some of the drugs that we're doing, if they're new drugs, they don't qualify for 340B until we use them. So we got to pay full boat upfront for them. And the third leg of that is big pharma reducing, increasing what some of those costs are. Sure. Okay, and do you think the ortho has flattened out or do you think it might continue to grow in next year? I think it's gonna grow. I think probably in a two to 5% range, we've got a new orthopedic surgeon starting in September. September. And we have the Greenfield Market, Greenfield, Massachusetts, as was on one of the slides, where they do not have an ortho presence. So we've targeted our growth really in that Greenfield Market in Massachusetts. Makes sense. Great. So, Herning. Please make a court report. The last person that answered, please. Sorry, that was Chris Darty. Sorry about that. Thank you. You bet. I'm just taking a quick look at my notes. That may be all I have, but let me just check one more tab. Oh, in terms of your savings initiatives, I know in your narrative, you, I think, if I'm remembering correctly, and please let me know if I'm not, that these were fairly new initiatives that you had started in 22. So at the time, of course, that you submitted your budget, you weren't necessarily able to reflect those savings estimates in your budget. Do I remember that right? Yeah, that's correct, brother. Do you have estimates of what you're targeting for fiscal year 23? Not yet, Robin. We're, I'm sorry, this is Chris Darty again. We are working on that as we speak of trying to come up with those estimates. Okay. Thank you very much. I think I'm all set for now, Jess. Thank you. Great. Thank you, Robin. With that, I'll turn it over to board member Tom Pelham. Well, good afternoon. You do have a very typical task ahead of you and we all hope for your success. And if you are a success, you'll look back on this period as something to be very proud of, but clearly there's some difficult decision-making that is before you and before us, but we wish you the best of luck. I want to shadow Robin a little bit on a different table. I was looking at the pair mix tables and just to kind of see by revenue category what was growing relative to what, and I noticed that for two columns, the commercial revenues were growing at 39%. And then I noticed that for 22B and 22P, they were identical. So there's some noise there and so rather than use those and the result of that noise is that on the income statement, you profile NPR at $105 million and on the pair mix table, it profiles at $111 million. So there's some noise there that I think needs to be fixed. So to get another view of the relative growth, 23B budget over 22 budget, I went to the same table that Robin just mentioned a minute ago, the reconciliation table. And there you can see that there's a big increase in commercial of 47% year over year. And as Robin kind of noticed or questioned, 6.7 of that eight plus of that increase is from the rate. But I also noticed that the Medicare amount went from 37.2 million down to 33 million for an 11% reduction. And the Medicaid amount went from 13 million down to let's see, 9.8 million for a 25% cut. And so my question on this is, why those large reductions in Medicare and Medicaid? Well, you're looking at budget to budget, Tom, I think, and without actually seeing it in front of me, there's been a change in how we were looking at some of this. If you remember, Mike Rogers used to do all of this work and then Foxpro, and I'm not exactly sure how he had some of that stuff mapped. What I pulled out was actually was in our general ledger. So that's what I'm relying on. And I couldn't go back to 2022 budget into his files. He used an extensive Excel setup as well as a program you may have heard of Foxpro to run these numbers. And I don't have the mapping that he had in Foxpro because I do not know how to use it. So I think that may be a large part of the difference. So the numbers that I use were based off of what is actually in our general ledger. That I know how to go back to in baseline. So in the adaptive material that we have, what is the best that we should use to understand any pay or mix changes? 22 proposed budget over 22 approved. In adaptive? Yes. I'd have to go back and look at that, Tom. Yeah, okay. My next one had to do with the provider tax. And I asked this question because I thought I might see something that could be a benefit to you, but I don't know. So you're booking the provider tax increase for 22, 23 over 22 at 15.5%. That's a $1 million increase, a little over a million dollars. And so if you take the 2022 and I know that there's a number of ways that people calculate this tax. So I'm just probing to see, to better understand what you did, if you take the prior year NPR amount and multiply that by 6%, which is the size of the tax, you come up with like $5.55 million, significantly less than what you have budgeted. And so my question here is what is the methodology that you used and it could be the correct methodology. There's a lot of noise in this calculation. What is the methodology that you used to calculate the increase that resulted in the 15.5% increase? I took the, I just basically took the budgeted net patient revenue plus the FPP and multiplied it by 6%. Okay, well, you might want to go back and check that calculation. You know, I get a number that's lower than yours, kind of using that same logic, but. Do you include the dish revenue in there and back debt and charity and net revenue? Say that again? Do you include the dish revenue in there and charity here and back debt? Well, I'm working off the numbers on the income statement. And so they do have that. So just a double check. Yep. Because I think if it breaks differently, it'll break to your favor. Looking at travelers, how much, I mean you, so on page 12 of the narrative, there's a statement about the 16 FTE, nurse allied health travelers. How much have you budgeted for these 16 FTEs in 2023? Please budget for all of this. It's $3 million, 2.8 million. 2.8 and Tom, what we did was we have vacancies and this probably may go down the wrong way, but we want to make sure we don't budget an FTE, a full FTE that that traveler would be taking the place of because it's vacant at 1.0 and 1.0 traveler. So what we do is we budget the FTE and then we back down the traveler a little bit to offset it. So we're not double budgeting. So basically we were looking, it was either 14 or 16 FTEs when we built the budget and we figured that that was going to run through the majority of next year, not the whole year. Because we don't see any signs of that labor market breaking or softening at all. Well, my question is- Pardon me, court report. And the last person that spoke, your name please. Andre Desnec. Okay, thank you. I mean, my interest in that is just kind of an emerging interest kind of looking at hopefully 24 and 25, if things start to break kind of back to normal. And so for some hospitals having built their 23, 22 and 23 budgets on a lot of travelers, that all that money might not be needed down the road. And so the thought is, does that money just go to other expenditures within a hospital? Or does it go to fund balance? Or does it go somehow back to a rate payer? So I'm just curious about how much we're building and in travelers that at some time may be freed up to do something else with. That's a great question. This is Chris Stardy. And we're aggressively going after the expenses of the travelers and trying to wean ourselves off the travelers in 2023. Our hope is that when we get to fiscal year 2024, we will virtually be completely off. And Jody, our chief operating officer, chief nursing officer has a whole host of programs, including nursing residency programs to start infusing more nurses that will hire and start to pull ourselves away. We see 2023 honestly as a transitional year. Again, increasing the wages. We've gone through a lot in 2022. We'll continue to do so in 2023 to try and keep pulling ourselves away from needing the travelers. Right now it's just that there's such a high number of vacancies that we've had to deploy them. But our hope is by 2024 we'll be completely off of the travelers need. Let's hope. The net, my next question has to do with free care. And I just noticed, I mean, they can't call it a pattern because there's only four or five data points. But I noticed that for free care, the actual amount on the income statement was basically a cost or a deduction from revenues of $778,000. And then the budget amount for 22, the budget was $2.8 million. And then, but the projected now for 2022 projected is back down at the 2021 actual level of $755, $756 million. But the 23 budget amount goes back up to $3.8 million. So I'm just wondering about the rhythm of that where the budget amounts seem to be, it's not conclusive, but seem to be higher than what actually occurs. Yeah, and if you look at the bad debt, it's gone the opposite direction of the charity. And one of the things that we need to work on is getting those patients to come back in to complete the applications. And we saw that during that first phase of COVID where we weren't able to process those applications for the free care. We know it's happening. A lot of times from a financial standpoint, look at it as a complete bucket as opposed to an individual bucket between bad debt and charity care. Because if it's not gonna fall on the charity care, it's gonna end up in bad debt. And our goal is to move it from bad debt to charity care. So we need to do a better job at being able to get those patients in and probably marketing that we're here for them and it's fine to come in and talk to us. I think there's probably still a little bit of fear out there with patients coming in and talking to our financial counselors, more from a COVID fear than anything else. And let's see, let's see. I'm gonna try to get your pictures back up and looking at spreadsheets while I'm talking to you. It's kind of weird. The numbers are sitting there chattering away. So I'm looking at total operating expenses and your budget to budget amount is a 12% increase. And that is kind of right near the same place that the entire population of hospitals is at for other 2023 requests. And the entire population is at 12.6%. But I'm wondering just hypothetically if things turn out that there is a 2% reduction in your operating expenses or there's some kind of pressure for a 2% reduction in your operating expenses, that would take your total operating amount down from the $108 million down to 106, still a 9.8% increase over your 2020, hang on a second. Let me just get you up here so I'm making sure I'm talking to the right thing here over your 2022 budget. So just hypothetically, if that were your world and you can bring it home and get half the kind of success and sustainability that you're hoping for, but it would cost you 2% on your operating expenses. Do you have a list of backup or of ideas that you would employ to get yourself to that stabilization point? Well, this is for Stardy again. We are constantly looking at ways of both enhancing revenue as well as reducing expenses. We're developing that list. I think Laura shared some of that opportunity, but we're looking at a whole host of different things including we have some vacancies in our revenue cycle management system. We're very interested in looking at digital workforce and other ways of reducing labor costs. These are just things that haven't come to fruition at this point in time. Our biggest concern is with the margin that we're running and just hopeful to have a positive margin next year, we've just fear the degradation of services, even the quality of the care that we're providing because the capacity of our system keeps getting constrained and we're very concerned about that, but we are looking at every opportunity for reducing our operating expense. There's things, as Laura mentioned, even this year, we looked at ways of maintaining cash by not funding some of the capital that had been approved so that we would maintain our cash. We'll constantly do everything we can to manage as effectively with the most prudent financial stewardship as possible, but at this point, we don't have really a list of all those things except these are all things we're exploring. Well, I fully appreciate given some of my history that it's hand to hand combat and the little things do add up. Absolutely. So I wish you the best of luck and we'll be deliberating sometime in the future about all this. So with that, I will pass it back to Jess. Great, thank you. And with that, I'm gonna pass it over to the other Tom. Tom Walsh. Thank you, Jess. Hello, Chris. Hello, everyone in Brattleboro. It's nice to see you again, Chris, and to meet everybody. It's great to see you again, Tom. I really enjoyed our conversation. Thank you. It's looking over the material that you sent us. It's obvious you're in a very difficult spot and you're all, I guess, I want to commend each of you for being willing to enter into it and to try to make a difference. It's your new, I'm sure that you saw some of this when you signed up for it. It doesn't make it any easier, but thanks for doing what you're doing. I think the retention plan, getting the compensation and culture improvement, I think that's really the right place to be starting. Having a stable workforce makes all the other improvements and identifying savings and improving systems and processes. It's the workforce that does that. So I think you're on the right track there. I think, too, I just want to give a word of caution about maybe being overly optimistic about volume increases as the pandemic recedes and with the focus on ortho with the new surgeon coming on. The reason that I feel some sense of caution about that is not only are you all in a difficult point, but the community is too. And the price increases that are rippling through the community, not just in healthcare, but everywhere, I think it's more emotionally and mentally more emotional and mental strain on the people we serve. We see that in the ED story that you mentioned, Chris, I appreciate that story. I think there's also the possibility that with higher prices and higher premiums out of pocket expenses, people may not be returning to healthcare as much as we anticipate, not because out of fear of COVID, but out of fear of death. And so the balance that you're trying to have, having being paid enough to keep going and do these improvements, it's a tough balance, but I haven't read yet of people modeling or thinking about a reduction in volume because the prices are too high, but I think we need to be thinking about that. So the, finally, the savings that you mentioned that your staff is looking to achieve or leadership is looking to achieve, I just recommend really engaging the staff trying to find every place that you can. As board member Pelham said, the little things add up. And we've heard of successes across the country and different organizations of really engaging a staff to try to find a way through this and to find more savings, particularly in the orthopedic line and joint replacement line. There's a bunch there for streamlining that service line, especially if you're developing a new one and negotiating with the vendors for implants and supplies. So just keep looking under every rock. And I don't have any questions, I just want to commend you for stepping into this. You're all very new and it's a tough spot. Thank you, Tom. And thank you, Chair Holmes. Thank you for that comment about involving staff. They are the ones that know best at all times where the trimming can come and where we can have a relentless war on waste, but it can't happen in the C-suite, it has to happen. And I think board member Pelham said it so well, it's in the hand-to-hand combat that's going on every minute of every day that we really need to be focused on. Great, so I guess I'm the last one up and some of my questions were actually already asked, which is helpful. It's good to be last in this case. One of the questions I did want to ask was about the charge master, the rate increase of 14.9, call it 15. We do know that charge master increases don't translate into one-for-one increases in what the effective commercial rate that the average commercial payer will face because of different payer contracts. So I'm wondering if your team can help us understand that historical relationship has been between the charge master and what I'll call the effective commercial rate for Brattleboro and that's what your best estimate of what that 15% increase in the charge master will translate into. Boy, I'm not sure I could give you an accurate answer off the top of my head, Jessica, on that. Okay, you can follow up if you want. That's fair, I'd rather have it be accurate than a guess during a hearing. So we can just put that in, perhaps you can share that estimate with Sarah Lindberg. Afterwards, we're trying to really understand how this is gonna hit pocketbooks and recognizing that there's not a one-for-one relationship. Yeah, so you're saying that what you're looking for is if we're raising our overall rates by 15%, what is the average commercial payer gonna be reimbursing us? Yes, yeah, you know, discount off charges, the fixed, like I know there's a combination of ways in which you have payer contracts, and some of the work that our Berkeley Research Group did really looked at the relationship between increases in the charge master and what actually materialized in commercial rates, and it's nowhere close to a one-for-one relationship, and it varies by hospital based on their contracts. So I'm trying to understand what does this really mean? Okay. Thank you, that would be helpful. And I guess my second question then is how are you gonna apply whatever rate increase is given or allowed to Brattleboro? How do you apply it across services? You know, we have heard from carriers that there's an average rate increase, but in some instances reimbursement rates are higher, some reimbursement rates are lower, and it may depend on what potential margin might be, what potential volume is, market competitiveness. How do you decide where you're gonna apply whatever rate increase is allowed? Yeah, this is Andre, this and that. The way that we're planning on doing it this year is, we outlined the areas of service line type of areas. So all of our hospital based charges will get a 20% increase. The practice, all of the physician practice billings and in the charge master and our supplies and our pharmaceuticals would be 1%. We haven't raised those in a long time and some of the contracts have a greater or lesser of charge. So if their fee schedule is greater than our charge, they'll pay our charge. So we wanna try and make sure we're not leaving any of that on the table because we haven't adjusted those prices in a long period of time. I figured we'd take a shot at it with 1% and see if that actually moved the bar at all. But overall, all the hospital charges would get a 20% increase. I don't know that. Straight across the board. Yeah. Every time across the board, okay. Thank you for that, that's helpful. So there was some discussion in here about the strategic relationship that Brattleboro has with Dartmouth-Hitchcock and I wanted to talk a little bit about Dartmouth's new patient pavilion, right? With its 65 brand new beds that are slated for completion. I think this fall with an opening scheduled for 23. And I think this is gonna be wonderful for patients. It's gonna increase capacity in our system in Vermont. But one of my concerns is that particularly in hospitals that are saved within an hour or so radius of Dartmouth-Hitchcock, that this is gonna create more workforce pressures and certainly may impact your ability to reduce your reliance on travelers. If there's a, I think about it as like a giant sucking noise from coming from Dartmouth. People are lured by potentially higher wages by the opportunity to work in a brand new facility, whatever the case might be. So I wondered if you could talk a little bit about that risk that you face. And also, to the degree that it may affect your daily census. If there's now some more capacity, not too far away, how does that impact your estimates of your average daily census going forward? So I didn't see it as a risk. Listen. Good point. So I think it must be, no? Yes, good point. We'll add that. Thank you, Jessica. So this is Jodi Stack. I can speak to the workforce. We have folks that travel now that could be at Dartmouth. I think that our goal right now is to keep people who live here in this community working here. And I'm confident that we're able to do that from 2019 into 20, even after the first surge. That's what people want. So we don't necessarily have to compete that far out. We just not need to make it so there's not a compelling case to leave their community, if that makes sense. And so we're always looking at that kind of equity, but we've done it before. And we're really looking at the folks who have reduced their hours in the past couple of years who had needed a respite. They're still here in this community. And what can we do? And what kind of environment do we need to create so that they will reenter the workforce? So I'm not saying it's not a risk, but it's not one I'm overly concerned about. Great job, Jodi. This is Chris Stardee. I'll answer the second part of that, Jessica, if I may. And that had to do with volume impact, potential volume impacts. You know, we know the lane that we swim in and it's very much primary acute care. We don't try and swim in the secondary or tertiary care world. And so our relationship with Dartmouth Health has always been a mutually beneficial relationship. The community feels so connected to Brattleboro Memorial Hospital to care for those primary healthcare needs. And that's where we see our strength. We don't believe that our inpatient or outpatient volumes will be impacted adversely due to this. And our growth is really in the outpatient world. So the shiny new inpatient tower is not where we're looking to grow. It's actually what we're looking to move away from. We're seeing tremendous gains in endoscopy services and the things that we should be doing for this community and doing it as close to home as possible. So we would really push our efforts on those things that need to be done right here in Brattleboro and partner with our strategic partner in Dartmouth on those things that could leave this community. But I don't see that as having a tremendous volume impact. I asked Dr. McGraw to see if she feels differently. Yeah, this is Dr. Cat McGraw. The thing that I would add is that we track our transfers and we know that our transfers go to Dartmouth, but we also know they go substantially to Bay State down in Massachusetts and other places in Massachusetts as well. The distances that our transfers have had to go has been quite tremendous at times. And so I think that the additional beds at Dartmouth would be extremely helpful with relationship to that. I think we have found in our relationship with Dartmouth that they are very willing to be helpful to us to keep the patients that belong here, here, and provide assistance as necessary, whether through tele-solutions or even just over phone consults because they do want to have their beds open for the most ill patients because those are the ones that really belong there, that fits their educational goals as well. And so I think that there's not as much risk as it would appear at face value. Okay, great. I mean, that's good to hear. One of the things I would just add related to that, there was a part of the budget guidance that asked for occupancy rates for both licensed and staffed beds as well as historical average daily census data. And I didn't see it in the narrative submission. So I'm wondering also as a follow-up whether that could be supplied to Sarah and our team as well, just unless I missed it, I didn't see that section. It was under the utilizations. I don't believe it was in there or no, but we'll work on that Jessica and we'll work with Sarah. And I must say, Sarah, we wanna give a shout out to Sarah. We're all new here. We went through a transition with Andre moving on to another site and Laura jumping in as we awaited a new CFO. And from what I've heard, Sarah has been incredibly helpful in this process and helping us learn what we need to do for our submission. So we'd like to give a shout out. I don't know if she's on the call, but if you can help me for a shout out. Okay, thank you. She's on the call and she's very well-deserved. Oh, thank you. Thanks. Jessica, this is Andre Disnett. Yeah, going back to the transition that we had from, when Mike Rogers was here from Fox Pro, all of the stats ran through Fox Pro. We had to actually build all of the stats in our new accounting system now. And I think we can add those stats to it going forward. So we weren't able to rebuild everything. This really started happening from November, end of actually first of December to now and being able to get all the stats that we were actually able to get and get through the budget process in season with rebuilding everything. I think we've done a pretty good job, but obviously we missed a few things. Yeah, no, and that's okay. And trust me. Morning core reporting. Last speaker, please. Andre Disnett. I was just going to say, Andre, that I totally can appreciate transitions and being placed in positions at the end of the day. So, you have sympathy and all else. If I can just add just one more request and I fully understand this will be for next year, but Dr. McGrath, you and I had chatted so much about wait times and all of that. And I think it would be really helpful next year to have the referral lags and visit lags as best we can broken out by practice area. We're trying to understand where some of the specialty bottlenecks are in the system. And I think what was submitted this year was just medical group as an entirety. It doesn't help us really understand, is it cardiology? Is it neurology? Is it dermatology? Is it just in this region that it's dermatology? Or is it across the state? So I recognize the constraints that you're under this year with transitions and new data systems. But putting a plug in for next year in the hopes that we can work on that and have a better understanding of just access issues throughout the whole system. So just a parking lot for that. Delighted to, this is Chris Stardee. We are extremely concerned about access and basically quality of care. And ultimately the long-term reduction of cost is all predicated on good access to care when needed, where needed. And so yes, we will certainly commit to that. Perfect, thank you. And my last request is also just a follow-up request that I'm asking all the hospitals to do, but since the budget submission, if there's been any known or likely changes to any federal or state payments, relief funds, grants or unexpected increases in Medicare and Medicaid reimbursement rates to just follow up with our team just so that we can understand, because there are some things out there at play and we would like to make sure that we have full information as we go into the budget deliberations. And to the degree that there's also, somebody mentioned this morning with Southwestern, if there's big swings on the cost side, that's also something that we need to know. So to be fair on both ends, pluses and minuses, if there's just big substantive, I would say material changes in any of those categories would be helpful if you could share that with Sarah. You bet. Thank you. I think that is it from all board members. Are there any other board members that have just a follow-up question, burning question? Seeing shaken of heads, no. Okay, why don't I kick it over to Sarah Lindberg and Russ if there's any staff questions or move on to the HCA? Yeah, hi, this is Sarah Lindberg. I had the finance team here at the Green Mountain Care Board. I wanna thank you for presenting today and also say that in retrospect, I wish it would have been a little more helpful along the way as we were all going through this transition. So thanks for being responsive and helping us work through any kind of missing material. I did wanna say that we're just kind of digesting now that we have all the actuals in through Q3 to try and see what that might be doing for projections at the end of 22. Looks like you've already done some of that work in this presentation. So I just wanted to say Laura will probably be putting our heads together to make sure I've got that correct and that my question though is if you're seeing kind of any stabilization, particularly in the expense cycle at this point or if it's still pretty mercurial. I would say seeing the beginnings of stabilization in our expenses is still to use your words on mercurial. But we have seen, we're hoping that the contract temp line will smooth out. We did have some hits early on in the year in our benefits line. We used to some of our employees hitting a stop loss threshold which has since smoothed out. We were seeing a lot of expense increases in the medical, surgical supplies, which is also volume driven and somewhat reimbursable for us. We saw some of that come down and in the last couple of months. So I'm optimistic about the last quarter and hoping that we will come closer to a positive outcome. Excuse me, court report. Will I have to make a name please? This is Laura for now. Thank you. And this is Chris starting just to add to that Sarah as well. A lot of the things that we're challenging ourselves with in terms of expense reductions will also start to take some shape here in this last quarter as well. They won't come to full fruition but I believe that we will see a stabilization in our operating expense in this last quarter. And thank you again, Sarah, face to face. You're welcome, yeah, yeah. I think that was it from the team. I just pulled us all. So that should cover us for now. Thank you very much. Okay, you know what? We have the HCA questions and then a possibility for public comment. Do we want to take a 10 minute bio break recess? Would that be helpful to the Brattleburg Memorial Team? I'm seeing some shaking in the pen. So I'm ahead of schedule. See, I have lots of empathy and sympathy today. Why don't we come back? It's three o'clock. We'll come back at three 10, okay. Sam, I see you on. Are you kicking off HCA questions or will Mike be doing that? It'll be me and Charlie Becker is also on for the HCA. He's going to ask any questions that I missed or follow up on anything that I missed. Okay, great. Take it away. Awesome, thanks so much. So, Sam Pye for the record, Sam Pye is a health policy analyst with the Office of the Healthcare Advocate, also the HCA, also known as the HCA. Thank you, Brattleburg, for being here. Thanks for your submission. A couple of the questions we have, a lot of them are really follow up based on your narrative and some of the questions that we had have been asked by the board, so thank you for those. Our first question is, please describe your plan to come into compliance with the provisions of Act 119. I think you know this, but this is a reminder, this is the PFA, Patient Financial Assistance and Medical Debt Protection Bill that was passed last legislative section. And just wanted to say, in your submission, you said there weren't any obstacles and you haven't revised your policy yet and I know they're two years. Just so do that, but I'm just wondering if there are any obstacles to that and when you plan to review your changes in policy. Sure, if I may start. This is Chris Starty and Sam, it's nice to meet you. And why we said that we didn't perceive any obstacles is our current financial assistance program is actually very robust and there are some sort of maximum points or end points that we actually need to increase. For example, our 75% charity discount only goes up to 350% of the federal poverty level so we would have to increase that to 400%. We are starting to actually piece through that and make sure that we'll be ready for compliance certainly by July 1st, 2024, but I believe well before that time as well, Sam. I'm gonna ask if Andre or Laura have anything to add from a finance perspective. I don't wanna overstep my bounds, but I do not see any issues of coming into compliance with that. No, and Sam, this is Andre, this and that. Yeah, the other thing is we usually, when we have changes like this, we've also engaged other entities like we have a compliance group through the VAS group, a hospital association, attorneys and our tax accounts to make sure we're consistent and in compliance and making sure we're dotting all of our I's and crossing all of our T's. Awesome, great, thank you, appreciate that. It's great to meet you both too, at least virtually. And so our next question is related to affordability and access by no surprise. Given that we know from the recent Vermont household health insurance survey, there are a lot of folks in Vermont, 47% that are either underinsured or uninsured commercially. And so I'm wondering if how your institution, if at all, calculate some sort of inflection point or assesses affordability and then use that to inform its charge request for next year. Well, I'll start again. This is Chris Starty once again, Sam and very important question. And I think right now what we're looking to do is re-institute our patient family advisory council and working with patients and families, talking about affordability, talking about the out-of-pocket costs, coming up with plans. Again, I think we're kind of in a good situation because of our very generous financial assistance program at this point in time. But this is something that always constantly needs to be evaluated. And I believe working with our community, our patient family advisory council is gonna be a big way for us to really to make sure that we're constantly keeping our affordability across all spectrums of our community. We do have a wonderful patient family experience officer that works with patients and families if there are any concerns and we get those resolved quickly and immediately. But we do need to have a proactive approach and I believe with the patient family advisory council we can do that. I don't know if Andre or Dr. McGraw or anybody wants to add anything to that. Thank you, Sam. Thank you. Just as a follow-up, as far as that council, it sounds like it existed previously. I'm wondering if there's community represent or patient representation on that council or there would be. Yes, sir. Actually it would be made up virtually of all patients and family members. COVID had challenged that as it did everything else just bringing people together has been challenging but we're going to reinvigorate that. Okay, great. Makes sense, just wanted to confirm. Based on identified community needs I'm wondering if you have any current partnerships or planned partnerships with local community organizations to improve or address housing, food access or transportation issues for monitors, particularly low income for monitors in your community. This is Dr. McGraw, I'm happy to discuss that. We've been working very closely with Grand Works Collaborative which is our local homeless services organization as well as with the retreat and ATRS specifically to look at issues around homelessness and how we can work with that. Our folks in our community health team are also very focused on this working with food insecurity and we have collaborated with Vege Van Gogh and ensuring that that's here and available for our community as well. So all of these issues are things that we think are really front and center to the health of our community and are and will continue to be involved with. Thank you. I'm curious if OneCare Vermont is involved in coordinating any of these efforts or if you partner with them at all? I will say we do. We have an accountable community for health group that meets regularly and certainly OneCare is a part of that. We have a clinician and so it's really a bridge between all of the healthcare organizations and then the human service agencies. So that's been very helpful. Oh, sorry, Jody Stacks. Jody Stacks, sorry. Thank you. Good job. Thank you, appreciate it. So this shifts a little bit more building off the conversation that we had earlier around workforce shortages and use of travelers. On page 12 of your narrative, you reported that you have 16 FDA nurse travelers at the moment. On the job listings website for Brattleboro, there are only two full-time RM positions open, 13 part-time and nine per diem. So I'm just wondering if you could speak to that. It seems like a discrepancy. I wonder if you could explain why that would be the case. It is, we try not to post duplicative positions. So if we have an emergency department position that's nine a.m. to nine p.m. 24 hours a week and we have two of those, we post one when we fill that, we post another one. Got it, okay. And how do you go about deciding which nursing positions in particular to fill as a permanent or full-time position versus a contract part-time traveler contract? Because I know you spoke to one to reduce that over time. I'm just wondering how you make that calculus. I always want to fill our positions of full and part-time nurses. And just as the slide into bringing travelers back happens, once we start to get ahead of the curve like we did in 2019 going into 20 and we're investing in our workforce and reducing travelers, we're able to spend more money, I mean, more time and money on our own staff and not on the traveler. So it really does grow because there's not just the financial cost of bringing in travelers, but it's an administrative burden. We're providing education that we really get no return on and onboarding is a constant cycle. So we always want to fill those positions with our own staff. And so we only bring them in. It's not a one-for-one. We bring them in when we just don't have the staff to meet the acute need. So we don't have contract camps in the ambulatory setting. It's really in our progressive care unit and the emergency department, ORs and birthing center. Those are really the only places that we utilize. Good, okay. Thank you. And you spoke just building up the population health investments. You wrote in your narrative that there's limited patients with long-term population health investments which don't yield short-term returns. So I'm wondering if that's both understandable and I'm also wondering how you calculate that return on investment or lack thereof. And if so, what recommendations you have or kind of ideas to maximize short-term and also long-term. So I think definitely a lot of these, if I may editorialize a bit, a lot of these investments do take some time to materialize. So I'm just wondering how you go about calculating that ROI. But this is Chris Stardy again and actually Sam, you stated it very well. I think what we were trying to convey is upfront we're investing money into population health management and it's not going to have any impact in that current fiscal year most likely. It's something that you're really investing in for the future to change the course of the health status of the population over time. So how we will measure that is right now we sit in one of the unhealthiest communities in the state of Vermont at this point in time. So seeing improvements in the health status of our community, seeing better management of chronicity of illness in our community, hopefully seeing reduction in certain types of illnesses or the prevalence of certain illnesses due to investing in things like lifestyle medicine and other activities that will over time change the course and costs of health care for this community, but not immediately. And that's what we were trying to convey is that we have to make the investments now in preparation for some return on investment in the future. Got it. I'm wondering if that investment becomes easier. Oh, go ahead. I think you're getting feedbacks on. Oh, okay. Just didn't want to interrupt anybody. I'm wondering if the partnership with one care of Vermont could help or does help in that area in terms of reducing that kind of risk of investment or what that relationship looks like. This is Chris Stardee again. And yes, I do believe it helps. And I think it's something we want to capitalize on on more and more and more. We, they generate very good reports for our whole health services area, which is very helpful to us really emphasizing and focusing on preventative work that should be done. And that's incredibly helpful. And I think constantly looking at ways to partner with one care is something vitally important to us because we do believe that ultimately we're going to be fully at risk for the lives of the community. And we embrace that challenge and want to be well-prepared for it. And I think one care can be a very useful partner in that regard. Thank you. Just following up on the COVID-19 reduction in services, I'm wondering if any services are still being reduced or if you're back to full capacity that just wasn't totally clear from the narrative. Sorry about that. This is Chris Stardee again and we are back fully at this point in time. Okay, great. And you also talked about the use of screeners. I'm just wondering if you could describe how they're currently being used and how long you anticipate using them. Sure, thanks Chris Stardee again. So our screeners sit at the entrance to every one of our buildings. And it's really to, again, once again screen to see if there are any prevalent COVID symptoms that we need to be aware of, temperature checks, et cetera. And also making sure that the right PPE is in place, hand sanitizing as people come into the building. So it's really something to try and keep everybody in this building as safe as possible by catching them as soon as they walk in the building. Everybody that is coming here electively also knows these protocols and are prepared for that. Our hope is, is if they have those symptoms they're gonna choose not to come in that day, but it happens. And so it's just a chance to catch them before they walk through the doors and potentially expose our staff and other members of the community that happen to be here. Great, makes sense. Last question for me, unless Charlie has any. Just wanted to provide an opportunity for you to answer one of the pre-hearing questions that we didn't see a response for, just to provide examples of any policies, procedures and initiatives that your hospitals undertaken or plans undertake to address systemic racism within your institution and community. Sorry, we didn't answer that. Sam, this is Chris Stardee again. That's my oversight, I'm sorry about that. Again, it's gonna sound kind of like our patient family advisory council. We had a very robust equity, diversity and inclusion program that was being worked on here. And then as COVID hit and changes in staffing hit it sort of lost its real progress and momentum. We're right now reinvigorating that. We are again, looking at working not only with tremendous representation from our community that have a lot of expertise in justice, equity, diversity and inclusion but we're also working with other health systems or looking to work with other health systems such as the Dartmouth Health System, University of Vermont Medical Center and other national leaders in equity, diversity, inclusion and healthcare. We've actually looked at some consultative firms as well that bring tremendous work in that regard. So we see this as a top priority for us at this point in time and we're just starting to gain some traction in that regard. Great, thank you, no problem. And I do want to commend you for, in relative to your size, you do have a dedicated DEI budget, which I think is important. I mean, I think resources and allocations track priorities. So I want to recognize and commend you for that. And in the health equity space, I appreciated the earlier, or we appreciate the earlier comment about committing more, trying to commit more of a share of uncompensated care and converting to free care rather than bad debt. So we think at the HCA that has a big impact on access and affordability. Charlie, I'll turn it over to you if you have any questions. Thank you, Sam. Yeah, so I do just have one follow-up question. So this is Charles Becker with the HCA staff attorney with the Office of the Healthcare Advocate. Again, just thank you to the Brattleboro team for your presentation today. My follow-up question is related to free care and bad debt and it relates to some of the numbers on the income statement. So the income statement, and I apologize if this got asked previously, but so the income statement appears to show that 2022 budgeted free care was in a neighborhood of 2.8 million and that projected at a reduction of 77% to 635,000. So I'm just wondering if you, which is roughly parallel to what the 2021 actual was. And I'm just curious if you could speak to why there's that discrepancy in the budgeted to projected in the free care line on your income statement and what that might say about your 2023 budgeted figure for free care, which is the 2.7 million. Yeah, like I mentioned, this is Andre Disonette. Like I discussed before, I kind of look at it as a complete bucket with bad debt and free care when you combine them. It's more in line. And what we've seen is that free care drop off when COVID hit that first round and it seems to still be down there. So we've got to beef up and see what we can do to do a better job to get those patients in to complete the applications. We would much rather see those patients getting the free care than the bad debt. My experience is that patients will, if they're not on a free care program and they qualify, they'll put services off just because they don't wanna, they're almost embarrassed in the command that they know they're using something and they're not able to pay for it type of thing. That's in general what I've seen. So I would much rather get them on the free care charity program. So that's kind of what's happened. And I'm budgeting so for next year that that gets moved from bad debt over to free care. If I could just ask one more follow up to that though. I mean, I'm hearing you say, which makes sense to me that bad debt and free care are one large bucket. But the bad debt line remains constant at roughly 3.8 million. So I guess I'm still just struggling to see how there's a shift from one to the other if the bad debt is remaining the same. Yeah, what's gonna happen is with the increase that we've put in there, it's gonna also increase that line item in total. Okay, okay. So it's kind of balancing it out over the long run. Because it will mean that's a big dollar amount of additional gross revenues. And when you write it off the free care of bad debt, it's that increased amount. So it's trying to compensate for that additional dollar amount. Okay. Thank you. That's all I had. Thank you. Great, so both, you're both good. Okay, fantastic. Well, at this point, I am gonna just open it up to public comment. Is there anybody from the general public that would like to make a comment? If you do, you can just raise your hand on the team's function. I will see you. Anybody on the phone that wants to make a public comment? Another way to do it. You can just start speaking. I am not hearing any. We're seeing any hands raised. So I'm gonna assume that that, Reddleboro, you did an amazing job of answering everybody's question, including everybody out in the public who might possibly be curious about something. So thank you very much for coming today and sharing all of your updates with us. And it was nice a chance to meet some of you. And I really appreciate the time that you took to prepare your proposals. And there's a couple of follow-up questions, but I know I have full faith that we'll see that in the next week or so. Hopefully, Sarah will reach out to you. You bet. And we thank you. We thank you for your time. Good luck with your new role and endeavor. And we really look forward to partnering with you all to make a healthier Vermont. Thank you. We will look forward to that. So board members and team here, we are, that's one day down. We have two hospitals done and a lot more to go, 12 more to go. So I look forward to seeing everybody back here. We will be back here at 8.30 a.m. on Wednesday. And we'll be hearing from Grace Cottage, Springfield and Northwestern. And the day was extended a bit to make more time for board questions, which I think we're a little cut short on the original schedule. So I appreciate that. The staff to help make that happen. Is there a motion to adjourn? So moved. I'll take that as a move, then a seconded. Simultaneously. Take your pick. Any discussion on that wonderful motion? No. All right, all those in favor, we say aye. Aye. Aye. Opposed? Nope. All right, we are adjourned for the day and then we'll see everybody back online at 8.30 on Wednesday morning. Thank you all. And thanks to the hospital budget team for all your help. Thank you. Thank you. Thank you, Blattable.