 So we're going to start out by asking Kim to square in anyone from Grace, who is going to be providing testimony this morning. Good morning. Can you hear us? We can. Okay. Great. Would you please raise your right hand, you are about to give shall be the truth, the whole truth and nothing but the truth to help you God. I do. I do. Please state your name. Hi. Good morning. This is Doug Devello, president and CEO of Grace Cottage and Stephen Brown, CFO. And Doug, whenever you're ready, you can proceed. Sure. Great. Wonderful to be here. Thanks for allowing us to present today and we'll try and get through this as expeditiously as possible so that we can all have lunch at a reasonable hour. I want to start off by saying that Grace Cottage is an organization that's, I'm sure, extremely well known to the Green Mountain Care Board. Since 1949, we've been delivering healthcare to the residents of Townsend in southern Vermont with a human and personal touch. Our culture of caring combined with our knowledgeable and skilled team of providers and nursing staff has really enabled us to provide exceptional care while achieving simultaneously really, really high patient satisfaction scores. In 2017 and 2018, we were recognized as the top 20 critical access hospital in the United States for patient satisfaction by the National World Health Association, something we're really quite proud of. And because of our size and our independence and our collective sense of duty, we're able to provide our patients with a very high degree of individual attention compared to what one might find at a larger, more complex healthcare organization. We're a 19-bed critical access hospital, as all of you know. We run an average daily census of between 10 and 14 patients, and that fluctuates rather dramatically over the course of the year. We have a 24-7 emergency department that sees roughly 27 to 2800 visits annually. We have a diagnostic imaging department with X-ray and CT scanning capabilities, as well as bone densitometry. We have a laboratory that provides approximately 40,000 outpatient tests per year and approximately 6,000 inpatient tests per year to our patients and our community. And we have a very sophisticated inpatient and outpatient rehabilitation program at Grace Cottage, providing over 16,000 outpatient treatments a year and over 25,000 inpatient and swing patient services by our rehabilitation team at Grace Cottage. We have a rural health clinic. I think we're really quite well known for rural health care. We're one of the few organizations that I'm familiar with that I've worked at that really focuses on the health and wellness of our constituents, our patients and our community, rather than in driving volume and interactions and billable services. We do everything possible at Grace Cottage to actually keep people out of the hospital. And we believe, I personally believe, and I believe my team also shares the belief that primary care is really the most important solution to fixing our national problem of continuously increasing health care costs in this country. Making people healthier and keeping them out of the hospital is really the only way that we're going to drive down the cost of care in the United States. And every day of the year, Grace Cottage works tirelessly to improve the health and well-being of the patients that rely on us by providing them access to primary care providers, providing them access to an emergency department that could link them to a primary care provider once the acute episode is resolved, and by making sure that our patients are doing everything possible to manage their chronic health care issues like hypertension and diabetes and obesity and mental health and doing everything possible to be healthy and to stay out of the hospital and to stay out of the emergency department. We also have a community health team with two FTEs who provide services free of charge to our community members. And we have two advanced practice providers who provide behavioral health services to our constituents as well. And in addition, we have a retail pharmacy right here on our campus that does a very brisk business of helping our patients have access to getting their prescriptions filled so that they can continue to do the things necessary to control their cholesterol and their chronic health care issues without having to deal with long distance travel to a commercial pharmacy in Brattleboro or in New Hampshire. This year, we're really pleased. I think all of you know that the town of Brattleboro has an annual, the Brattleboro Reformer, rather, has a reader's choice survey that they conduct here in the region where people who live in this part of the state are able to to vote on the services that they feel are the best in the region. It's the Readers Choice Award and in 2020 Grace Cottage won every health care award available to us to win, including best hospital, best emergency department, best physical therapy, best pharmacy, best doctor and best pediatrician as well as the best place to work. I think that really says a lot about Grace Cottage and about the level of service, the level of dedication and commitment we have to meeting the needs of the people that rely on us for their health care. So a little feather in our cap at Grace Cottage for being so well thought of by our community and the people that use us on a daily basis for their care. Our next slide talks about hospital mission. Our mission is to serve the health care needs of our community to promote wellness, to relieve suffering and to restore health. I think all those attributes were covered in my earlier comments this morning. Next slide talks about our vision. We're dedicated to providing personalized, competent and accessible primary care, rehabilitation, wellness, prevention, inpatient care and emergency services. We really focus on preventive care as I mentioned earlier about keeping people healthy, about prolonging the well-being of our community. We collaborate with other health care organizations in the region, hospitals that are more full service organizations than Grace Cottage and we work very closely with organizations like Dartmouth-Hitchcock, with Brattleboro Memorial Hospital, with Cheshire Medical Center across the the state line, close to us in New Hampshire. We embrace, our community embraces Grace Cottage as a welcoming resource for health and wellness and the diversity and culture of our region will be reflected in all that we do. We're working very diligently on expanding our diversity and our ability to provide services to a diverse and ever-changing cultural community that we provide services to. I want to turn it over now to Stephen Brown, our chief financial officer. He's going to go over the income statement, the balance sheet and review our cash flow statement and then we can go into some specific discussion about our financial plan for the coming fiscal year 2021. Stephen? So our fiscal year 21 net patient revenue budget is based primarily on volumes experienced during the first five months of fiscal year 2020 from October through February prior to the pandemic with no additional growth projected beyond the trends that were showing in various service lines. For instance, it emergency department was trending up through all of those months and we expected that trend to continue. Didn't budget further growth beyond that but based it on what was showing during those times. We had experienced growth in some areas particularly in primary care as a result of providers, relatively newly hired providers, maturing as the last fiscal year ended, the beginning fiscal year started at those practices becoming full. So that's what the projection going forward for fiscal year 21 is based upon. I included in the presentation slides the income statement as well as the balance sheet and the cash flow primarily as reference points. I'm not going to read through them line by line be since you will call have them. The income statement is a very high level summary of an extremely detailed budget that was built from the bottom up based on extensive discussions and evaluation and truthfully best guess estimates of what might happen next year by each individual department, you know, forecast trying to forecast what may or may not happen, whether are no more government shutdowns or no more large outbreaks of COVID. It's extremely unpredictable, you know, impossible to predict, I guess, as everybody is well aware. But we used our best judgment to come up with where we thought we would be from a revenue standpoint and the associated expense standpoint. We did a really good job of trying to maintain an expense level that was really not a lot different than what was budgeted in 2020. It is certainly higher, of course, than 2020 projection. But 2020 projection would have been higher had volumes continued throughout the whole year. The next page, the balance sheet is again a very high level snapshot of where we're at, where our position is. It separates out our COVID funding sources that we will have left at the end of 2020, as well as where we believe we will be at the end of 2021. We were, which I'll talk about in a moment when we get to the slide that talks about COVID funding. We were very fortunate to have received hopefully what is more than adequate funding to get us through the crisis, even if it lasts through all of next year and into the next one. Cash flow statement I included simply to show where some of those sources of funding were coming from and going. Our overall change in charge requests for requesting for a rate increase for the coming year is 3.2%. We felt that we needed to ask for at least that much in part to keep our charge requests in some areas above what hopefully inflationary requests will be. In many cases, as we've talked about every year in the past, the majority of our reimbursement is cost-based reimbursement as a critical access and rural health clinic, particularly all of Medicare. That rate request doesn't really affect that reimbursement much on the bottom line. Actually, it doesn't really affect it at all. Where it affects are the things that are paid on fee schedules. If you're fortunate enough that a particular insurance company increases their fee schedule from one year to the next, you need to at least increase your rates enough to cover that because they aren't going to pay more than what you're requesting. Not that I'm ever hopeful that any of them will increase at 3.2%. I will turn it now back over to Doug to talk about service lines and any changes in the facility. So we have no immediate plans either short term or next year to make any major service line adjustments. We obviously are focused on risks and opportunities, which is the next slide. Clearly the biggest risk to us is what could potentially happen with the pandemic. We've been very fortunate. We've tested over 1,000, almost 1,100 patients here at Grace Cottage for COVID-19. We've had, I believe, 12 positive patients out of that total number tested and only one of those 12 patients actually died from the disease. The other patients were able to go home and recover without any complications. So we've been really fortunate in the fact that the disease has not been as damaging to the local community and to our employees as it has been in other parts of the state and other parts of the country. But that still doesn't tell us what could happen in the coming months. There's a lot of discussion about disease escalation as we get into the flu season, the influenza season. We don't know how COVID is going to react during the winter months when things get cold again and people gravitate back indoors, which is where the disease tends to spread most effectively. So we're not going to let our guard down. We've changed a lot of things operationally at Grace Cottage to ensure that our patients and our employees stay safe. Things like PPE and screening and visitation policies and things of that nature. We're going to continue those efforts and we're going to follow the advice of the health department and the governor as we move forward in managing COVID here locally and at Grace Cottage. But it's certainly a risk and I think it's going to have an impact on how people view healthcare. We've seen by virtue of the fact that so many patients, at least early on, were more interested in non-contact consultation with their providers than face-to-face visits. And we believe that's going to continue for a while. People are going to continue to be somewhat reluctant to go into hospitals, to go into the provider office. So we continue to tout the message to our patients that it's safe to come to Grace Cottage and that it's really, really important not to ignore your health care issues, not to ignore your symptoms. Don't put off your care. If you're not feeling well, make sure you reach out at least by telephone and give us an opportunity to guide you on the best course of treatment to deal with your specific problem. The other risk, of course, is Medicaid. It's been a risk since 1947 at Grace Cottage. When we opened, it's going to continue to be a problem going forward. Medicaid expansion is something we feel strongly about. I think a lot of hospitals in Vermont feel strongly about expanding access to patients who are struggling financially, who don't have health care insurance, who need Medicaid to gain access to care. Again, keeping people healthy is the way to lower the cost of care in the state of Vermont and across the country. And the only way to do that is to make sure that as many people as possible have access to particularly primary care, if anything else. But we can't continue to expand access to Medicaid while reimbursing health care organizations at a level less than half of what it costs to provide the actual care. And so expanding Medicaid access is important for the health of our communities, but it also creates increasing burden on health care organizations like Grace Cottage to figure out how to pay for the care, to pay for the cost of the care, and to keep our doors open and keep the lights on. You've heard that expression earlier today from the Rutland presentation. So those are the two biggest risks that we have our eye on right now. With regard to opportunities, expanding access to primary care, it's one of those important things we focus on at Grace Cottage. It's instrumental in our mission and vision for the future. We believe it's what makes Grace Cottage the phenomenal organization that it is. And we want to continue to provide access to primary care. So making sure that people get appointments quickly. In many cases now, same day appointments are available at Grace Cottage almost every single day. And we're going to continue to build upon that access going forward into the future and into next year. We're also taking advantage of an opportunity in the local area with the unraveling of a very busy pediatric practice in Brattleboro and the loss of pediatric providers in the region. We just took on an advanced practice provider in pediatrics to join our pediatric physician to create a two provider pediatric office to increase access to care for pediatric patients here at Grace Cottage. We're really impressed at the number of patients, families who are contacting us even before this new provider has hit boots on the ground asking how they can get an appointment and can get on to the schedule in the very near future. So it looks to be to us, even early on, to be a demand for pediatric care here at Grace Cottage where we're going to build on that access and the need for increasing demand for pediatric care. Steven, you want to say a few things about our capital budget plans for Fiscal 21? Sure. Our 21 capital budget includes primarily two large projects, both replacement or upgrades of existing equipment. One is the regular every five or six year replacement of our PIXIS med stations and the second is a large IT project which includes a complete upgrade and refresh of our wireless and physical network for connectivity which will bring our hopefully our entire IT infrastructure well into the 21st century and position us well for the next several years to effectively use our electronic health record primarily but everything else involved and particularly now the importance of being able to zoom correctly or efficiently and have good connection for that. Unfortunately, that's probably not going away anytime soon. We do not have any approved or planned CON projects at this point in time. So at this point, happy to open things up for questions and comments. A little bit of a delayed reaction on my mute button. Apparently when you hit it twice it goes right back. Sorry about that. We're going to start with board member Lange. Robin? Sure. Thank you and thank you very much for your presentation and all the work that you've been doing in terms of your operational changes in response to COVID. I've heard a couple questions around embedded assumptions around the Medicare reimbursement. I know that as a critical access hospital you are cost based and that sequestration had made a pretty big difference in terms of cost based actually being below cost. So I'm wondering if you've quantified or looked at the impact of the elimination of the sequestration through the end of this year on your 20 budget in the first quarter of 2021? So the 2% sequestration if you look at our net patient revenue of roughly 12 million Medicare and net patient revenue of roughly $12 million amounts to about $250,000 for a year. So what would be included in that three month period going forward is about $62,000. So it's, you know, it's pretty modest to have but it doesn't make a huge difference in the bottom line of a $20 million budget. Yep and I'm assuming that your Medicaid assumptions were a flat rate, no rate changes. Correct. Thank you. To get a little bit more information about your telehealth implementation, how, you know, what you if you did tell some telehealth changes in response to COVID and how that's been going. We've done a little bit of everything with regard to telehealth but not the actual volume impact has not been all that significant other than the loss, you know, the loss revenue initially when we weren't getting paid for for non-face-to-face contact with our patients. We've seen a little bit of relief in that regard now. We're actually getting, you know, paid something for connecting with patients on a non-face-to-face basis. But again, you know, everything we do is primary care. So, you know, telehealth with, you know, with other organizations for specialty and sub-specialty services, not very robust in Southern Vermont at the present time and probably not going to be very robust going forward because, you know, it's very difficult to rely on specialists and sub-specialists to provide you with telehealth consultations when the cost to them to do so and the lack of reimbursement makes it financially untenable. So, you know, until there is a national solution on how to reimburse not only the organizations that have the patients in front of them but the specialists who are on the other end of the technology chain to make, you know, telehealth an economically viable solution to expanding access to care. There's not going to be a lot of appetite for expanding, you know, telehealth anytime soon, at least from what I'm saying. That's interesting because actually in other parts of the state, we have seen a very robust expansion of telehealth in particular in primary care in terms of it replacing face, a lot of face-to-face visits. So, it's just interesting that that pattern is not necessarily reflected in your situation. We did reckon during the initial, you know, that during the shutdown period particularly, we did use a lot of telehealth in primary care for primary, for basically necessary visits. You know, most of our patients who did it for anything that they thought they absolutely had to have, it was difficult in part to make it very widespread because connectivity in this area for video ones particularly is quite limited. Getting good connectivity outside of downtown areas in the towns we serve can be very difficult. So, a lot of them were, you know, they relied on telephone visits which can only go so far. So, yes, we did do a fair amount of it, but as soon as people were able to start actually coming back to the doctor's office, that's what is happening because it's just not a substitute. Yeah, just to clarify, my comments around telehealth were really not telephone-related interactions. Zoom, FaceTime, things of that nature where screen where you can visibly, you know, the patient can see the provider and the provider can see the patient. But Stephen's right. We have a lot of telephone calls early on from patients who were concerned about their health and really didn't know what to do. Should I go to the emergency room? Should I speak to my doctor? Can I speak to my doctor? Can I talk to a nurse? Can I get some advice on where to go to deal with this problem? So, I have a lot of that and we provided a lot of that care by telephone and really weren't getting paid for it. Okay, that's also interesting because my understanding is that the Department of Financial Regulation Order requires commercial reimbursement. So, I don't know if it's out of state insurers that you're referring to, but certainly in Vermont telephone visits were being reimbursed. Not at the level of a face-to-face encounter, always. Sometimes you're right, some of them were. Thanks. So, the other question I had about the we have someone who is not on mute. I think it might be George for Williger. So, if you could please mute yourself. Thank you. In terms of the net patient revenue assumptions, looking at the first five months, I was curious if those assumptions also factor in the new pediatrician provider or how you factor that into NPR, if at all? For the year going forward, generally providers are budgeted at the level they are at. So, I look at each individual provider, what they've been doing, what they would do going forward. In the case of the pediatrician, that is a whole new position. So, yes, I make an assumption of what I think in the coming year she will be producing from a net patient revenue standpoint. But from a volume standpoint, each individual provider is more or less expected to continue the volume that they were doing in those first five months. Got it. Thank you. That's all I have for questions. Thank you very much, Robin. Next, we're going to move to Member Pelham. Tom. Good. Thank you. I'm almost instinctively, when it comes to Leland and Grand Townsend, want to say, go Eagles, beat Rebels, but that was longer going far away. My first question is, you say in the narrative that both Medicaid and commercial relative rate changes in charge has little effect as long as our charges are higher than the fee schedule when it comes to Medicaid and commercial. And so, I'm just wondering whether the 3.2% requested increase in charge leaves anything on the table in terms of commercial and Medicaid relative to your commercial Medicaid fee schedules, or is, in other words, would a higher change in charge result in more revenue or have you maxed out with a 3.2% increase in charge? A higher rate increase would make a small difference on a small part of our business. So, for those, essentially, all of Medicaid is on a fee schedule. So, you're only going to get paid what they decide to pay us on that fee schedule and what we charge doesn't matter. On the commercials, for instance, Blue Cross, Blue Shield, we get paid for outpatient services on a fee schedule for laboratory and diagnostic imaging services. So, it doesn't, again, it doesn't matter what I charge as long as I'm charging more than what that individual fee schedule for an individual test is. Where it does make a difference is on the rest of, for instance, Blue Cross, the rest of outpatient services as well as all of our inpatient services are paid on a percent of charges. And several, some of the other commercial insurers as well, usually all inpatient and most outpatient are also paid on a percent of charges. So, yes, the more I charge, the higher they're going to pay me. But they also, we negotiate contracts, for instance, with Blue Cross each year. And the more I increase my rates, the more they want to increase their discount and therefore reducing the percentage that they charge. So, it's a fine line. How much of it I'll end up actually getting? Thank you for that. So, I mean, it looks from your balance sheet that this CARES money has been quite helpful. And it looks like about four million dollars there that seems to be, you know, will be there over time and not have to be spent. So, what I'm just curious is to what is your view of this one-time money that's enhanced your balance sheet going forward in terms of trying to save it and use it as an investment or to spend it down slowly? What's your thought about that money? So, just quickly, I meant to talk about that sooner than I never did. I really forgot that it was in the budget submission that had the slide about funding sources rather than our presentation. So, if you had recall from looking at our budget presentation, we essentially, at the beginning, back in April and May, got roughly 10 million dollars of cash coming into the facility, about three million dollars in Medicare advanced funding, which of course is strictly a loan, a three million dollar payroll protection loan, some of which will be forgiven, and about four point three million dollars in CARES Act stimulus money. As of projection at the end of this current year, we, wow, let me back up one second. The three million dollars worth of Medicare money, they're going to start deducting very soon and we fully plan to return all of that money and have not spent any of it. The remaining money, the payroll protection loan and the CARES Fund money, we will have used as of the end of 2020 roughly only about two and a half million dollars of that money. And assuming we use the eight hundred thousand dollars in the 21 budget that I put on that line, at the end of 21, we're still going to have about three point seven million dollars left over. I don't honestly know, as of today, how long we're going to be able to keep that money. I mean, based on the last thing I read a couple of weeks ago, the current plan is that you have to have spent all of that money by next June, or July, I believe it is, or returning. Fortunately, we have got all of the money still sitting in the bank that we cannot justify having spent for COVID related loss and revenues or COVID related expenses. We're not just spending the money on things that are not COVID related because you have to justify to the federal government for the CARES money what you spent that money on. So, you know, we're fortunately in a comfortable position right now that we still have more than enough money to cover any revenue shortfalls related to lack of volume due to patients not coming in here due to the COVID crisis and or increased expenses related to such as some of the things Doug referred to, you know, that we've added full-time screening positions to screen patients coming into the building. We've had to remodel or working on remodeling registration areas for that purpose, additional positions in areas such as housekeeping and places like that due to the extra work involved. Of course, PPE, spending a lot more money on that. But at this point, as far as we can foresee, we will have plenty of COVID funding available to cover any of those increased costs or reduced revenues. Thank you. Another area, and this just could be, you know, the issue having to do with your size and small numbers. But I was looking at your growth in bad debt and free care, first by 88% and the second by 34%. And the statewide averages across all hospitals, which is huge number in the billions is at 12% and 14.6%. So I'm just wondering if you could talk a little bit about your increase in bad debt and free care and what's behind that? We fortunately have a relatively low percentage of gross revenue to start with as a write-off percentage. You know, I think truthfully what has happened is people are making choices who to pay. And, you know, we're not high on that list of people that are going to stop providing them service if they don't pay their bills. They don't pay their fuel bill and they're not going to get fuel. If they don't pay their grace cottage hospital bill, we're still going to take care of them every time they walk in the door, whether it be an emergency room visit for primary care or needed library x-ray done. So I think it's simply our community and our community knowing that we're near, we're here when they need us and we, although we'd like to get paid, we don't force them to pay, which is probably also one of the reasons that our community is also so generous to us. Well, speaking of that, when I was down there, you talked to me a little bit about the finance committee that you have and that there are a lot of second homeowners on that finance committee and that you have all these second homeowners down there and they want to have a hospital that's up and running to their to their standards. And I'm just wondering, with this COVID event over the first part of the year, what have you seen in terms of the second homeowners and their support for the hospital and their comfortableness or their inclination to spend more time in Vermont? From what I can tell, all of our second homeowners are now primarily primary homeowners. I think pretty much every second home in the area has been occupied since March. I don't know if there's any current plan for any of them to leave. Truthfully, you go down to the local grocery store and there's as many non-Vermont cars as there are Vermont cars in the parking lot. And it's not, although there's still plenty of people coming to visit, it's not just people coming to visit. It's the people that are here. And they have continued to be extremely generous. Even during this, our foundation truthfully was shocked at the generosity of donors specifically during such a difficult time when some of those donors were probably thinking, should I spend my money because the stock market is down so far. But they've continued to show their support. And my final question is, in terms of overall NPR, you folks are seven tenths of one percent. I mean, you were very small. You've also the only hospital that over the period up to 20 or through 2019 had negative operating margins all five years. There's no other hospital that's been in that circumstance. So I'm just wondering if you have any advice for us at the Green Mountain Care Board, how we can better support a small hospital like you? Are the things that we can do that that can help you strengthen your financial structure over the long run? Especially if this one time COVID money kind of goes away and you have to pay it back at some point. So it's just a kind of an open ended question. To be perfectly honest with you, Doug already touched upon it as our biggest risk. And truthfully, the main reason for us not being able to achieve a positive bottom line is the abysmal Medicaid reimbursement and the fact that this tiny facility contributes almost $2 million a year to the state of Vermont Medicaid fund. I sadly know that you don't really have any control over that. But that is the bottom line. I mean, continuing to essentially write a check to the state of Vermont every year for $2 million. This facility, I don't think truthfully can ever have a positive bottom line. Well, on that note, I'll pass it to Tom. Anyway, yes. Thank you, Tom. Now we're going to move to member Yusuf or Maureen. Thanks. I'm actually going to take a little different take on what Tom was just talking about. You have had negative operating margins for the past five years, and you continue to miss your budget each year. And I know you're small. I know it's not going to move the needle tremendously. I really want you to be a successful hospital. I think that as we look at your requests for this year, it's similar to what we went through last year. So last year, you would ask for an 8.7 percent increase, which we reduced to a 3.5 percent increase, although the trend would have been looking at much lower than just bringing you to the 3.5. And I remember there was a lot of pushback about how you were going to hit these high numbers. Through February to that revised budget, you were tracking that negative 6.8 percent. And as we look forward to what you're forecasting for next year, if I just take you at, you're going to go at the same rate that you were at this year, which was at the minus 6.8 percent, you would come out to be about 18.6 million dollars, which is about where you've been for the past several years. Your forecast this year has your fourth quarter up projected up 12 percent from where you were a year ago. So one question maybe to help me feel comfortable that you can achieve these numbers would be, do we know where we were running through July for the fourth quarter? Were you up significantly? And I really want to get the point that the concern here is your expenses are built on achieving a budget of 21 million dollars and you're spending 22 million dollars, 22.8 million dollars is your projection. And should you come in around 18.6 or 19 million dollars, which was the push we had last year, your expenses are going to be quite out of line and you lose a lot of money. So I'm just trying to understand how you're going to get this potential growth again that you're forecasting. And yes, you're small. It's not going to move the needle. It's more for the health of the hospital because if you end up coming in around 19 million, you would eat into that carers money pretty quickly. But as you've said, you're probably going to have to return a bit of that because it wasn't for loss volume. So just trying to get a comfort on your NPR forecast as it relates to you being down 8% for the first five months of the year to the revised budget and then projecting significantly up in the fourth quarter. A lot of them, you're right, being small is difficult in a lot of ways. But one of the issues with it is it doesn't take much of a change in a specific line of business to make a big swing. And part of that is in what we're doing for business. To give you an idea, as an average for outpatient revenue for the hospital, we collect, give or take 50% of what we built. For the inpatient side of the service, a queue and or swing patients, we collect more like 85 to 90% of what we built. So it doesn't take a very big swing or flux in inpatient volume of collecting a lot more of what you're actually charging to offset even a small decrease in outpatient volume because you're only collecting half of what you're charging. And we have been, as Doug said, our patient census has been up this year and particularly truthfully since not so much during the true shutdown period of COVID in April. But since then, we've been busier on average than we normally are in the inpatient unit. No COVID related admissions, but we've had more acute patients in days than normal. We've had a lot of swing bed patient days. This past week on, I think it was Thursday, we had a six or eight people trying to get in here to be swing bed patients and we didn't have space for them. So that's where kind of the projections are going. Yes, there's a total gross patient volume. It doesn't necessarily change a lot. The net patient collection is very different depending on what you're doing for a service. And I hear you about expenses while it appears that the expenses are built on a particular volume. The majority of our expenses are fixed. Whether we're projecting a million dollars worth of diagnostic imaging revenue or $500,000 worth of diagnostic imaging revenue, I still need the same amount of staffing because I have minimum staffing levels in most of those departments. Diagnostic imaging, laboratory, they're all in order to keep the doors open. The emergency department is a perfect example. I have to staff the emergency department with a 24 seven provider and nurse, whether I've got one or two patients, which is exactly what we had a day during part of the period of the COVID. There were days we only had one or two patients or I've got 25 patients. Those same two people still take care of all of them. So we daily try to keep our expenses as low as possible and they're all tied to the volume we're doing. And a small change in volume does not increase or decrease the cost of our running this facility. Yeah, I just, I mean, I'm going to need a quarter. I hear you and I'm and truthfully you're only looking at five years not to make this sound good, but I have been here far too long, 36 years, I guess it is now. And I can remember one year out of 36 years that we had a positive operating margin. I appreciate that your community really helps out. I'm just, you know, in 2018, you were at 18.2 million, 19, you were at 18.7 million, 20, if I were to track where you were for down 7% through the five months, you would have been about 18.4, you know, and then now asking for the 21 million. I mean, the question on July, do we know, you know, to make me feel more comfortable in July? Do you know roughly how far ahead you were a year ago? Or can you get back to us on? I could get back to you. This week, as soon as we're done today, we need to try and do the July financial reports because honestly, they haven't haven't had time getting working on the budget to do those. But the other thing that speaking a little bit earlier in Rutland's presentation, Judy mentioned revenue cycle, and we've actually, that is actually accounts for a little bit of the revenue increase net patient revenue increase as well. We have a new director of billing that's been here now, a year plus, and has spent a lot of time assuring that we're actually getting paid for every service we provide. The emergency department is a good example, whereas, you know, rather than just if you come into the emergency room, rather than just billing a facility fee and a provider fee, if you have specific procedures and things done that insurance companies pay for, they're now billing for all of those that we were providing the care. We just weren't always billing every dollar that you could bill for and get paid for. Not that there's a lot of that, but that contributes to the bottom line as well. Yeah. I mean, I'm not going to keep just, you know, last year when we brought it down, the point back was, oh, we're going to have to cut services in order to get to the reduced number that we gave you. That's not the intent. The intent is, and we said, no, don't cut these services. If you can really get to that number, get to that number. Right. But it just doesn't look, again, like you're going to get to the numbers that you're putting forward. And again, you were trending down for the first five months of the year significantly, 7% on a budget that we reduced by 5%. So the whole point is to try to make sure you can be around and be sustainable. It's, you know, you're not going to get it obviously from commercial rate is a small ask and it's a small contribution because of your pay or mix. So I think I got my point across, but at least like to get July where you are, because you're tracking that you're going to be 12% ahead for the fourth quarter of this prior year. If July is not tracking well ahead, you're going to miss the fourth quarter. Okay, thanks. Okay, next we're going to go to member Holmes, Jessica. Okay, thank you. And thanks for the presentation. I'm not going to belabor Maureen's point, but a couple of things I just want to suggest about the NPR. One is we just heard from another hospital that their revenue predictions are down because of the social distancing and the disinfectant that has to happen in between patients. And so that reduces productivity. So I think that's one concern in sort of assuming a return to pre COVID volumes is simply like, do you have the capacity and the productivity availability to do that? And the second concern I'm saying is the second homeowner, right? I'm sorry, Jessica, you cut out. There was some background noise there. The second concern, if you could just start that over. Sure. The second concern I have, it's not volume, it's not background noise here. No, you're cutting out. We couldn't hear you either, but it sounded like your connection was cutting out. Okay. Can you hear me now? Yes. Okay, perfect. My second concern is just that if second homeowners who have stayed through the isolation and the quarantine next year in 2021 return to their primary homes, that's another reason why volumes may also decline. So those are two concerns that I have about the projections for returning to pre COVID revenue. I don't want to belabor it. We've talked about it enough. I'm just going to, if you have an answer that's great or a thought about that, that's great. I don't want to belabor it too much. While they may be included in the projected amount for the month of July, August, September, they really were not included in the budgeted amount going forward because, as I said, the budgeted amount was based on volumes in October through February. So they weren't here to start with. And honestly, like I said, in October through February, emergency department, for instance, was continuing to trend up, although those people might be coming at the moment to the emergency department because they don't have primary care providers here. I truly don't think we have huge amounts of business at the moment from the secondary homeowners being in the area. Okay. Actually, the emergency room was interesting to me. You staff a 24 seven emergency room. Correct. It sounds like you have about seven to eight patients a day on average, right? That is correct. Yeah. And I'm just wondering at what point of patient level do you say this is just not cost effective? I know you're critical access hospital. I know there's cost plus reimbursement, but at what point, given that Brattleboro is 25 minutes to the south and Springfield is what 40 minutes to the north, at what point does it just become cost ineffective to fully staff or, you know, have two providers, as you said, 24 seven for such a small patient count? It became cost and effective many, many years ago. But if we choose not to staff an emergency room 24 seven, that would be making the decision not to be a critical access hospital because that is the requirement of a critical access hospital is to have a an emergency room 24 seven. All right. And if you explored other designations, we used to be a regular PPS hospital. I'm not sure if there are designations as a hospital that you can continue doing what we do with Q and swing, which are important to the facility, and also not have an emergency department. And just on that note, however, truthfully, the emergency department having the emergency department is one of the reasons that our community are the primary reason that the large dollar volume comes in from fundraising of that $1 million we get a year give or take from those second homers that want the emergency department here. And you're correct that Bratabro is only 17 miles south of us. However, many of the patients that are coming to our emergency department live 42 minutes to an hour north or northwest of us. If you happen to look at a map and see where we are located, Springfield is a good 40 minute drive to the northeast. Rutland is an hour and 10 or minutes more to the more or less north, slightly northwest. And then you've got Bennington an hour plus the other direction. So there's a huge, huge area of people that have already traveled 45 minutes or more to get here and would have to travel another half hour to get that 17 miles to Bratabro, which is about what it takes. And I know that from experience because during my early years here, I spent six years driving our volunteer ambulance service that we had at the time. And it's a long way trying to get to an emergency room. Okay. I guess my last question in the interest of time is you didn't answer the health care advocates question about the average commercial reimbursement to Medicare reimbursement because you claimed that you couldn't calculate it by individual payer. Just for completion of your submission, if you could follow up with at least to the hospital budget team, the average commercial, so not by payer, but across all payers commercial to Medicare reimbursement, that would be helpful. Okay. Thank you, Jess. Steve, in a perfect world, what would be the percentage of your loan that you would hope to be forgiven? When I did the budget submission, I was looking at probably 65 to 75% of it being forgiven. Truthfully, we've actually just started looking at that with the change they made to the number of weeks of payroll that you could include now. I'm hopefully optimistic that we actually might get the entire thing forgiven. That would be great. At this point, I'm going to turn it over to the health care advocate, Mike Fisher. Mike? Let me unmute myself. Let me just say thank you, Jess, for your question about our question. And with that, we have no other questions for Grace Codges. Thank you very much. Thank you, Mike. At this point, we're going to open it up to public comment would anyone like to issue a public comment on Grace Codges budget submission? Okay. That was very short and sweet. And actually, we are now ahead of schedule if you can believe it.