 So good morning, everyone. My name is Kevin Mullin, Chair of the Green Mountain Care Board. I'm going to call this meeting to order. The purpose of today's meetings is to hear from two hospitals for their hospital budget presentations. The first will be Mount of Scutney and the second will be Copley. After each of the hearings, the board will ask questions, then the healthcare advocate will ask questions. And then I will open it up to the public for comments on that particular budget hearing. Just as a reminder to the public that there is an open public comment period on now and you can log on to our website and issue a public comment anytime in the next couple of weeks. So with that, Kim, if you could swear in the three people from Mount of Scutney. Okay, would you please raise, excuse me, would you please, excuse me, off to a good start this morning. First, I can't hear. Okay, raise your right hands, please. Do you swear the testimony you were about to give shall be the truth, the whole truth and nothing but the truth, so help you God. I do, I do. Thank you. And just checking, I see Jess, Maureen and Tom, Robin, are you on? I am. Super. So Joe, whenever you're ready, take it away. Great, I assume someone will share our presentation The way I understand it, the hospitals in the guidance were informed that they were this year. Okay, sorry, just give me a moment and I will bring it up. I thought we were not doing that so that we wouldn't have any funny business, but I will bring it up, just give me a moment. Apologize. Abigail, do I have that correct? Yes, you were asked, but if you can't, I'm happy to do it. Nope, nope, we're coming along here. I don't know what that funny business could be. I don't know, Dave, Dave Sandville, it's always. Well, that's true, say no more. All right, getting started. I had to take an oath before we get on here not to provide any shenanigans, so. We'll see if you can uphold your end. Don't lose the humor, though. We look forward to your humor, Dave. Thank you. Sorry about that. There we go. And how does that look? I can't see it yet. Okay. It's posted on our website too, just as a reminder, this is Susan Barrett speaking. Sorry, it's my Microsoft Teams inadequacy. I think we're getting there, though. There you are. All right, just be still there. Does it look better? It's still in the mode where you see the other slides as well, but that's okay. How about this one? Now that's my screen. Yeah, it's still in the presentation mode, but that's okay. I mean, instead of seeing one side, we're seeing the one big one and the three on the side, but that's okay. I will get going then. Most of this is, most of the good stuff is narrative. We all have it too in paper ourselves, so. Great, super, as do I right in front of me. So thanks for having us this morning, giving us a chance to share our budget and review some of the work that we've been doing over the last year. Starting with who's here, it's myself. This is my eighth year at Montesquotney, my sixth year as the chief medical officer, and my fifth year as both the CEO and the CMO. I looked at all the hospitals in Vermont last night, I think as interesting as it sounds that I'm the fourth longest serving CEO at a single hospital in Vermont right now, which is shocking to think about. Dave Sanville, who you all know well, is our CFO. He's been at Montesquotney for nine years and Teresa Tabor, our controller, has been at Montesquotney Hospital for 10 years. So we've had some significant stability in our finance team, which has been a huge help for us. This is what we'll go through today. We have a, this is a very long presentation, but we will try to move through quickly and really focus on the important stuff. The obligatory drone shot of Montesquotney Hospital. So Joe, just so you know, you're not advancing your slides. So I'm sorry, jeez Louise, so annoying. I apologize, let's try this. Says I'm sharing, which is interesting. Try this again, screen share. How about that? Is that working a little bit? Drone shot, are you all seeing the drone shot? We're seeing the drone shot. Perfect, so our mission, again, to improve the lives of those we serve, our mission statement has not changed. That's one of our rehab, acute rehab patients in our vector gate training system. I believe that it's only us and Spalding that have this gate training system for post-stroke and post spinal cord injury patients in all of New England. Our org chart has not changed. We remain a member, system member of Dartmouth-Hitchcock Health and have been since 2014. I do wanna call out our assisted living facility, historic homes of Runamied in Windsor, Vermont. It has 40 to 50 beds slash apartments in the assisted living. It is an organization under significant stress right now due to staffing, due to the pandemic, due to some leadership changes in the last six months. It has been a struggle for our entire leadership team to keep HHR going through these times. I think we're moving to a good place, but it has been a significant drain of resources at the hospital level going down to help support the assisted living. Our current integration activities, I can summarize this by just saying there's really no aspect of our business enterprise or our clinical service lines where we are not fully engaged in integration. I would describe the first five years of our engagement with the system as involving kid gloves on both sides as we figured each other out. And I would say the last three years it's been pedal to the metal, let's start behaving like a system, let's do everything we can to reduce expenses, let's rationalize how we deliver care across the region and also look for further regional partners. Our current service lines are on this slide. Everything you see in red is directly supported by Dartmouth-Hitchcock Health with specialists. They provide one of our general surgeons for four days a week. They provide a cardiologist one day a week, a gastroenterologist one and a half days per week. They do Dartmouth-Hitchcock Health radiology performs all of our radiology reads and procedures. We have a pain management specialist that comes down a couple of days a week. We also get support from DH for telehealth in both emergency medicine and psychiatry and neurology. We hired the neurologist, it's been a long time search to help support our rehab hospital and heavy stroke population on the inpatient side here at the hospital and on the rehab. I want to also add that our physical men rehab, neurology, podiatry, psychiatry are all regional services since many of those are surrounding neighboring hospitals do not offer those clinical service lines. I always try to find an opportunity. It's a little bit tough to read, but I'll summarize. These are the 10 areas for inpatient H-CAPS, Patient Satisfaction and Quality Surveys. And Manuskanee Hospital for the last few years has led the state of Vermont in overall scoring. This past year we were the highest ranking hospital in seven of the 10 areas surveyed. The year before, I believe we were eight out of 10. And this is the result of a lot of effort over the last seven years to improve, to invest in our quality and safety teams, to improve employee engagement and the flow really was almost a linear progression in our patient satisfaction and quality scores as we invested in quality and safety and engagement. These are the two I'm most proud of. How well do patients rate the hospital? We have the highest scoring in the state and would the patients recommend the hospital with friends and family, same result there. So with that introduction, I'll hand over to Dave for the next few slides and then he will transition back to me. Dave, I'm happy to be your slide advance, sir. Just let me know. Okay, thanks, Vanna. So we do have a lot of slides. So I'm really, I know you guys are excellent readers. So I'm just going to hit the high points on the finance slides. And certainly if there's anything that you wanna have for discussion or questions beyond that, happy to address them. Our overall price increase for the year is 2.2% and essentially what that equates to is a 2.5% across the board, inpatient, outpatient physicians, but a 0% increase in pharmaceuticals, which becomes a weighted average of 2.2 across all lines of business. As for some perspective, for the last eight years, we have been on the lower side of the average price increase. And number six of eight for Vermont CHs, in other words, two CHs with lower average price increases than us. So we've really made good attempts over the last several years to manage down our price increases. And as you saw in our narrative, despite the low price increase, we are having an MPSR FPP increase greater than the 3.5% allowed. Next slide. This is the P&L, essentially a 1.65% operating margin, a 3.6% total margin. So it is what it is. Next slide. Balance sheet, obviously a very good investment market this year. We've been having a good operating year as well. And so our balance sheet is definitely stronger than in prior years. Next slide. Our cash flow, this may look a little bit different than what you have in front of you. We really couldn't make this work for us. So we converted these numbers to something that matches what we use internally and what we use with the Dartmouth-Hitchcock system. But essentially at the end of the day, we expect a negative flow of cash of $2.7 million during the course of next year. And mainly that is because of capital investment that may be lower if we decide to do some loans to fund some or part of that. But at this point, it's in our budget as cash transactions. And our capital is up from normal years, mainly because we did so little spending last year. And despite efforts to make sure we spent what we committed to this year, lag times and availability of folks to get in here is just killing us. And so we're gonna grossly underspend again this year. Next slide. Next slide. If that didn't advance, Dave, sorry. No, sorry. So some of the assumptions that we used, I know there's been some discussion and we addressed it in the narrative, but this was a very difficult year to estimate. Last year I thought was difficult. This year was actually more difficult because we have really zero trend. So we use what we budgeted for 19 and 20. We looked at what we did in 19, how 20 went and how 21 is going. We tried to incorporate any consideration that we could come up with related to COVID, whether it was relocation of services, additional staff needed to make sure patients are safe, moving through our system and other known changes in operations. Really impatient. If you were to look at our statistics, our in-house patients are the ones with the biggest changes year to year. Early on in COVID, we received virtually no swing bed patients unless they were recovering from Dartmouth or other facilities and needed skilled level of services in our swing bed unit. Acute has gone up, mainly because we've been a COVID accepting facility and we've had a great deal of services referred to us from other facilities because they did not feel they could provide those services. Impatient rehab also took a big hit during COVID, although it's come back to normal numbers at this point in this year. So really we're kind of just right sizing back to normal in-house levels for FY 22 as compared to say 19 or prior. If you were to take 20 and 21 out of the data trend, you would see that our average impatient census in our utilization has stayed pretty consistent over many years. Next slide. I'm not going to go through these, but suffice to say that what we did is we looked at how we were trending as 21 really seemed to get some, well, we got some traction. We had to go back and look at prior years and generally, if I were to make an assumption over FY 21 annualized, our budget for FY 22 isn't that much different on the outpatient side. I will tell you that over the last few months, our ER, we have historically budgeted 13 to 14 patients a day. We are now running over 20 a day and we've had days as high as 41 within the last two weeks. So we're being crushed right now in the emergency room. Lab testing I'm sure with everybody else is up significantly this year for the testing in the pandemic and most other departments are performing fairly well. Next slide please. Clinics is a mixed bag. We knew that primary care with volume would go down this year and it did. We are functioning pretty close to budget in that regard. We've lost a couple of providers in primary care which has put a little pressure on meeting volume targets. We did close down the Otakuchi Health Center from COVID testing and had everybody come to the main facility and so that affected their volume pretty significantly over the last year. Psychiatry, we are kind of blowing out that budget currently as we have three FTEs but we have one of our psychiatrists who will be starting that glide path towards retirement and that accounts for most of the decrease in psychiatry. Rheumatology is increasing 32% mainly because that was hardly seen here. We have a very part-time service and with the complications of COVID that FY21 performance was significantly down. Oncology has actually been surprisingly solid this year but we expect it to go back down to more normal levels which is a 50% reduction in that clinic. Our specialists are performing fairly well and we expect them to continue. Neurology was a new service that we budgeted for FY21 and we are sharing that provider with the VA but she is very productive and that's actually turned out better than expected. Next slide. No significant changes in commercial reimbursement rates. Medicare, again, predominantly cost-based reimbursement. We did assume that sequestration would come back into play at some point during this next fiscal year. Depending on how long this pandemic lasts, we'll see if that holds true. Medicaid, our assumptions are basically the same. We know that they would typically lose some ground on inflation but nothing radical compared to historical filings. Next slide. So the change in net patient revenue increase, a very large increase for these years and again, we already talked about the rate changes are all 2.5% with the exception of pharmacy which we base off of actual costs. So we don't just add an inflationary increase on that in any year since I've been here. Next slide, please. We have no provider transfers. We have no reporting or accounting shenanigans. Material price changes in ancillary services is something that is not entirely recognized in our budget. And what I mean by that is that because we're having a solid year, we've taken the opportunity to reduce some pricing in some of the areas that we were very high and expensive in. At this point, actual price increases annualized that we have put in over the last couple months are totaling about $1.5 million in growth charges. So when we say we've filed for a 2.2% increase when we put through the last couple that I actually have sitting on my desk right now will probably be functionally a 0% rate increase across the board. Next slide, please. So other operating and non-operating pretty much standard fare for us. We do put a $150,000 subsidy in grants, 340B, no significant change. There's some uncertainty with blueprint funding which I'm sure you're all aware of. And 5% investment income return and fundraising of 250,000. This is pretty much what we budget year in year out. Next slide, please. Expenses, two to 3% increase for all employees. 2% will go into effect as of 10-1, 21. And then we'll do additional markets as affordable for the other remaining percentage point. We have a fairly small increase for health benefits which I think you're seeing in most places because a lot of folks are lost runs, so to speak have stayed down with COVID, although we're picking up in that area. We're gonna have a 3% contribution for 403B for our employees. As a reminder, we terminated our pension costs last year which is a savings of a few $100,000 a year which is recognized in 22 completely. And we do have an increase in FTEs next year, 3.3%. And an overwhelming majority of that is related to COVID either front door, door screeners, managing any vaccine or booster clinics that we'll be doing in the respiratory clinic that we're running. Next slide, please. Nonst, oops. Sorry, Dave, there you go. Really not a lot to talk about in non-stallery. Pretty much everything is, the one made to be notable on here is purchase labor which I'm sure you're hearing from everyone else. We've had more travelers in this last year than we've had in probably any two years combined since I've been here. And that's despite very high employee engagement scores, fairly low turnover. It's just really been a struggle for us this year. But we also have outsourced our anesthesia professional component. They were employed and next year they'll be purchase labor. Actually, they are right now. We changed mid-year this year. And additionally, we're also working with Dartmouth to kind of pick through opportunities for shared labor between the organizations. And I think as Joe kind of touched on in the slide about all of our specialties, one of the benefits that we are getting from them is sometimes it's, you know, we just need two days of a doc or two days of a certain specialist and we're able to contract for that. A lot of times when I've been in other facilities that didn't have a relationship with the system, you know, well, we only need 0.6 urology, but we can't get any, we can't get a 0.6. So we have to have a 1.0 and we really don't have the volumes or the population to justify that. So we're a little bit more efficient in that regard as being, for being part of the system. Next slide please. So margins, we can just go to the next slide, Joe. This is, I always like to provide some perspective. Matt and Scott and he had some kind of assorted history and really what we've tried to do starting with the Kevin Donovan era and now with Joe Parris is really try to, you know, get back what had been lost many years ago and get back to a place of days cash and things that would be triple B, triple B plus rated. And the purpose of this graph is really to show, you know, where did we break even from 2011? I started the last month of fiscal year, 2011 and we went into a major computer conversion in that month and through 2012. And you can see that large negative blip in 2012. And some improved trending of performance since then. And you'll see on the right side, the break even line of kind of going into 21, we had kind of gotten to, or with projected 21, gotten to a break even for all of those years. And this is just a cumulative measure of that. Next slide please, Joe. And then this is, for those of you who've been kicking around the state, we used to use this chart at Gifford for many years. We called it the chaos chart and it's everybody's performance against what they said they would do. And the blue line is us. So what we're measuring the area is, what did we say we were gonna do one year and then how close did we come to it? Zero being the goal. And as a system, you can see the orange line is pretty much operating at zero for the system. And again, I'm measuring change in percentage. I'm not measuring dollars here per se. And so we've become one of the more consistent. There are about three other CAHs who have been more consistent than we have been at predicting ourselves over time. And we are in the upper half of all hospitals as well. Next slide please. And I think I'll jump back in here for a big chunk of slides coming up. We were asked to comment on the risks that we have faced in 21, but specifically in 22. And obviously we're all living in the time of Delta. We are hopeful that the modeling is correct and that Delta will peak as far as inpatient and outpatient cases over the month of September and then hopefully decline quickly at the end of September into October. I think there's also some hope that the widespread and highly virulent nature of Delta will suppress other variants at least for a bit as Delta as I said has swept across the country quite quickly. And our challenge is how do we maintain our three phased approach to the pandemic when we're suffering both acute and chronic labor shortages? We committed from the end of March to rapidly expand our testing and respiratory evaluation capacity with a designated respiratory clinic. We built out a acute COVID unit in our hospital and committed to caring for both acute, post-acute and acute rehab patients with COVID, basically all comers that did not require critical care or intubation, we took all of those folks. And that includes patients from other EDs and other hospitals around New Hampshire, Vermont and New York. It's one of the reasons why we did not, where I should say why we recovered quickly after falling off the financial cliff in March, we were able to keep our inpatient units full. It was a big stress on our docs, our staff, but we provided care that our surrounding communities needed and continued to as recently as last week. We had three COVID inpatients, although we're starting this week with zero. But we are running out of staff and it has become a challenge as all the per diem staff, all that extra FTE that we had to take on to man our vaccination clinics, our nursing units and our assisted living for that matter, have either returned to their old jobs, it left the workforce. We've had, there's been significant comp pressures and we've had to repeatedly, even during the pandemic, make changes in comp across the board so that we can both recruit and retain our workers. I've said this before at budget presentations, there are significant regional pressures being 25 minutes from DH as they compete with Boston for a significant talent. They, the wage and benefit expense is significant and as they make changes, we have to make changes as well. We are trying to act as a system when there are significant changes, say in nursing comp or technical positions, which doesn't help us from a budgeting standpoint, but I know it definitely does not help our neighboring non-system member hospitals who then have to make changes to keep up with what we have to do. And just keeping in mind that there is a new patient tower at DHMC going up that will require hundreds of new nurses and other staff to operate within the next 18 months. Other risks, our ACO engagement is staying the same for 22. We remain in Medicare, Medicaid and the blues of the commercial exchanges as approved by our board of trustees. I would say there's split organizational enthusiasm around increasing engagement, even with upside only programs. There's a phenomenon with inpatients when there are these folks that things always go suboptimally for when they're admitted to the hospital, either a medical mistake is made, something gets lost in the transition, these kind of snake bit patients in the healthcare system. There's a sense among our board and our leadership team that we've kind of been the snake bit hospital with the next gen ACO. Happy to go into more of that later in the presentation, but our road has been a rocky one, but there are other real beyond just financial risk and reporting risk and accounting stresses. All of our specialty and expensive care for the lives that are attributed to us, such as orthopedic, psych, all specialty care, critical care, that all for us, that all happens at Dartmouth-Hitchcock. Most of our regions orthopedic care happens in New Hampshire, whether at Alice Peck Day or at Dartmouth-Hitchcock and even some at Valley Regional over in Claremont. So we have limited control over some of the, most of the expensive care that occurs for our attributed lives. As I mentioned, we are dealing with wage pressures and then uncontrollable inflation, especially around the cost of PPE. The insurance products, Dave will probably comment on the huge increase in premiums across the board that we've had to face as an organization. We always make a point of this around trying to thread the needle of system needs versus our local hospital needs versus ACO needs and what we can do from a budgeting standpoint. This is a challenge every year. We're getting a little bit better, I think, on the system side. Again, as we've evolved over the last seven years or so and what we do well and lines of business that we're likely not going to get into, which functionally hurts us budgetarily. If I had a four or five person orthopedic program, we wouldn't have any worries financially, but that's just not really what the system needs. And frankly, not what our region needs considering what's at DH, what's at Valley Regional and what's at Springfield. We continue to have a high proportion of subacute patients on our swing unit. I know folks on the agreement on care board, remember the data from the sustainability work that we've all been engaged with the Green Mountain Care Board. Manna Scottney and UVM had the highest utilization of inpatient beds in the state in the high 70s. For us, most of those patients are subacute while this past year we've had a really a doubling of our acute inpatient volume due to COVID and other pressures and also driven by our, almost doubling of our ED visit volume as well. Generally, we're full of swing patients and that is tough to float the bottom line on. And as Dave mentioned earlier, there's yearly, there's ever increasing dependence on other operating revenues. We've really met work to maximize our opportunity within 340B, we get, we bring in around $1.2 million in grant funding to support our community health initiatives. I have a slide coming up describing some of our work with prevention grants for tobacco, substance abuse in coordination across the state. But Jill Lord, our director of community health does a phenomenal job bringing in money to support the community health efforts that otherwise do not get reimbursed. Opportunities, we are continuing to work very closely with Valley Regional Hospital in Claremont, New Hampshire. And we feel that we know that that work will accelerate in 2022. We did spend a significant amount of time, six to eight months working on possibly bringing together kind of a three hospital microsystem in our region between us and Valley and Springfield while Springfield was in bankruptcy at the time. The end result of that work was a proposal that the leadership at Springfield at that time and their board and their bankruptcy attorneys did not want to pursue. So they have remained independent but the work with Valley continues to move. We share managers, we share directors, we are constantly looking to fill in holes for each other's organizations. Right now it's been on the management side and on the director level. But we hope to bring together pools of technical workers, rad techs, respiratory therapy, physical therapy, occupational therapy who can move between the two campuses where 17 minutes apart and while we're in two different states we feel like we can continue to move that along until there is limited, there is a, there are limits on senior leadership sharing between the two hospitals as Valley Regional is not in Dartmouth-Hitchcock health as of now but we do expect further consolidation to occur over the next 18 months. We are working to increase and improve some service lines but the urology has been a struggle for us really just personnel mismatch. We have a locums urologist now so that we don't lose too much of the momentum. Ultimately, we would like to have a single urology program serving a Scutney and Valley. Dartmouth-Hitchcock is out of operating room space and capacity at this point. At some point, I would expect some surgeons to make their way down to our ORs which are wildly underutilized currently but that's a tough sell. I worked at DH for almost 14 years and lived close to the hospital up there and folks don't wanna drive down to Windsor when they can get some OR space at Alice Peck Day or New London Hospital in New Hampshire. So we've extended that invitation to surgeons that do wanna come down and do work here but right now there's really no immediate plans to do that. Hopefully it happens at some point to keep our staff busy. Won't spend too much time in this. This is just raw data of our attributed lives and Medicare Medicaid. These questions we were asked to respond to around our value-based care participation. As I said, we are in all three of the core programs and we'll plan to do that until the end of version 1.0 of OneCare Vermont. To provide a little context for our response, I'm the incoming chair of the Rural Health Services Council for the AHA and describe our experience as a rural hospital in a next gen Medicare ACO frequently at national meetings. And I'm often met with surprised looks around the table from other rural hospital and rural health system CEOs on how it's possible that Vermont's kind of been the tip of the spear with so many rural hospitals. I think there was a fundamental flaw, I wouldn't call it fatal but a significant flaw when we left the state left a huge amount of transformation funding available from CMS at the time of the ACO's founding. That's led to hospitals having to fund the transformation while putting themselves at risk when our budgets typically oscillate around 1% or negative 1% operating margin year after year. And again, I'll say for our experience, thinking back to the metaphor I used before as that one patient that bad things happen to all the time that at some level it's felt that way. But again, I spent a lot of time speaking with national rural health leaders as well. And I'm not sure anyone's convinced that the current model of next gen Medicare ACOs are ideal for critical access hospitals. We were I think reasonably well situated to move into value-based care because of the work that we've done and all the other hospitals have done around blueprint and our community health teams that provide complex care management in the outpatient setting. The population health management funding through the ACO has allowed our clinics to bolster nursing staff. It's been very helpful. And the data that we get, I believe is the most important aspect of our relationship with one care is the data that does allow us to identify areas of need for individual patients and for populations. When you only have anywhere between 1,000 and 2,000 attributed lives, the populations become thinner sliced and moving the population health needle becomes more challenging with a small end. But there have been individual and anecdotal cases where we've identified folks that for some reason slipped through the cracks with our EMR and our primary care setting. And our one care data allows us, has allowed us to identify them and reach out to them to prevent ED visits, hospital admissions, et cetera. What factors support or inhibit hospital participation in more value-based payment programs, i.e. what is the tipping point or threshold? Dave and I spent a lot of time on this one. It's hard to come up with what a true threshold is. As I said, we've been all three of the core programs for the last few years and we'll continue to do so. We face some stress from being right on the New Hampshire border, about a third of our business is new, Hampshire-based and therefore is fee-for-service. We've had migration of patients from other HSAs which can sometimes complicate the accounting required to keep track of everyone's care and the finances associated with that. We've had issues with shifting attribution. COVID has obviously skewed everything for the last 18 months and suspect will continue over the next year. And again, I'll go back to that point. I don't want to beat a dead horse but having to fund the transformation really I think started the state off on the wrong foot in building the network within the ACO. As I said, we have, in response to this question, we have developed systems and abilities to manage laundry through our blueprint foundation. If we truly got to a point where, for example, maybe we had global budgets like the Maryland model which I think is maybe the best model to move toward, I think we'd still need additional staff again in a tight labor market to really move that to shift to true population health. We would need to meet patients where they are which is not in the clinic and not in the hospital. I used to say we need to keep people out of the hospital. Now I'm saying we need to keep people out of the hospital and out of the clinic and meet them where they are in their homes in urgent care. We need to look, we need to be, if we're gonna be the tip of the spear with innovation, we need to look at hospital at home care. We need to ramp up our relationships with home health agencies which who were also under great stress from a staffing and a reimbursement standpoint. But these are the things, again, at national meetings that I'm hearing that larger health systems are investing in as they move toward true value-based reimbursement and care delivery. And it'd be nice if we could actually show that what we're doing is actually improving access quality and outcomes. I think it's hard, you know, four years in to show any of that data. It takes a while with population health efforts, as I said, to move the needle. And I'm a believer in, frankly, Medicare for All, Dave, close your ears or some form of universal coverage or universal primary care within Vermont to make things better for our patients in our communities. But it's gonna take a significant amount of more transformation funding to get there. I won't delve too much in there. Again, we have been engaged. We did draw the limit with the three core programs. Again, that was a board of trustee decision. I would say our senior leadership team is probably split down the middle and how they view our ACO participation so much so that even this year, even with upside-only savings programs and some of the private insurers, we felt that that was not something we could take on at this time. Dave, do you wanna take over from capital budget? Yeah, so again, as I mentioned earlier, we're gonna be doing a lot of catch-up from 20 and now 21 in FY22. And so usually we run somewhere between $2.5 and $3 million in capital spend budget. So this is nearly double that. We do not have any CONs for 2022. However, we expect to file a CON in 22 for FY23. And that will be for IT integration onto the Dartmouth-Hitchcock platform for both the electronic medical record, other clinical applications and all of the financial applications as well. Next slide. And this is all stuff you guys have seen with one addition. The biggest issue we have right now is bandwidth getting some of these projects through while maintaining access for patients because all of our clinical folks are as with most CAHs, if not all CAHs, our managers are working managers. They're doing patient care. They're doing whatever they need to do. And sometimes that causes us to have bandwidth issues if the project is planned at a time where we're very, very busy on the floor or in a particular outpatient department. And so those are, we do our best to get the capital done in the period budgeted, but sometimes Murphy's Law. If we have to pick between getting the four new EKG cards rolled out or taking care of patients on the floor and the ER, the floor and the ER win every time. So next slide. And I think this is back to you, Joe. Yep, I'll take this. We're asked to comment on the impact of COVID on access to care and wait times, use of telehealth and telemedicine, COVID-19 related safety protocols, other relevant factors. I want to stress on this slide, this is for non-urgent emergent visits. Anyone that has a urgent general surgery, medical, neurology, et cetera issue, they will get in that day. We've got a devoted group of providers that make room for people that need to be seen urgently and emergent, emergently. This does show that we've got a lot of one day a week providers, as I mentioned earlier in the presentation. And there can be significant wait times to get those people in. For new visits. It's something that we have worked on. I think small hospitals in Vermont, New Hampshire sometimes think that Dartmouth-Hishcock has this huge bench with a lot of depth and can just provide services to everyone two, three, four days a week. And that's, they don't. I work with their section chiefs frequently trying to find some extra help. And it is challenging for them to find the personnel who can come down to our place to provide care. As far as the COVID impact on these numbers, I would say each has crept up a bit. Some have crept up significantly more like podiatry. That reflects the closure of podiatry practices around the region. In our, we have one podiatrist and one nurse who has been extraordinarily busy even during the pandemic, foot care never took a break. And it's the same with ophthalmology. There have been a number of area practices closing. So our volumes there have increased. Again, we have plans to consolidate some specialty services at either Mount of Scottney or at Valley Regional over time so that we can provide more robust services at one campus as opposed to one or two days on two different campuses. I think it will be better for patients for access, better for providers. We increased like every other hospital you're hearing from this year, we rapidly increased access to telehealth options for our entire patient population. We actually had, for all the complaining we do about our EMR, VR, Cerner based solution for telehealth was actually quite good. It did identify some problems. We didn't have enough of our primary care visit patients enrolled in our portal. So we did significant outreach efforts to get them enrolled, which is important outreach that we needed to do and then had to do very quickly. We probably flexed up to about 35 or 45% early on in the pandemic that were telehealth and our primary care populations, but then quickly fell down to 5%. Why it's, we've got a heavy Medicare, Medicaid population that at least in our neck of the woods did not really embrace telehealth or broadband access issues, other demographic issues, especially with our very heavy Medicare population and some inability to embrace the technology there. And frankly, we had some provider dissatisfaction. I think everyone was enthusiastic early, but then patients and providers missed having folks in clinic. We actually were hopeful that a sustained presence of telehealth would help to solve some of our staffing woes around flow mix, around our patient flow texts around our nursing, because if we have, if there's a lot of telehealth, we suddenly aren't as pinched from a staffing perspective, but that hasn't been borne out and we're back to being hungry for more patient flow staff and nursing. Psychiatry went up very quickly in state up for telehealth support that has been, and we have actually added over the last two years, two more psychiatrists to the team, which is much needed considering the explosion of behavioral health needs in the region during the pandemic. So we have significant backlogs for screening endoscopy that we're working to reduce. Our workforce has been incredible in their adaptation to our safety protocols and spacing of patients and our respiratory clinic and keeping the sick and COVID suspected, segregated from folks coming into our clinics for other evaluations that has worked out reasonably well. And again, most of our access and capacity issues now are exclusively due to staffing and labor shortages. We've had to close some inpatient beds. As I mentioned earlier, we tend to run full and have been for the last seven years, but we've actually had to close some inpatient and swing beds because we just don't have the nursing staff in August. Hope that was amplified by very much needed vacations and we do think there's a light at the end of the tunnel. And we've had successful nursing recruitments over the last month. So we do feel that the Calvary's on the way. We were asked to comment on COVID-19 impacts on everything. So it did impact everything. We made some good decisions as a system early on, which probably hurt a little bit financially, but as we called on folks to help recover both clinically and financially as the pandemic wore on, I think they were good decisions. So we did not have any layoffs or furloughs at our hospital or across Dartmouth-Hitchcock Health. We did hold on recruitment and froze hiring for non-critical positions. We definitely reassigned staffing. I recall looking out my office window on one of the many Zoom meetings and seeing a couple of our physical therapists doing some raking and cleanup in the late spring. Again, our staff has been incredibly adaptable here. COVID certainly did push some staff on our provider staff into retirement. Folks that were on a one or two-year glide path said, this is enough. I don't wanna end my career in a hazmat suit every day. We did add 12 FTEs for screening COVID clinic and vaccinating as 26 people's worth. And that has been an FTE variance that we look at every single week. I chose one example on the impact of COVID on our community and that's what substance use disorder. Our Windsor County overdose death rate rose dramatically. We have tried to get ahead of the opioid epidemic after initially falling behind very early on. We, our providers have the lowest rate of new prescribing of opioid medications in the state. We thought that was gonna be the fix early on, but all it did was allow for cheap heroin to become an option in overdoses continuing to rise. We developed ED and emergency room initiation for MAT working with our first responders who go to overdoses in area homes and bring people in and say, hey, we can start your care now. We work very closely with our hub and spoke providers. We're a Narcan distribution site. We brought in recovery coaches, 247 in our emergency room. And despite all of those efforts before the pandemic, we have been continuing to deal with rising overdose death rate in Windsor County. Those does seem to have leveled off and we do expect that will decline, but this has been a challenge. Every time we think we've got it right, we're gonna make a difference, something else pops up and we have to change our strategy again and I just think that will continue. The other community impact has been behavioral health needs beyond substance use disorder, loss of jobs, financial stress, isolation, remote learning, loss of socialization for children. Our pediatrics clinics have an immense amount of behavioral health resources embedded in their clinic and they're still overwhelmed as everyone wore masks. No one came in with viral illnesses anymore, but behavioral health crises have become the norm, I think in all of our pediatric clinics. And we've, like everyone else, again, you've heard from this year, marked increase in volume of patients with behavioral health crises, waiting in our inpatient beds. You can see our impact on financials. As I said, we made some choices very early on in the pandemic to bring COVID patients here and to care for COVID patients in the acute unit, the rehab unit and in our swing space. And we were the only people doing that for a while. I think most of our other surrounding hospitals over time got the structure in place that they needed to and that has started to dip again and then get a somewhat recent uptick once more with the recent surges. But that really was a shot in the arm during the pandemic, especially early on. And I won't spend too much time in here. It's just what our volumes have done pre-COVID to current. And Dave, I don't know if you have any comment on these. Pretty... Yeah, I think they're pretty self-explanatory and I thought I would provide it because it's interesting some lines of business were more affected than others. And like the slide you have up here is, we lost a lot of the swing bed referrals that we would get from primarily Dartmouth, but some other facilities as well, elective knee surgeries and hip surgeries. And they would come here and get three, four days of rehab and be sent home. Those were all off the table during COVID. And then you look at other things like acute. We did fine and rehab, we had a couple of dips during the course of the year, but overall pretty close to what had been budgeted. And then maybe, I think, let's see. So you can see emergency room, that trend has continued. And then the operating room, we took a big dip with the accommodations and some creativity with staff and docs. We were able to get that back to where it was expected and just as some perspective, we kind of estimated the more urgent or emergent, the less elective the service was for FY21, the more likely we were to hit the budget mark. And for those that were contrary to that, the opposite. So when we look at kind of year-to-date financials, we nailed most of those. I think what the one thing we didn't expect was that swing would go down that low, but we were bailed out with the number of acute patients that we took on the unit. And then just go down two slides, Joe, because they're good readers. Pair mix, this was kind of interesting. I thought, so Medicare before, during and to current, you can't even tell there's two lines there. And then Medicaid kind of bounced around and we had a dip, but then we had a little gain in FY21 quarter three that kind of offset the dip. So we're kind of as a whole pretty even on that. And the story on commercial and Blue Cross is that they basically, Blue Cross went down as a percentage of our business, but commercial went up. So they kind of offset each other. And then this is a slide, just some of the funding that we received related to COVID and the bottom two showing the current reserve that we're carrying on the books for returning that money. And then one, this is just expenses. Again, we didn't furlough anybody. And we tried to keep things as flat and predictable as possible for staff as well as the providers. And I think you can see here from labor and non-labor, we kept that pretty tight. Great. So I'll finish us up here. So we've included our responses to the healthcare advocate questions. So first one, how much funding in your current future budgets has been allocated to DEI work interracial equity focused projects, trainings or collaborations? So we have current, as I mentioned earlier, we've got about 1.2 or so million dollars in community health grant funding that we actively pursue every year to fund efforts that under the umbrella fall are our DEI work. We just did a community assessment education program for our BIPOC and LGBTQ plus populations. We're waiting on analysis of that survey and that'll guide some, specifically guide some of our outreach work. We have a very active prevention group, the Montesquat & Ate Prevention Partnership, otherwise known as MAP that has funding in all three of its major prevention grants. And this is well over half a million dollars in funding, but it's around tobacco. It's around, let me get my, make sure I get my acronyms right. The prevention grant expansion, which is PEG, the PCE grant, which has made our region a prevention center of excellence and the prevention network grant. We all have, we have money set aside for DEI work there. They're part of a larger overall budget. It's difficult to get the numbers down to the dollar, but the folks that are doing this work are estimating that 20% of the grant cover this work. So it's between $100 and $120,000 for those efforts. In the past year, MAP has also provided LGBTQ plus training to community partners will offer this, again offer this grant to early childhood providers. They sponsored a docu series for a community audience around LGBTQ plus issues. And we are sponsored a 5K with health disparity, disparities messages all along the route, which I think was really well received by our community. We've drafted a needs and disparities statement compiling health disparities data and also updated it for 21. And we'd be happy to share that with either the healthcare advocate or the GMCB. We have much of our work around substance use and misuse is spent addressing some of the health disparity issues. We utilize our health disparities reports such as the YRBS data briefs. So that's the youth risk behavior survey, the Windsor County profile, et cetera, to understand how we can direct resources and interventions toward underserved and high risk populations. As a reminder, YRBS really tells us what the has our, allows us to get our finger on the pulse of what's happening in our schools. The PCE grant dashboard tracks disparities between the general middle school and high school populations and LGBTQ students and students of color in our center of excellence work looks to reduce those disparities for both risk and then protective factors. What percentage of staff and administration, administrative leadership have received training in language access needs implicit bias and cultural competency. So every month it's got me employee every year undergoes annual compliance training around cultural compliancy through our Ulearn modules. We've made an operational goal for our hospital in 21 and 22 to increase the amount of trauma informed staff members we have at the hospital and in our clinics. And we've set up a process to review all our current policies in our policy library to make sure that they reflect sensitivity toward trauma informed care and DEI issues at Montesquatney. I wanted to pull out a specific example where we've had some success in some of the DEI work in our rehab services department, which is our acute rehab and our outpatient rehab services. They've focused on LGBTQ issues. We revised screening tools for all patients coming in to our rehab services department to identify folks. We all 16 individuals in the rehab services department participated in this and that includes PT OT care management, nursing staff, all of our rehab aides as well. And we've also welcomed international traveling nurses onto our units. And with that have developed some specific cultural competency education, kind of a curriculum around the home regions of where these nurses are coming from to prep our staff and to get them ready to accept nurses from the Philippines and from Nigeria. And it's been wonderfully successful, I would say. Questions around languages. I would say that this was a wonderful question and triggered a lot of investigation on our side for our HCAP surveys, which is our inpatient patient satisfaction. That was the data I shared very early in the presentation. Languages available are Spanish, Chinese, traditional Portuguese, Brazilian, Russian, Vietnamese, our outpatient CAPS is Spanish, Chinese, traditional Russian, race and ethnicity are also an available data field in these surveys. We've also for our own workforce have collected that data through our engagement with an outside consultant, a healthy workforce initiative, our community health needs assessment and the Dartmouth-Hitchcock Health Systemwide Employee Engagement Survey. All that said, I think we look better on the slide than we do in real life. The ability to get the appropriate language surveys depends entirely on the data feed that we provide to Prescaini who performs these surveys on our behalf. So if we don't check the correct boxes internally and that's an ongoing EMR project for us then folks aren't getting the right language. And that's been through this question, we've identified that as a quality improvement project so that we can make sure that our patients are getting the right surveys from a language perspective. The last question, any changes around bad debt and free care during the pandemic? And we really haven't seen all that much. And Dave, I'm not sure if you wanted to add anything to that. Yeah, this ebbs and flows, the changes are fairly immaterial. I think generally the fluctuation is 10 to 20 basis points a year plus or minus. The one thing that my staff identified is that they've seen a lot more applications from younger applicants out of work during the last year and a half. But we really try to be creative here where most of my revenue cycle folks are working remotely and have been. For our financial counselors have rotated them through so they do some time here on campus. We took over the gift shop and the lobby to make it easy and people wouldn't have to navigate through the whole facility over this pandemic and be easier to follow the safety measures. So we've been able to have pretty good access. Zoom and some of those features have also helped in talking about some maybe more complicated financial situations. But by and large there hasn't been a big change either way. And what we've budgeted for 22 is commensurate with what we've historically budgeted somewhere around 2.75% between bad debt and free care and the same proportion between the two. And that's it. Thank you for listening. That was quite a rundown. This is a pick from our emergency room. This must have been a quieter time. As I said, we hit a mark of 41 visits in a day in the last two weeks. And in a seven or eight bed ED that is hopping and not sustainable. Hopefully we can return to some more normalish volumes over the rest of the summer and fall. So with that, we'll open for questions. Thank you for listening. I'm sorry, I can't hear Mr. Mullen. I think you're muted. I am. Thanks. Thank you, Kim. Thank you so much, team Manus Kutney and we're gonna start our board questions with board member lunch, Robin. Thank you. Thank you as always for a very complete presentation and very clear submission. Appreciate it. I wanted to actually start where you ended Joe around the ED utilization. And I was just curious, you had mentioned obviously behavioral health which is certainly something we've been hearing with other hospitals around the state as well as sometimes ED utilization being up from deferred care and higher acuity. I was wondering what your kind of thinking is behind those numbers? Yeah, I've been trying to figure that out. I do think that there was some pandemic word on the street around where you were, if you showed up, where you would be admitted. And again, I think early on we just said, yeah, we'll take everyone, just send them, we'll figure it out. Again, I think that was based on years of other work to be able to do that. And again, neighboring hospitals did get to the point where they could keep folks in their ED although there are still some within the health system that do not. So we take them too, which is fine. I think we all saw lab utilization and radiology utilization through the roof across the state. And I know otherwise, I know what is happening regionally with our surrounding hospitals and where ED volumes are most have recovered pretty close at this point. And I'm not sure if patterns that were established early in the pandemic have just continued. And even though other facilities capacity has increased, people are just now following where they've gone over the last 18 months. We still see significant pressure from the New Hampshire side as well that flow of patients across the river is still occurring. And I'll say the other, our other's system partner in New Hampshire is Cheshire Medical Center in Keen. They have been at significant capacity for a couple of months. So we are getting numbers of patients from the Keen area. Basically everything between Keen and if they don't just go over to Brattleboro, they're coming up 91 to us. And our transfer center does try to, the regional Dartmouth-Hitchcock Transfer Center does try to, if Cheshire calls with a patient they can't keep because of capacity, they'll say, okay, and they'll bring the escutney person online to say, where are you guys? What's your capacity? And so we've become a little bit better at moving folks across the system. And I think this may be a contradiction but new historical referral patterns by self-referral patterns in patients have occurred. Our ED volumes also reflect a loss of primary care access especially in the last six weeks or so. We've had two providers leave our Woodstock Clinic both for valid family reasons and that has reduced capacity. So those folks show up in our ED. We don't have an urgent care option at Montesquotney right now but we are trying to frantically set one up on the fly so that patients that do have ambulatory sensitive conditions get ambulatory sensitive care and not show up in our ED. We're trying to do this in a 30-day timeline to go from zero to urgent care or fast track at least. So if we can pull that off that will help reduce ED volume, reduce cost, which is a big issue. Well, thank you. That's helpful to kind of understand the context. I appreciate it. And Dave, I just wanted to follow up on the blueprint uncertainty. So I'm assuming you are talking about the blueprint indicating that they're gonna work on changing their payment methodology. I just heard last week on the executive committee meeting that that won't happen until 2023. So I wanted to mention that and see if that's what you were referring to or if there's something else going on the blueprint that we haven't heard about. So yeah, we're aware of that as well. Although I don't think we had a timeline for that, but also when we received some accounting for our current year, ACO report, the end of last month, it was interesting that the blueprint funding from Medicare, because Medicare stopped funding that has now been rolled into our Medicare risk number. So that was the first time we've kind of heard that that might be coming. So that's here. So now it's kind of a risk issue, regardless of budgeted it, but there's like a little asterisk next to it that we're not sure how certain that is. Yeah, and if I could add just to that, as you all know, I'm vice chair of the board of managers at OneCare as a DH appointee. So conflict of interest hats are on all the time. As we've, in OneCare, as we've responded to hospitals saying we got to be nice to reduce our downside risk, our risk corridors, we have certainly, while we limit our downside risk, we also limit our potential shared savings. And we all know that we fund the blueprint from advanced shared savings dollars. So we have to be cognizant that as we lower risk corridors, which we're asking for, we're also reducing our ability to really get shared savings. Have we created just a break-even ACO, which is not the biggest incentive to grow our network. If like, well, there's not much downside and there's virtually no upside because of how we fund blueprint. I think it raises the bigger issue of how a program, which has been immensely valuable to all of our practices, gets funded moving forward. Thank you. And then my last question was in your narrative, you talked about when you were talking, this is on page two, when you're talking about the utilizations, you mentioned that you also recently implemented provider productivity initiatives. Could you talk a little bit about that? Actually, I don't have that in front of me, but we have not instituted provider productivity. We measure that and we've been measuring it for many years. In fact, I just presented the year-to-date numbers to our finance committee last month. So this is something that we look at from a senior management perspective and we do it as part of our budget process and planning process. And we report back to our finance committee and therefore the board, kind of how things are going and much of what Joe touched on already, where podiatry has become a regional practice. So his productivity has radically changed because he says yes to patient need. And then we have losses of primary care, but we just try to look to see the visits per FTE, very simple measures, just to see how a given practice is changing or staying the same over time. We have a single provider, surgical specialty provider, who does have an RVU incentive. That's a, and our entire medical staff. That's what I remembered. Our primary care pediatrics, all other providers, surgeons, are have a straight salary. But as Dave said, we kind of like to know the context. As we build compensation models, you wanna try to match comp with productivity with some guardrails. But no, and it's a great example of that threading the needle I mentioned with DH and us, all the other system members are, if they're not already there, are moving toward RVU-based incentive comp for their providers. And I've been a proponent of the ACO and population health. And I feel like I'm talking out of both sides of my mouth if I say we're focusing on population health, getting to a point where maybe we have global budgets or effective prospective payments, regardless of how many times you see a patient. Oh, and by the way, see as many as you can so you can get your RVU bonus. I mean, that's, we moved away from that years ago and no plans to go back right now. But again, it is an example of that needle threading. Could we get a mandate, certainly, but we've been able to artfully dodge it so far. Great, well, thank you for that clarification. That's, having remembered that from prior years, it's quite frankly why it caught my eye in your narrative. Okay, that's my questions. Thank you so much. Thank you, Robin. Next we'll turn to board member Pelham. Tom. Well, thank you both, Joe and Dave, for a very thorough presentation. It's clear to me that you are well-grounded not only in your facility and institution, but in also the dynamics of your region. And so it's a very helpful presentation. I have a couple of questions. One is on the provider tax. You are carrying in your 2022 budget $1.87 million, which is only 3.1% of the $60.5 million in 2021 projected NPR and FPP. And so I think you have the lowest percentage across all hospitals. Most of them this year are within a few decimal points of 6% of their 2021 projected NPR, FPP. And I'm wondering if there's an answer to that question. Well, I'd like to say that I'm smart enough to beat the system, but that hasn't happened. What has happened is that we have a very high percentage of swing bed business, as well as a fairly robust clinic line of business as a percentage of total business. And those two areas fall outside of the provider tax calculation. So it's really inpatient rehab, inpatient acute and the outpatient acute services. So we've historically been in similar positions and swing bed is a very large carve out as is the physician practices. I think you guys will recall that when the physicians on Southwestern's campus became Dartmouth providers, the provider tax went down significantly for them that they're off the radar screen. So it's similar here. So the 3.1% plus or minus number is within your traditional ballpark. Yes. There you go. Thank you for that. I have a question on the COVID advances. I note that in the appendix seven you're carrying at the end of September 30th, 2022, $3.2 million in I think that was in CARES Act and another $2.7 million for a total of 5.9, but a 2.7 million in Medicare advance. And I'm just wondering, so that's at the end, September 30th, 2022, how do you expect that to unfold? You're starting to pay back the Medicare advance as I think I recall like $500,000 a month. So where do you truly expect to be in September 30th, 2022? And do you think some of that CARES Act money will end up being accounted for as revenue as opposed to the liability that profiles in appendix seven? So you're exactly right. We are paying back 500,000 give or take a month and have been since the Medicare advanced payments have been scheduled to be returned. And so we actually, when we looked at that schedule, we played with that a little bit. It's like, well, we really should put the number that it's going to be on September 30th as opposed to anything else. So we expect to be paid down to 3.2 million by September 30th. Relative to the PRF funding, we built that reserve of 2.7 last year. And we're trying to figure out how that's going to change if at all from our current position, because that's a huge risk for us. We bounce back and recovered so well that all of a sudden a lot of that funding, the necessity for that funding went away. So our last calculation falls within the same parameter, but they've changed those, that interpretation at least nine times that I'm aware of. So every time we get a new release, Teresa and I go back and we do the math and see if that reserve has changed. And we talked to our accounting firm probably a month and a half ago, I would say. And there's just no compelling reason to reserve more at this point and there's no compelling reason to loosen the belt on that either. So at this point, we expect to owe that 2.7. So on the Medicare advance, so at some point in prior to September 30th, 2022, you will have, they will have recaptured what they're scheduled to recapture. And then the Medicare payments after that then will be increased because you don't have the $500,000 hit every month. So are the numbers that we see in the payer mix account for that that at some point in time in 2022, that $500,000 payment or a recapture amount goes away. No, because we have reservists, so all we'll do is eat away at the reserve. It won't affect our numbers going forward. Okay. My next one is having to do with, let me just make sure here, just a quick one. So I'm looking at the FPPs and I go back to 2019 actual in terms of FPPs as a portion of NPR FPP. And the dollar amount has dropped from 6.4 million in 2019 actual down to your 2022 budget at 1.7 million around it. And that's all Medicaid according to Appendix six. And I'm just wondering at some point, does the kind of administrative effort to take care of a smaller and smaller number just not make sense? So yeah, so this will be a great answer. Buckle up. So the Medicaid FPP actually works fairly well for us. The accounting is clean, the reporting, there's a lag on the data as would be expected, but generally that's pretty clean on our books. It's pretty clean as reported by OneCare Vermont. So we don't have any compelling reason to get out of that. We've had some migration from other service areas to ours. And so that's all been recognized by OneCare Vermont through their normal process. So I'm not messing with it. I'm just leaving it on the Medicare side. We jumped out of the FPP but still participate in risk because that was a completely different story. Okay. And now I'm looking at the payer mix and I'm looking at your Medicaid amounts. And for, you have a trend going back to 2019 of Medicaid growth at 41%. It's quite a hefty growth rate at least on the payer mix presentation. But so you have it in 2021 budget is that 3.46 million Medicaid 2021 projected at 3.34 million Medicaid. And then in 2022 B, it jumps up 53% to 5.12 million dollars. And I'm just wondering what that bump is. Yeah, actually that's an error on our part. We understated Medicare a bit and overstated Medicaid and because the numbers associated with Medicare are so large as compared to Medicaid, it skewed that. Part of the issue, and I know you guys heard this in a couple of things is that we don't always slice our data the way that you guys would like. And so when we try to take out of our model and assimilate that to adaptive and the reporting standards and we did make a mistake there and we can work with Lori or whoever to correct that if that would be helpful. But if you look at our total percent of charges that we would realize through net patient service revenue it's pretty consistent with history. And there's no changes, material changes with our commercial or Blue Cross business. But there was some money in Medicare that dropped to the Medicaid bucket when we sliced and diced. And I apologize for that. Okay. And let me see. That's all for me. Thank you very, very much. That was helpful. I'm sorry you're muted. Kevin, you're muted. Thanks, Tom. Next we're going to turn to board member, Yusuf or Maureen. First, thank you for your presentation. A couple of questions. When we look at your NPR projections from the 2021 projection to the 22 budget you're the only hospital that's showing a decline. All the other hospitals are showing some type of increase year over year. And just wanted to talk about, I know you've talked some about the swing beds and things like that, but are there any changes in your projection for 21? And when you end this year, do we think we really will be below where we end this year for when we net out in 22? I apologize. I missed the beginning of your question. I had my great-granddaughter was born this morning. I'm on the side managing COVID testing so that my granddaughter can go home and not come to my house. So I apologize. I missed the beginning of that as I was responding to the local just where your NPR for 21 projection to your 22 budget is showing a decline. And that's the lowest of all the hospitals and the only ones showing a decline, an expectation that we're gonna be lower next year than where we really end up this year. And just wanted to address that. And I know you've talked about swing beds and things like that, is that realistic to assume you'll be lower next year than where you end up this year? Yeah, I guess we backed off a couple percentage points not knowing whether the volumes that we've had over the last year plus that have come from other service areas or have come from within the system that didn't go to other system hospitals that that would be sustained. And so, and we also figured out that we would take a hip with sequestering as well that we talked about earlier. And Maureen, I'll add, I mean, you've seen our data for 21. I mean, it's kind of a remarkable year for the organization. And I'm always thinking about when the wave's gonna crash, but in preparing for what's next, knowing how tenuous small hospital finance is in performance. I'm not sure this year is reproducible. Since budget presentation, a budget submission to our presentation today, we've lost a couple of docs. Actually, I think we've lost four docs including our outpatient physiatrist who's going to the VA, two primary care docs. And those have huge implications. So you'd think, you know, what is physiatry? What is that loss? And we're not gonna let that program die because we have an acute rehab. But, you know, that provider does EMGs, electro, myelographic studies which are reimbursed at a very high level. So we're losing that. So it just doesn't take much to push us over. And I think if just knowing our trends, submitting a budget that looked just like, that really looked just like this year's performance in 21 would have been, I don't think I could have stomached that. And I don't think Dave could either knowing what changes are on the horizon, potential gain or loss of services. Maybe I would have been more optimistic but one fantastic year is not really moving us off our historical strengths around expense management, appropriate service lines, not building up boutique services. We've got to stay on the roadmap here. I think the other part of that is that as our volume has grown greater than expected, our cost per unit has gone down on our cost report. And it's really, you know, the beginning of the year we weren't too crazy, but now it's really gotten crazy over the last three or four months as far as positive. And that is going to drop our Medicare reimbursement down. So our cost per unit will go down. And so we factored that in, although again, this data was submitted a few months ago and since then we've gotten even busier. So we don't even have a projection for that and we won't until we close the month of August and run an interim cost report. Okay, thanks. Can you talk a little bit about the 2.7 million you still have on the balance sheet for COVID funding that you may be able to recoup and what the status of that is. So not the repayments for- Right, the 2.7 is the provider relief funding. And we received over $5 million in funding according to the HHS calculation. And when we accounted for it at year end last year, September 30th, when we calculated out what we would be allowed to retain, we determined that $2.7 million would need to be returned as of the close of last fiscal year. One of the issues with that to be frank is that we actually could swing either way. We could keep a majority of that 2.7 million and pick up a $2.7 million gain or we could actually have to pay that back and more. The reason is that the standardized reporting for PRF is this, I wanna get into all the details, but there are a number of ways, options that they give you to measure that. And if we use a standard change of net patient service revenue between the two years, 19 and 20, we actually look entirely unfavorable and would have to return the money, most of it, except for the COVID direct expense. The problem is in 19, because of our Medicare FPP relationship with One Care Vermont, it resulted in CMS not accurately reporting our net reimbursement. So we have to use atypical reporting to HHS to justify the retention of those funds. Now, Theresa and I understand that reporting and we understand that it's a completely legitimate measure that gets us to only a $2.7 million return. I have zero faith that the federal government will understand that atypical reporting, which by the way is allowed under the current interpretation, but it's to be reviewed and may or may not be accepted. So really we could end up with a very large gain in a future period or we could actually have the 2.4 million that we did recognize taken away from us if that non-standard reporting methodology is not accepted by HHS or whoever ultimately audits this. And when will that be resolved, you think? Sometime next year. Okay. And then in your commentary, you talked about right sizing and rationalizing and reducing some pricing, particularly for CT and MRI. I think you went down like minus 21 and 20%. And also talked about other potential areas where you're looking at to do that. And can you talk about what areas those are, what implications they might be? And I applaud you for right sizing these pricing. Yeah, we'd actually been wanting to do it when 19 went well, we decided we were gonna start shipping away at that and then 20 are budget cut. So we decided not to take the risk and then we slid right into COVID during 20. So there was so much uncertainty. We were underfunded with the Medicare advance payments by approximately 100%. So we said, okay, screw it, we're not touching it in 20. But then as we rolled through recovery and then into 21 and things were going well, we said, okay, we've gotta put this back on the table. So we did do CT, we have done MRI to very high ticket services. We have done laboratory and I have done the calculation for outpatient therapy as well as other diagnostic imaging, ultrasound X-ray and bone density and mammogram and some of those. So we estimate that it's probably about $1.8 million in gross charges coming off the books. And that started a couple of months ago and we've been, as I put them into place and they've rolled through the system, we've sent notes to Patrick and to Lori advising them of that change. And not all of those are incorporated in the budget as I referenced earlier. Okay, great. And just a comment on, you know, when, and I know you did answer the healthcare advocates question about, you know, your pricing index to Medicare. You know, one of the things I've been looking at is looking at all the hospitals and their submissions and just doing kind of the gross to net calculation and then comparing that to Medicare to commercial and Medicaid. And so far, you're the lowest. So that's good. That's a good number. You index 1.2 to your Medicare rate. So it helps us at least from a benchmark. I know it's not completely apples to apples across, you know, all services, all hospitals, but at some point you have all your services that you're doing and, you know, you have that reconciliation. And so, you know, it does help to look at that as one benchmark. So thank you. Appreciate that. Thank you. I'm all set. Thanks. Thank you, Maureen. Next, we'll turn to Board Member Holmes. Jessica. Great. Thank you. I'm going to echo a lot of thanks actually for I think what was a really impressive and thorough presentation. I want to say that I appreciate all that you've been doing with the pandemic, but also your efforts in the areas of improving costs, quality access and actually all the efforts you're doing for reducing health disparities. I think it's incredibly, you're like a model for the state in many ways. So I want to acknowledge that. One area that I would, you know, as you were talking, Joe, about, you know, some of this NPR growth that potentially is, well, some of this growth that's coming from other areas, New Hampshire in particular and some of this engagement you have with Valley Regional. I'm wondering if you're able to track some of that growth and NPR separately. And the reason I think about this, and I think I've mentioned this in years past, but I wish we as a Board could track that better. We limit NPR growth, right? But I've always been personally open to the idea of setting aside growth in NPR that comes from out of state. I view that more as medical tourism, right? That promotes job growth in our state and doesn't count against us in, you know, areas with the all-payer model. So I'm wondering if you have a way to track in-state out-of-state traffic and, you know, particularly as you're engaging more, you know, in New Hampshire going forward. Honestly, I wouldn't want that growth to be held against you. As we're looking forward. Yeah, well, we can agree on that, Jessica. So thank you for that. We would like it not held against us as well. What I can tell you is so we can absolutely determine the percentage of net revenue growth for out-of-state business and by line of business. So inpatient versus outpatient. Last year or going from 20 to 21, our outpatient percentage of business went up 4.5%. So what was 100 last year is now 104.5 this year. It's a little bit skewed during the pandemic because we were accepting patients from Bay State in Massachusetts, New York, Connecticut. You know, very sick patients coming up and staying within our rehab department. So it was a little bit bigger than we would have normally banked on, but about 28% of our business comes from across the river. And I would be happy to provide some supplemental schedule if that would help out. I think we did one for you in 20 so we could probably use that same format if that was helpful and provide that to you. But we are definitely seeing a fair amount of patients and it grew 4.5% from the prior year. Yeah, I just think in general, our border hospitals, it would be helpful for all of them to track this flow of patients. And in particular, going forward, as you've mentioned, you're engaging more in these collaborative relationships. So it's gonna only be, I mean, I recognize the pandemic is a unique year, but I suspect Mount of Scotland is gonna have this traffic increasing over time. So helpful either in the short run or next year's budget submission to help us understand some of that in state out of state would be really helpful. I also just wanna acknowledge and thank you for initiating your own pricing reductions, you know, particularly in the areas of imaging and to continue to look at that, I would say, you know, in my time at the board, it's happened, but it doesn't happen all that frequently. So it should be acknowledged when it does. Dave, in your presentation today, you mentioned that the change in charge will actually now really be effectively be 0% when you factor in those changes that you've already made. So I'm actually asking you, would you like to amend your request to that effect? I feel like you should be getting credit for that fiscal responsibility and the efforts that you're making to make healthcare more affordable for your community. If it's really gonna be zero when you factor that in, do you wanna actually amend the request? So we've talked about it. So again, thank you, I entirely agree with you. And we've talked about this more than once. And, you know, we've run some studies on it and tried to figure out what we think is absorbable, you know, to some degree, reducing a charge for a CT for a Medicaid patient. Who cares? It doesn't mean anything because, you know, we don't get paid well for it. And so we've tried to figure it out as best we can. We do, as Joe said, we thread the needle all the time here. So we're competing with New Hampshire business, right? We're subject to Dartmouth's expectations for margin and whatnot. We've got one care of Vermont to deal with. We've got our own board of trustees and their expectations. And so what I think we've done is we've threaded the needle. Because one of the problems we have is that you guys have a MPSR FPP growth cap. So we've tried to come as close as we can to all of our competing priorities and, you know, satisfying them at a reasonable level. So I appreciate the offer. I'm willing to roll the dice with the work we've done as long as I'm getting credit for doing the right thing. I doubt very much that our math was off enough that I will be concerned at any point next year. But if we are, I guess we can talk about that. But I'm thinking we've threaded the needle and we're gonna see how it goes. Thank you. Okay, I'm gonna give you more credit, actually. I'm just giving that credit today. Lots of credit. You are. I'm gonna thank you for completing the HCA table, you know, where you compared the commercial to Medicare ratio. And not everybody complied with that request. And so again, I wanna thank you for that. I appreciate that you didn't took the time to do it. So more credit where credit is due. I wanted to ask you about in your, in the narrative, there was a discussion about the shift that you're seeing to Medicare Part C or Medicare Advantage. And in particular, you say Medicare Advantage generally do not have Medicare-like reimbursement rates require higher admin operation costs and do not settle on costs. And I'm wondering if you can elaborate as we are seeing this shift to MA, what is that gonna do to the cost shift? Is it gonna mean that commercially and short are gonna have to pay even more if we see more Medicare Advantage plans not reimbursing with traditional Medicare fee for service? Administrative costs going up. Can you talk about this? Because this is something new to me. So yeah, so this is, it was kind of like a minor irritation a few years ago, but our percentage of Medicare Part C, it grows literally every year. And companies that we had no footprint in this area, UHC in particular, UnitedHealthcare, was just very, very small. Now it's actually becoming substantial. So you've hit the three points and one of them is that they don't settle on cost. So Medicare gives us a prospective payment, whether it's inpatient, outpatient. And at the end of the year, we kind of settle up. Well, we saw more of your patients and there were more expensive, high acuity patients. And we settle up on costs and they write us a check or we write them a check. Part C, they don't settle. And so the other problem is that when Medicare changes our perspective rate, we send that to these Medicare Part C. Most of our contracts are some derivative off of Medicare. So 1.01 is something. And so when we get those updates, when we file our cost report, they have 60 days and I mean, we're all adults here, right? So costs go up. So generally speaking, our costs go up and Medicare rates go up every year, but there's a delay on that and there's no settlement on costs. So there are a month periods of time, depending on the payer and when I get updated rates from Medicare, that I can go three to nine months without that bump up from Part C. And then the overhead, the administrative overhead, Medicare, we just take care of our Medicare patients if they're traditional Medicare patients. There's not Medicare authorizations and pre-certifications and all of that nonsense. We just follow their utilization review standards and stick to them and everything goes well for everybody. But with the Part C, they have pre-serts, concurrent review, where we check in on patients on a daily or every other day basis. They get really nitpicky and we do have to throw some money in some bodies at that. I'm currently in the process of collecting $110,000 rehab stay from one of those payers because they say we didn't complete the concurrent review, which we have all the notes and we have all the documentation, but now we've got to go through a formal appeal process to get the 110,000, they already owe us. So this is, does it, there's a safe Medicare money? Yeah, it probably does. Is it killing us? No, administratively it kind of is starting to. Yeah, we've, I've heard data nationally that up to 30% of referrals for specialty imaging inpatient stays are denied by MA plans. And again, my AHA work, we are trying to, we are focusing on the moving MA toward at least consideration of some cost-based reconciliation that comes up with, from every CAH across the country, but just the overall denial ethos of the MA plans is a killer. And yeah, as Dave said, that's one case. We've got a number of them in the books with UHC and SIGNA and others. Well, it'll be interesting. We're gonna have to track what happens. We hear a lot of that administrative costs already. We hear about pre-offs already. And so if the MA footprint grows in the state, I guess we're gonna be hearing more about that. And my worry too is that the cost shift will increase and commercially insured payers are gonna bear more of that burden over time. So I think we just have to keep track of that. And you're highlighting that was important to me. Dr. Parris, I have to say, you know, I hear you when you talk about a significant obstacle to delivery reform being the state's unwillingness to match some of those transformation funding from CMS. I don't disagree. I completely agree. In fact, I don't know if you recall, but the board wrote a letter to the administration to that effect. And I guess what I just wanna ask you about is we didn't receive a lot of corroboration, support from hospitals at the time saying, yes, we agree, this is gonna be a significant obstacle. So I'm just wondering, what can hospitals be doing to convey that message to the folks who hold the purse strings, which we don't with respect to those dollars being drawn down from the federal government. So when I hear it, I think, yeah, well, we tried. What can hospitals be doing and why didn't they do it at the time? Well, I mean, I know we did. And I, you know, it's a, there were changes in leadership, right, as well. And I still kind of think that the ACO as we constructed it was really, it was the best we could do at the time. But was not the perfect vehicle for a rural health network, which we'll just call Vermont a rural health network for the most part. I think CMS has come up with newer models for rural health ACOs, which I'd love to be considered for version 2.0 of the ACO. You know, I think we do have a model for what works pretty well with the Medicaid program. If I can get Dave to support that, then that's an effective model to change how we deliver and reimburse for the care. Now, I remember sitting in meetings at the hospital association, talking about the transformation funds that were available and then went away. And there was a lot of consternation, but to a CEO, we were supportive of the move. So I think there was reluctance to inject a poison pill into the process by saying, do we really want to be the folks saying no to payment reform? No. So there was some sitting on of hands and some teeth gnashing, but it was kept private. But it's, I think we've seen the downstream effects of that. It was, you know, I think I'm editorializing here. I think Grima on care board has been more responsible for leveling off the rate of growth than the ACO has been. And I think it's really hard to tease out, that's my personal opinion. I think it's hard to tease out what really is it? Caps on NPR growth or is it population health? I don't know. I don't think we can say that right now, but $100 million is a lot of transformation funds. That's nurses, that's broadband, that's stuff to do, like I said earlier, to get to patients where they are. You know, I think we built the ACO around a model of giving people out of the hospital and getting them in the clinics. I'm not sure that's the model five years from now. I think it's out of hospitals, out of clinics. I think it's at home and urgent care and all ambulatory sensitive conditions being treated at home, not even coming into bricks and mortar. So I think that's where we should be thinking. And you know, that's a hundred million bucks easy. So I'm happy to carry the banner on that. And so let me know, I've weaponized me. I'd like to, I'll do it, I can't. Well, then I have one final question. And it actually revolves around that, your vision for the next five years. I mean, you've overseen continued integration with Dartmouth-Hitchcock over the years. And I'm wondering what lessons have you learned at a mountain of Scotland that can help our whole system move towards a more rational distribution of clinical services? What opportunities have you seen that we can apply to the whole system for quality improvements or cost savings? I mean, you've learned so much and I look at all these individuals stand alone hospitals and I wonder what can be learned from integration, shared services, economy, scale, things like that. So, six months ago I would have said, shared services are incredible, they're great. Now I still think they're that, but now that we're actually getting cost allocations for shared services across the system, it's less great. When you're getting it for free, it's much better. But it still makes sense. I think what we have seen is more around expense reduction as opposed to truly rational distribution of services. I think if as our work with Valley continues, we'll be kind of an incubator for that. We'll see how it works to have, five days of oncology at one spot. But orthopedics is somewhere else or urology is somewhere else, but it's a more robust program. Right now everything is still fractured clinically. I think where we've had the most bang for the buck in our system work has been in quality and safety and building a network across DHH, focused on quality and safety and the patient experience. And then better, really, better purchasing power for insurance products, for PPE, for kind of you name the back off, you name the overhead. When our new CEO came in, she said everything beyond the care of, everything beyond the interaction between a provider and the patient is overhead. And the strength of a system and the financial health of a system depends on the reduction of everything else, which is overhead. And she was pointing to all of us as leaders, you're overhead, you're overhead, you're overhead, because it's true later in the week, I'm working as a hospitalist, so I'm not overhead on those days, but every other day I am. So I think that's where engagement with a larger system has provided the most bang for the buck. That said, Dave pointed out earlier that we need cardiology care, but I don't need five days of cardiology care. I probably need two days, as you can tell from our wait times to get into the cardiologist, but it's better than no one. And it's like that for every specialty service that we have. And DH can't do it for everyone that wants it. They don't have the bench depth. And I think there's a move to focus on the system. DH operates in New Hampshire, so it's a different environment. We're kind of the, we're sometimes on the outside looking in, asking for stuff, because we don't have the geographic benefits that some of the other system members do, but we're working on it. I think my hope is that next year's budget presentation, I'm talking about more clinical service line work instead of the savings we got on paperclips and PPE, for example. I would add one thing, and that would be that one of our hopes with Valley and at the system, the Dartmouth system is to develop kind of internal travelers that could be assigned to multiple facilities, which is why the IT integration becomes a little bit more critical because we can share staff and the operating system is the same no matter where they go. But we've already talked, we've already covered some shifts for Valley and with some side deals with them and they've subsidized some of our services as well here and there. So we've been doing these small experiments to see do they work and when you're bringing in a traveler from across the country, well, there's a rent a car, there's a hotel, there's three squares a day, there's all these costs, whereas if it's somebody who lives in Cornish, New Hampshire, works at Valley, we take a lot of those unnecessary costs off aside from the egregious hourly costs. So those are the things that we're trying to figure out. If we have one extra respiratory therapist in the area who can cover for vacations, sick days, vent patients, these types of things, what are the savings of that? What does that really translate to? And I think we're making some small incremental progress towards that. Great, thank you. I always learn a lot from your presentation and I did today. Thank you. Thank you, Jess. Joe, in the past, you guys have described a better payer mix coming from the other side of the Connecticut River as far as your patients. And with the construction that's happening at DH and the fact that you're traditionally getting all those referrals, especially for rehab, are you concerned about an impact on your revenues? More on staffing, honestly. I think all those patients that are getting acute care at DH, those that need acute rehab and swing stays are all going to come to us as they have before, as long as we have open beds because of staffing. I would say that the workforce is a critical issue for the system. We're engaged in a number of projects. There is a massive amount of planning and strategy being developed to bring more people to the area. We need more workers. The 80-bed tower alone, like I said, is probably a couple hundred nurses and support staff. I mean, where are we going to get those? And DH has been thinking differently about that. They've, I don't wanna say have a controlling interest. They are actively engaged with a local college in New Hampshire to bring more medical services staff and really change the curriculum there so that it's rad techs and therapies and nurses and not just nurses. But we need more people. So that means we also need to address the housing issue. We need to address the transportation issue. I know how we're suffering locally. The rents in Windsor are a few hundred bucks less than the rents in Hanover. I mean, that's brutal. No one can afford to buy a house anywhere. We've recruited staff from the Midwest who stayed a year and a half and left because it couldn't buy a house. And even in Windsor with our payer mix and what has historically been more affordable housing. That's my bigger concern. I think the patients are still gonna come. I think that I'm not worried about that. How do we care for them is the bigger issue. We have an aging workforce. Nursing, average age I think is in the upper 50s here. We've, every year when we do our benefits, we kind of, we're aghast when we see how old our workforce is just at our hospital. So we've got to fix that. That's a Vermont, New Hampshire issue. We've got to bring in more people. On the other side of the river, are you seeing one of the drawbacks here in Vermont to fully maximize the nursing programs is the inability for maximizing clinical placements for the students. And is that a problem on the other side of the river just as it is on our side or? Yeah, I think you've heard similar stories. The trouble has been attracting and keeping nurse educators. We've got this, nursing schools have had to limit in the size of incoming classes because they don't have anyone to teach them. So, we looked at that and we actually hired, we worked with our local community college and said, I know it's expensive for you to hire a nurse educator. We'll supplement that so that the job is more attractive. Nurse educators don't get paid as much as a nurse working on the Florida. So who would do it? So we worked with a local college to supplement that comp and just cover that so that it's an attractive job and we'll keep educators. So we've had a recent influx because of that. And I think that's something that we're probably going to have to build out. We've had, as you've seen, a bit of a financial tailwind in 21. So things that have been on the wish list as far as that, that's a three year down the road benefit of an investment now. We've actually been able to make that investment and hopefully that leads to more new nurses, two and a half years down the road on our units. But that's a classic example of if you're just patient and make the investment, it should work. But it's a structural issue. There's not enough nurse educators on both sides of the river. Well, we've tried to pull from both. You talked about the issues at the assisted living facility. What's the compensation differential for working at the assisted living versus hospital-based? Yeah, it's varied. The medical assistants or patient care assistants down there actually make as much, if not more than what they do here at the hospital. This is an example of where our health system, larger health system has made decisions to raise the floor on the lowest paid jobs within our organizations. So they've all moved up to $14, $50, $15. Locally at their assisted living, we've moved it up even higher. It is, we've had to our nursing staff there, there's not a lot of them but we've had to provide a premium there as well to keep the staffing. The bigger issue with historic homes is we made a decision about five years ago to do what we did at a Scutney seven years ago. We said, let's just fill it up. Let's not worry if it's a private pay or a government payer, let's just bring it in. And so most of the patients down there are government payers which if you talk to people that run assisted living facilities, they'll say, what are you doing? That's no one does that. And so we've been able to do it on a shoestring and it's the most affordable assisted living within 50 miles of this place and it has a lot of residents in it but that's a tough business model to sustain. I think- What's your premium reimbursement there for Medicaid? Oh gosh, I don't want to hazard a guess, Kevin. Let me get that for you. So what we've done though within Medicaid is we've gotten waivers so that we can take sicker Medicaid patients there, don't quite beat nursing home but clearly can't be at home. So we get some added payment for caring for those patients and that's like someone with a feeding tube or someone that has mobility issues or advanced nursing care that's allowed us to, again, to meet the needs of the community but even with that enhanced reimbursement that's not covering our costs down there. So we can, we'll get a breakdown of that and send it over to you. So it's $60, $60 a day average resident regardless of payer source. So it's like better than staying at the holiday and you just don't get smarter. So Dave, you guys should work on that because that's at the pretty low end if what I'm looking at some of the daily reimbursements, you know, that's real low. Well, but you know, the other part of it is when you multiply that by 30 days, that's $1,800 and, you know, this isn't Wake Robin and so they're not paying for that level of quality. And we, except for when we tightened up during the pandemic, our occupancy is actually pretty high and is usually a small waiting list. So, you know, and we've got people who are in there and have been paying rates. So, you know, sit there and say, we're gonna have a 20% rate increase to get to market when you've got, you know, Nana's been paying $1,800 a month, you know, and then with, you know, three to 5% increases annually, we're gonna have a lot of upset families. So. Okay. Now I'm gonna turn the questioning over to the healthcare advocates office. Thank you, Chairman Mullen. I'll be really brief because I know we're tight on time and I'm sure the public has time to weigh in too. If you hear a groan, that's a puppy in the background. So hopefully it remains quiet. So I just wanna thank the team Mount of Scotney for all that you do, particularly during the pandemic. We're grateful. I know it's a challenge each and every day as cases continue to rise with Delta. Also wanna commend you for prioritizing race equity in your work and for answering the pre-hearing questions during the presentation. And I know you mentioned you're willing to share your health disparities data. We'd love to look at this data with you. If possible, so we can touch base on this perhaps. This is a focus area for our office. So I just have one question on behalf of our office. There was a high profile piece in the Sunday edition of the New York Times about the tremendous variation in hospital and insurer prices for the same product or service across the country. I was wondering if you saw this article and if so, could you provide any comment about how may apply or not apply to Vermont? And if you didn't see it, if you have any explanation for this variation in prices for the same service. Thanks. So I'll speak for myself, did read it with interest. Went throughout the article saying, yep, that's us. No, that's not us. Yes, that's us. I would say, yes, that's us and most other hospitals with different prices, depending on payer. No, that it's not us in regards to transparency. And how we submit our data and if can, I think a lot of hospitals said, okay, we're gonna do the, if they decided to post their prices, we're gonna do the bare minimum. It's gonna be unusable. No one can actually interpret what it means. We did not do that because we're not on the DHS reporting systems right now. We had to do it our own way, but it's still compliant across the system. I think it's still a difficult document and collection of data to read through. I think we have less variation than some of the real egregious examples in that Times article. And I'd ask Dave to chime in on this one because we deal with this every day. Yeah, I think, when we worked on our price decreases, you know, we did look at how we get paid by different payers for different services and all that. And in the emails that I sent to Patrick and Lori about the decreases that we had enacted and the ones that will follow in the next days or a week or two, you know, there our charge master is irrational. And because, you know, you've got 40, 50 years of changing technology, you know, something that legitimately on a cost accounting basis might cost $500 to deliver. Well, 20 years ago, it might have cost $700 because the technology wasn't as efficient or quick. And so you've got all of that. Plus, oh my gosh, we're having a bad year. Let's raise our prices up 7%, right? You've got all of this nonsense. And when I went down, I went down to a study per study level to review this stuff. And, you know, what I discovered is that the reimbursement, we do have some fee schedules from commercial payers for outpatient work. Those fee schedules are as irrational as our charges. So I don't know, it's a chicken in the egg. I don't know if it was the commercial payers fault or our fault. So I'll say it was both our fault. But I think what we've done with those services we mentioned earlier is actually rationalize them. So if something is two times the effort of another thing, it costs twice as much and we've tried to do that. And now I'm going back to the payers who give us fee schedules for some of those services and asking them to rationalize that as well. So that'll be phase two. We could have actually done more if the fee schedule was more rational, but it wasn't. So plenty of work to do there, Sam. Thank you. Thank you, Chair McMillan. Thank you so much, Sam. Now I'm going to open it up to public comment on the Mount of Scutney budget. Is there any member of the public who wishes to offer public comment? Well, Mike Fisher, you could have just spoken. Go ahead. But I just take a human moment here. I also appreciate MassGutney for your answers. Just a human moment. Dave, I think you may have announced a few minutes ago that you just became a great grandfather. How is that possible? And congratulations. For everyone who knows me, I do everything unconventionally and backwards. And it always works out okay at the end. And so yes, I am a great grandfather. This will be number four actually. And I believe that a CEO of another Vermont hospital has made an accommodation so that my wife and I can continue to have an empty nest and not have a crying newborn in our house tonight. So thank you, you know who you are. Thanks, Mike. Is there any other public comment? Hearing none. Again, I want to thank the team from Mount of Scutney and very well presented budget and we'll be back to you in September. So thank you very much. At this point, I'm going to put this meeting into recess for 10 minutes and we will return at 11.03 and we'll start with Copley at that point. Thank you.