 Good morning everybody. My name is Jessica Holmes and I'm currently serving as the interim chair of the remit and care board. Today is our sixth and actual final day of our hospital budget hearing process. So we'll be hearing from both Copley and northeastern today. Just as a quick reminder, I've been saying this at the opening of every meeting, but to arrive at our decisions for each hospital, we're going to be looking at our statute and our hospital budget rule for the guiding principles. We'll have to balance competing factors. On the one hand, we need to think about the growth in healthcare expenditures and efforts to slow those down. But on the other hand, we need to ensure that our hospitals have the resources they need to recruit and retain healthcare workers and provide the high quality care that we've come to expect in our communities. So as we attempt to balance cost containment and access and quality and ensure that our health system is sustainable, we should be mindful of this year's incredible headwinds. We've seen historically high inflation rates. We're seeing workforce shortages. We're seeing workplace violence. We're seeing provider burnout. And we're still experiencing the impacts of the pandemic. So both nationally and in Vermont, hospitals are facing unprecedented financial challenges as our businesses and families and individuals. So over the next couple of weeks, and at the end of today's meeting, I'll give a timeline about our deliberation and voting process. But over the next couple of weeks, we're going to be approving the hospital budgets for our 14 community hospitals. But in the meantime, I want to remind everybody that the board is working very, very closely with the Agency of Human Services to begin the work that was outlined in Act 167, which aims to move us closer to a more sustainable hospital system that ensures that homeowners have access to high quality, affordable care. That work is going to involve a lot of data analysis and real hospital and community engagement. And the hope is that the result will be a more sustainable path forward. So I'm going to turn us back to the hearing today. And as I do that, I want to extend a thank you to both the Copley and the Northeastern team for the time and effort that you've taken to prepare and submit the documents for our review. And a few housekeeping notes about the hearings today. The presentation is a public meeting. It's being reported and transcribed. So there will be a publicly available record. If at any point during the presentation or during the questions and answers, the hospital's leadership team feels that there's some confidential information that the board should consider, please just alert us before responding. If needed, we can go into an executive session and review confidential information from hospitals. Executive sessions will be limited and spoke just to that, which would be provided by the open meeting law, limited information such as contracts and information that would be deemed confidential under the Public Records Act. So if one of these potentially confidential issues arises, I can call on our legal counsel to determine the scope of what could be discussed in that executive session and if deemed appropriate and at the appropriate time, ask the board member for a motion to go into executive session. So enough of the housekeeping. I think we can kick off the first morning hearing with Copley's presentation. Note that I'm going to ask all board and staff to hold their questions until the end of that presentation. And before we turn it over to you, Copley, I'm going to ask Russ McCracken to swear in Copley's witnesses. So anybody planning to present or answer questions today, please participate in the swearing in process. Russ. Great. Thank you, Chair Holmes. This is Russ McCracken attorney for the board for the Copley team. Who do you anticipate would be speaking today? The list is myself, Joseph Wooden, Jeff Hebert, Donald DePuy, Nancy Banks, and Jody Legacy. All right. Terrific. If you could all raise your right hand, I'll swear you in. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth in nothing but the truth? So help you God. Yes. Great. Thanks very much by your sworn in. I'll turn it back to you, Chair Holmes. Thank you very much. And Copley team, I think to help our court reporter, if anybody, since you're all in one committee room, it'll be difficult. It'll be difficult for our court reporter to know who is speaking. So if you could just tell us who's speaking prior to your words, that will help our court reporter quite a bit. So with that, I'm going to turn it over to you. You can load up your presentation and we'll hear it. All right. Please, if you guys have any issues with seeing this, let me know. I'm not seeing it yet. Oh, now I am. Great. Great. Thanks, everybody. Joe wouldn't the administrator here just want to introduce Jeff Hebert. To my right chief financial officer, Jodi legacy, who works here at a variety of roles. She's a house supervisor, infection preventionist, a lot of quality work. So Jodi, very happy that you're here. Appreciate that. Talking to Pui is also on my left and she he is our chief medical officer and a general surgeon. And does a lot of work around this hospital. Appreciate it. Nancy banks is here. She's the board vice chair and appreciate the board's involvement and participation. So this is kind of funny. It's a big deal. We spend a lot of time getting ready for this. My daughter has a new job as a wedding coordinator for the end of Essex. Feel like after all the work we do over the year and all the forms we fill out and all our efforts come down to this presentation. So some of us it's a little bit like, wow, this is kind of a big deal. And the end we talked about a rate increase, but really we're hopeful to talk about all of what we do as an organization, because it's not just the rate increase. It's not just us describing the community or staff that we work on. So we're pleased to do that and happy to be here. And before we begin, I know Nancy wanted to make a few comments on behalf of the board. Yeah, thank you, Joe. So I'm the board vice chair and the fact that the chair is not here does not in any way reflect the enthusiasm that the board has David Silverman our chair had to have professional obligations today. But the board is very enthusiastic about the work that the staff has done. A few years ago, Kathy DeMars, who was at that time, the board chair spoke at this hearing, and she we had just brought Joe on at that time, and we were talking about the goals that we had for turnaround plan. I feel the board feels that in spite of the strong headwinds that there has been much accomplished. First and foremost, it's really the amazing staff that Joe has put together utilizing the talent that was already here at the hospital but also bringing in some new talent. During the last two years that that staff has shown incredible skill and grace and really commitment to our community which has been deeply appreciated by the board. And the second thing that we've done is earlier this year we approved a strategic plan that Joe led that effort with the help of the staff of the hospital with board. And so we feel that we're on a very strong path in terms of what we would like to accomplish as a hospital to continue to meet our missions. So with that, come back to Joe. Thank you again for all the work. Yeah, thanks. Thanks, Nancy. So just to follow up on that strategic plan, it took us a while we actually had a very productive retreat. We invited folks from Quorum Health Resources and National Group to look at us and give perspective. We also invited your health care board and Jessica and Robin show up and really appreciate that that was very helpful. We had one care and UVM there. We had Dr. Bernstead and it was a great learning opportunity to think about everything that's going on nationally and in the state. And then we stitched together. It wasn't easy strategic plan. And in the strategic plan, the four things that are most important to us. This is sort of standard is for us, it's financial stability, sustainability first, just you'll see through some of the slides that finances for us is really important that we get it right. We're really trying to manage that. So it's listed as number one. And we could argue about that, but it's listed as an important aspect of what we do. Second is quality. Dr. Pree is going to be ending on a lot of discussions about quality and some other aspects, but quality is key to everything that we do every patient experienced every provider that feels proud to work here. So qualities number two, workforce and culture. Of course, that's been a raging issue, the workforce piece and then keeping care local. I think for any small hospital or even even the medical center, you know, you want to be able to do the best job you can care the folks in the community. So that's kind of the crux of that process. But we follow that and we have some of them laminated so people can't tear them up and we hold each other accountable. So it's been a good process. So to begin, I wanted to just share with you a general list of the agenda items. This is something requested by the people care board, and we're going to sort of march through those things. But before we do that, there was four subject matters that hospital association, a lot of us talked about that were really important to bring to the forefront in our discussions with you and that is the fragile finances that we're all experiencing these past couple of years. We've actually been a couple of years now with COVID. Workforce challenges, aging infrastructure, and then kind of a stress system. You know what are the stresses that we're sort of feeling. So I'm going to walk through some of these. So in this particular chart you'll see this is sort of a run chart over time with bars and so he lines but it just shows our operating margin. And I think the operating margin at the end of the day is really important. If you're dipping into reserves that can be problematic. So we've had a history of that without the COVID funding. Last year we would have a loss of negative 1.2%, but we are trying to figure out the finances and manage and you'll see some of the issues that we talked about. There's a basic structure that we talked about in healthcare. There's a three-legged stool and the stool is quality cost and access to services. For us, the quality of course is important. Number one, the cost issue relates to prices too. And what you're going to see is we show you our prices are really low, extremely low. And that's why we sort of need a rate increase to at least get us towards average. One of the things here is at least treat us like average. We'd love to be treated like average. I think we can be more successful. So I just wanted to share that chart with you. It does remind us and keep us focused. Workforce challenges, we all know of these. In my whole career I've worked in six hospitals. I've been a CEO in four of them. I've never seen anything like this. None of us have seen anything like this with regards to what's going on with the workforce. We've never seen COVID, but never seen a worldwide pandemic. And so these things are aftermaths that are quite expensive. So, you know, the staff vacancy rate is highest 20%. I think at times in our emergency department it's 50% of the staff are travelers, which is a real problem. The traveler expense is almost tripled. Our contracted services for travelers and others has gone from about $2 million to about $6 million, which is just shocking. But there's not a lot of choices that we can do when the marketplace demands really high rates. We're trying to be flexible. We have a nursing union. The nursing union has been very helpful in accommodating. We've done a great job of allowing us to have some flexibility with certain positions so that we can take care of staff. That's been helpful. The labor rate issues in Vermont and elsewhere. One of our local health organizations has 17% increase in a year. They had to raise all labor rates by 17%. They had about 60 vacancies and every time they hire 30 more 30 leave, which was hard to believe they were giving bonuses to folks. People have been scrambling. There's been some desperation that has caused these increases, which is not as patient as thoughtful as we could be. But we try to be patient and thoughtful because the emotional response to these things has really cost us all too early. I know one place gave nurses 10% immediately and then another 5% later, another 5% kick and then a $5,000 bonus for any technical staff hired and then we found a hospital that gave 32% increase over three years. So that's huge. That's a commitment of 32%. So it's hard when you hear these things, it's hard to know what to do. We do sort of take a deep breath, work with our staff, try to be transparent. We ask them to pitch in because we know if you just respond, we're going to dig ourselves into a hole and it's not going to work very well. So we want to keep the culture and people together and caring about the place. Didn't have a great story about somebody in rehab got a 50% increase in salary, which you can't compete with and they also got free housing over in a place in New York. You hear these stories and it takes your breath away, but we try not to just respond because we just respond. We're just adding fuel to the fire. So we're working on this as much as possible. Any ideas, any suggestion again, our staff has been very flexible, which we need them to be to ultimately take care of the patients that are sitting in the beds or come in here to take care. Aging infrastructure. So I had a lot of slides. Jeff wouldn't let me put them in. There were too many of them. Jeff said, Joe, you can't put all those slides in, but I have like 1000 pictures of any of three years of the hospital and things that we're working on. So we've got some aging infrastructure issues and this is show and tell. So I brought something that's like when you're kids, I brought a show and tell I brought an object. But before I show it to you, I want to show the next slide. And that is, this is the only way I can get my head around understanding how we got here. And this is a chart that shows the blue is the one you budgeted and hope to spend on capital. The red is sort of the actual what you did spend. And those red circles are in cases where you didn't spend what you budgeted. So I make those red because it's kind of negative. Well, because over the years, if you go through the process of axing, asking the managers and supervisors and everybody, what do you need for capital? What is the appreciation schedule? So what do we actually need to make sure that we are doing well? And we bring bring that through the finance committee, the process, the board, the board approves it, and then the Green Mountain Care Board approves it. It's really a big deal. It means something. And on all of these circles, we didn't spend the money as we should have. And that's a problem. It adds up. So somebody could say, good job. You had a good operating margin. How'd you make it? Well, we didn't spend on capital. It's like that doesn't work. And I have, there's an IT gentleman in the room to the side in case we have problems. You know, our IT stuff is really in front of us and it's raging because we need to be safe and secure. So IT is one of many. But this chart up above on the left, it said cutbacks versus investments. This is just a 11 year chart. So the total budget for the 11 years was 55 million. We spent 42 million. So in 11 years, you know, somebody could say, that's great, you saved $12 million. It's not good. $12 million is a huge number of not spending on routine capital projects. So that's a bit of a problem. And I think some of them, well, I don't know if anybody wants to see, but here's my show and tell. Jeff is going to see technology never works. Okay, isn't that funny? So technology is good, but just trying to do so here. Look at this. I get zoom capability. How well is that working? I don't know how others can see what you're doing. I don't know if they can. I think it's okay. Jeff, shut off the sharing, didn't you? Can you? Oh, can you see? No. Anybody else want to see? No, I can see the box that is Jeff, but it's black like the cameras turned off. Yep, let's just go back, Jeff. Thanks. We're good. We did that some other time. But anyways, we've got a lot of aging infrastructure issues noted by the $12 million shortfall. So it's not like we're proud. I'm proud of that number. Can I just interrupt for a quick second? Okay, there we go. I was going to say we couldn't see the slides or you for a second there, but now we have your slides back up. Okay, thank you. Yeah, we're not going to try those things again. Technology is good, but it's not that good. So anyways, that's a discussion about the finances, the age, the aging infrastructure and sort of the stress system. So the stress system is most noted. And sort of the one of the areas most notably is the emergency department. And I asked Jodi to make some comments. She's a house supervisor. She's all over this place. Sometimes seven days a week depends upon her shift. She works weekends. Jodi knows this place intimately. And so I wanted to ever go through a couple of these slides. Good morning. Thank you so much for having me. Just to give you my background, I've been a nurse for 17 years. I've worked in level one trauma centers. I've done ICU and cardiology. I've done progressive care. I've been in the community. And I do feel that I am very well versed in the world of health care. And over the last 17 years, I have the opportunity to see the evolution of our health care systems. And as a house supervisor here at Copley Hospital, I see intimately what we're seeing in the emergency department, what we're seeing between intra facility transfers, and what we're seeing on our med surge unit. So when I speak to our emergency department in a rural health care system, if you've never worked in a critical access hospital, we don't have the luxury of having resources just handed to us. And so we have to often get creative. And what we found and I, I do want to speak to, and I think we all can acknowledge the fragile system that we had prior to the pandemic. And then a precedent event happened in our nation, in the world globally, and it impacted every single one of us. There's not a single person in this room listening to this conversation, patients, community members who have not been impacted. And by this pandemic. And so that goes without saying that there is a before COVID and now the aftermath and the impact and consequences of our actions during COVID. And one of the things that we see the most in the emergency department, and I know that I do not speak uniquely to our facility. I think I can speak universally to the world is the mental health and substance use problems that we're seeing in patients. It's not new mental health has not been it is not a new discussion that new to health care nor substance misuse disorders. But we have found that those were who were vulnerable prior to who had trouble finding care. No longer got the care that they needed for two and a half years. So who does that fall on to that falls into our emergency department. It's sitting on the shoulders of the doctors and the physicians, then the nurse practitioners, the physician assistants, the nurses, the healthcare staff and the emergency department. Because guess what, people don't have anywhere to go. So where do they go? When the police find somebody in acute psychosis in our community, where do we bring them our emergency department. when a child is thinking about committing suicide and we all know we've been in healthcare long enough to know that suicide in adolescence is the number one cause of death. It's rising. Is it going to supersede motor vehicle accidents? The time will tell. But when we have a pediatric patient who can't get a bed and they have to wait hundreds of hours sitting in isolation in a room, best it's heavy on your heart. And we're all compassionate caregivers and our compassion is being fatigued by the demands that are being placed on us. And I am very emotional at this because it's difficult to watch a young child sit there in a room. What we have to do is also have somebody watch them. We call them patient attendants or sitters, whatever you want to call them. But we have to in a critical access hospital within an already understaffed facility find people to take care of and work to observe these patients. So they're staying here longer. And they can't get out of here. Our last pediatric patient was 14 and they stayed here for 10 days waiting for a bed because the outpatient facilities did not have a bed for 10 days because of COVID. Those are things we can't control. But we need to think about more creative solutions and how we can help facilitate this because more people are coming into the emergency room for care. More people are staying longer. They're coming in sicker. And how are we going to take care of those patients? And these are all things that we really have to consider when you don't have the resources. You have to get creative. And we do get creative because we have no choice but to be creative. So how do we impact that? This doesn't just stay into the emergency department. But how does this emerge into the facility itself? So if we think about our med surge unit, we can go to the next slide, please. Our med surge unit. We speak about how people have nowhere to go. So we think about our post-acute patients on med surge. This is actually a very serious issue. Post-acute patients could be swing patients or custodial patients, whatever you want to call those patients who are here that have no place to go. There's no short-term bed rehabs. There's no long-term beds. And how do we place them? And so what is happening is we get constipated in the ER, lack of a better word, and then these patients are now having to board in the ER. Who gets those two beds that we have available to admit a sick patient? Do we leave the 90-year-old, demented woman who's confused and agitated in the emergency room? You know, that's unsafe. It is unsafe to do that. So we have to give them the bed. And so these swing bed patients end up being treated for their acute delirium, their UTIs, their pneumonia, and then we have nowhere to send them. And they stay there. So we have on a daily basis. I have to talk with physicians, my hospitalists, and my nursing staff to say, I only have two beds to give to the possible 12 patients that you want to admit today. So who can we safely board in our emergency department and take away more beds from the patients who need it? And so I don't want to dwell too much longer, and I won't take much more of your time. But I do want to say something that's really important is there is this old saying to say, work harder, work smarter. That only speaks to a broken system, because everyone is working as hard as they possibly can. The fatigue, the burnout, the overworking staff is trying because of their compassionate hearts and what they want to give to our community. But when there's no more beds in our rural health care facility, where are those patients going to go? Because our community counts on us and demands on us. And Lamoille County needs our critical access hospital to help manage their sick patients. So we just have to be more creative in how we do this. And I hope that we can do that together as a team and working across the state of Vermont. Thank you. Thanks, Jody. Appreciate the comments. I will just sort of jump in. You know this is true everywhere. So UBM is stressed. That's where we send a lot of our care. They're full. Dartmouth at times is full. We all of us sometimes are sitting on folks and calling each other, calling other critical access hospitals, calling some of the larger hospitals. It's been really fascinating. I don't think the public realizes how cracked, I don't want to say broken, but how the system really is under a lot of stress and it's been difficult to manage. I don't think they fully appreciate that, unless they've had an experience, which hopefully we do. I don't have a job to take care of them, but thanks on that. So covering those four subject matters, I wanted to move on, give you the mission of the organization versus where community, community hospital, we like to pursue service excellence, which is why we have pride at working here and all of what we do with our time and compassion for patients. Respect is important for all of us, for every patient, for everybody we take care of, respect and compassion. Learning is key. We're always trying to get it better, try to be smarter, but think about ourselves and one of the paradigms we need to work through to get better. And then we're a non-profit organization. So at the end of the day, all the resources, everything is meant to be put back into the organization and help us. So a few things. This is sort of an overview, our service area, service area population. We talk about that in healthcare. I have so many things we talk about in an old-fashioned way. It depends upon the service. So we can mention orthopedics. Orthopedics, we probably have a service area of close to 50,000 patients, but for maybe midwifery and birthing, it's 30,000. So emergency department visits, that says 12, 5, I think Dawn and Jody and some of their experience of late because lately it's just more screenly, more busy for some reason. We still don't understand clinically why all these things are happening, but we think the numbers much higher than 12, 5 employees, members of the medical staff, volunteers, donors, volunteers and donors. It's always a very grounding process to be reminded that they give up their time, which is extremely precious for their resources to help us out. I was in a foundation meeting yesterday and it's always just really great. It reminds us that they do care about us, ask how can we help, and it's nice to have those relationships because it means the world to us. So we're thankful. This, I bring this up. It's, I'll probably always do this, just to show us in relative size of we're dealing with Vermont, not dealing with England or the country, but we're one of the small critical access hospitals. We're at 3% of the spend. So it actually made me in stakes with us, you probably wouldn't notice them. It doesn't mean we're not important. We're very important to the community and the people that we serve. We're Vermont primarily is rural, so we're in rural Vermont, and we're a happy, we're one of the independent organizations that want to share our role in the system. And I'd like this chart to just remind us all that there are three payment mechanisms that are really key. And there's three types of hospitals. You've got critical access hospitals, you've got PPS hospitals, prospective payment system hospitals, and then you got tertiary PPS hospital, which is UVM. So that's really important through the CH model. We do get some preferential Medicare advantage, lovable costs around 99%. So that's helpful. The critical access hospitals help draw down federal dollars. That's really key, much like drawing down federal dollars for roadwork or infrastructure. We are one of those darling designations for a small hospital. If you're a small hospital in America, it did not have this designation. It's most likely you would not make it, you would have to be absorbed and become entirely part of the system. So going back to that chart about our performance, just going to go over the income and balance sheet, and we're going to go to some more financial tables here. All right. So getting into the assumptions in regards to the budget. Overall, for our volume, I wanted to take the opportunity to say when I look at this and I look at budget 23 to budget 22, we do see a shift of negative 39% down to an outpatient increase in 18%. And what was on the reason behind this, this was actually a variance caused by Medicare. Medicare last year, January 2021, a lot of block of what they call inpatient only procedures to be performed in an outpatient setting. That was our orthopedic practice. And we actually adopted that pretty much right when the rule changed. And so that is what's causing the variance budget to budget. However, when we take a look at the actual to budget, we are seeing that overall we're down 3.8%. We see that our inpatient's going down 3%. Our outpatient's going down 5%. And our clinics are going up 2%. Two big drivers that are affecting us right now is our lab we are seeing go down. And the reason that this is happening is, unfortunately, we had a for profit lab come into the area and take over our primary care lab volumes. And the other area that we are trying to be conservative is with the ED. Joe is communicating that our ED right now is very busy, but we don't expect that in the 2023 budget. And we use pre COVID numbers to come up with those. Moving down to payer mix on in regards to the payer mix, we are still seeing and this is actually being demonstrated in the data that you've been sharing with us as well that Vermont continues to age and we're moving away from commercial and into Medicare. Looking at our three buckets of payers, our Medicare payer, as Joe alluded to, it's a cost based reimbursement methodology. When we take a look at our rate increase, if our rate increases commensurate with our inflationary increase, we typically see the full benefit of that rate increase. Moving down to Medicaid for the budget, we did not assume any additional revenues from the rate increase. And then looking at commercial and we are realizing the increase, but this is based on our contracted rates and they're all a little bit different from payer to payer. Getting into the operating expense assumptions. Overall, when we take a look at our salaries, our FTEs, we are seeing that our FTEs are moving up. We are moving our nursing to an LPN model, which is helping increase our FTEs. We're also looking at our providers and making sure we have the appropriate mix of providers. This is key and this will help address the wait time issues that we have here at Cobley. With those providers, we also need to make sure that we have the appropriate supporting staff. So all of that is adding to our FTEs our salaries. Unfortunately, we have over the many years seen that losses and so we kind of go after our FTEs first and foremost when trying to write the shift. And what we have seen that happen is this is adding a lot of staff burnout. And so we need to rectify that. And then the last piece on salaries and wages is we need to be competitive. And as Joe was talking about organizations all over the nation are addressing wages. And so we need to make sure that we're addressing our worries as well. Looking into the benefits overall those are going up 7.8 percent. Health we have going up 6.2 percent. Dental is flat due to a contract in life and long term going up 6.2. There's some buckets within our budgets. Everybody's been hearing the inflationary pressures. Utilities overall are going up 37. But when you break into the oil and gas, we saw that actually double this year going from 358,000 for our organization to over 770,000. Looking at our insurance, our insurance is going up 31 percent. But then breaking into one of the specific ones is the cyber insurance. And that's cyber insurance is doubled for us. Our provider tax is going up and that's due to our increase in net revenue. And moving on to non-operating overall, this has been consistent. And we are keeping that same as last year. So looking at our rate increase, our rate increase that we're requesting is a 12 percent rate increase. Overall that equates 9.6 million. Breaking that down into a 1 percent, it equals 805,000. This is to support a modest margin. We only have a margin budgeted for 1.6 percent, which actually translates to 1.6 million. The reason we need this modest margin is to continue to rebuild our staff, cover our inflationary concerns, and invest in capital. I did take the opportunity to add an additional slide. It just basically breaks down how the 1 percent is spread by our payer. And overall for our commercial, we're looking at 1 percent, weights to 512,000. Medicare is 292,000. We're not expecting anything from the rate increase from Medicaid. And that's the 805,000 that I communicated earlier. If I take that and break that down to a percentage-based, we're expecting between 8 and 9 percent of our commercial. We're expecting 11 and 12 percent for Medicare. And we're expecting 0 percent for Medicaid. Now I'm going to pass it off to Joe. So a couple of things I'm going to go over. We're trying to make this interactive. So when we look at ourselves holistically, we always try to figure out what's our cost? What is the community paying for? What is our rates? We sort of think about these things. The board expects that. You can't keep raising your rates. You have to sort of think through this. So this is a chart that we picked up a couple of years ago. I've not seen it before, but it was a chart that sort of says what is our cost of care for the Morrisville service area county. And we're the lowest in the state at 482. Of course, I did my research. I love the chart so much that if you look at this one, we're lowest in the state by county going back to 2013 where we shared that by a dollar between us and Burlington. So we were pretty tied. But if you look at this chart, it's one of those confirmations that are we expensive or we too expensive? How are we doing with regards to cost of care? And I know this is not just the hospital business. It's more holistic. On the rate request side, I do like to look at data over time and we're talking about operating margin and kind of how we look at ourselves in Vermont. So that's the blue line is Copley. And the first column there is the five year average of what we submitted. So on that copy line, we submitted 6.14 and we were granted 4.18. So those are, I guess, being clipped or reduced in your rate request. And for that first column, the green and red represents the lowest five year request and the red represents the highest five year request the past five years. Springfield being the highest, understandably, because Springfield went through bankruptcy and it's been working very hard to write the ship there. So the next column is the 10 year average. We were the lowest. So we did earn that sort of bright green label there of 2.2%. We were at the highest, which is red. And then 15 years, we were the lowest. So this is us being sort of the lowest average approved budget in the state. And if you compare that to sort of what we have for the state average down below, in 15 years, we would have had, if we just got average, we would get 1.68% more every year for the past 15 years. So it's been kind of an interesting journey for us, for Copley, well before I got here. And on the right, we've got 2023. We're looking at a 12%. We look down below, that's close to being the system wide average. It's lower than the weighted average at 16 and the median is at 11. So we don't mind operating within what's considered to be fair and reasonable. If you look at the next chart, this sort of just looks at the all-payer cost of care, these, and again, our 15 year, we were the lowest. We were 1.68 lower than the system average, 10 year, 2% lower than the system average. So we've been really quite modest and very reasonable in what we've asked for and what would have been different. Here's some price comparisons. I know we don't talk about price that much. I mean, there's just the issue, if you're going to manage health care, you've got quality, which is hard to measure, although Dr. DePree's going to go over some of that quality piece. Access, we sort of continue to work on how to measure access, but cost of care, price is part of it. To never talk about price, to say, well, why don't you charge it? It does matter to people when they look at it. It matters to those that have an HSA, health savings account, et cetera. So this is something we did because of the reference that Jeff made with the Quest prices, and we updated it. But we are extremely reasonable. And then these are some other Vermont hospital comparisons. This is publicly available data. And so our prices are extremely low. If you look at the lower one, the bacterial culture, we charge 41. The Vermont average is 131. The highest is 186. We charge $41. The culture of urine culture is $25. The average is 75. The highest is 195. So it's interesting. We are extremely cost effective. We are some of the lowest charges in the state. If you look at this next slide, this is inpatient room and bed. That's an old fashioned term. Nobody talks about that anymore. But it all relates to what ultimately gets charged, whether it goes to commercial or self-pay or whomever. Emergency room levels of care and then diagnostic imaging. And if you look at these, anything with a blue star, we are the lowest in the state. We're not necessarily below average. We are the absolute lowest. And if you look at the bottom one, for example, MRI joints of the lower extremity without dire contrast, we charge 1732. The average is almost $2,000 more expensive than us. It's $3,600. And if we wanted to be the highest, we could charge an additional $3,500 per test, because the highest in the state is at 5156. So it's interesting. We are very cost effective, but it's one of the problems where our operating margin doesn't seem to be able to hit zero or move forward or invest in stuff. So we're one of those anomalies. When I tell you to look at data, you should look at all the data points. You should look at all the highs and lows in question, but we're definitely on the low side. So I wanted to just share that with you. The next discussion is about provider transfers. I can just mention this. Dr. McNamara, a podiatrist, joined us as well as Dr. Hollister, part of the orthopedic team. Very happy. They're both very experienced. And they came and joined us. We had podiatry, but we've expanded. I don't know, Jeff, if you want to add anything. Oh, that sounds good, Joe. Great. Thanks. And then key indicators. So operating margin at the end of the day is part of it, because if you don't have money at the end of the day, it doesn't matter what you're doing. You're not able to invest in the organization. So for us, we're not really proud of these charts, but they are the reality. We sit up there with the most red and the most circled. So that's not where we've been losing money. So the five-year average, we've lost half a million dollars. Springfield on the bottom was lost the most, but they did go through bankruptcy. The ones with the blue stars represent some of the hospitals that have been considered part of the sustainability group, right? It's not necessarily all of it. So there's the chart on the right, you know, coply average operating margin. It's something we have to work on. Next slide is just going to show you. So the same information, but it's kind of interesting. So our rate requests, again, I wasn't here. I've known about coply for a long time. I've worked in four from auto hospitals. So I've observed coply for decades. I'm new to the state. I've only been here since 1983, 39 years. The old timers remind me, yeah, you're new. Keep your comments pretty good. You don't have much standing. Anyways, when you look at our operating margin, so back in 17, we asked for 0%. We got negative 2018. We asked for 0%. We got negative 3.4. So it's interesting, some of those, I don't know the full history of appreciating that. It's hard to run anything at 0%, but we did get a change in 2020. And we're here asking for 12%, which is I think reflective of the chaos and the stressors throughout that entire healthcare system. And we're not void of that. So next chart is operating margin request for us. Again, that is, sorry, yeah, that's a 1.6% to blue, which seems fair and reasonable. Again, I always think with any of these issues, you should have what is a reasonable ban? What's a reasonable ban for operating margin? What's a reasonable ban for your prices? Your prices should be within a reasonable ban. There's variation, but so we're always trying to shoot for a 2.5 to 3% as that ban. Hopefully we're going to get to that point, which is great. Jeff's going to go over some of the long-term debt capitalization and a few other charts. So again, these key indicators, we did actually borrow these from the Green Mine Care Board staff presentation, and that's where we're getting our data for these. Looking at the long-term debt to cap, this indicator for me is it's debt allows us to provide more services than we could if we were only to be able to finance these through retained earnings. But when you take a look at the Coughly over the last five years, we're the second lowest that being Springfield is first on the five-year average. And when you take a look at the indicators, the Vermont CAH five-year average, as well as the Northeast critical access average, we're well below those. And right now, we'd love to be able to try to at least get to the Vermont critical care average. Can I comment? Yes. So I just want to comment that the black line on the far right there, the Northeast CAH, it's at 40%. I get concerns that Vermont and all of what we're doing around oversight and management of budgets and hospitals that for many of the hospitals, they're undercapitalized. And that becomes a problem. I think this chart kind of shows that that we do need to make sure that we're making enough to invest in all of the Vermont hospitals because that's a striking difference between those two. So anyways, thanks, Jeff. Next one I have is Day's Cash on Hand. I do look at this both ways or two ways. One is with the COVID advance payments and one's without the COVID advance payments. This one's without the COVID advance payments. And when you take a look at this chart, obviously, Day's Cash on Hand higher is better. Looking at the bar chart on the right, again, Copley over the five years is the second lowest only to Springfield. And when I talk to our auditors about this specific chart, they kind of communicate. If you're a hospital and you only have 60 to 70 days, that represents a hospital in distress. And we want to basically not make sure that we get into that situation. Moving to the next one, this is just with our COVID advance payments. And specifically, this was the Medicare advance payments. So when COVID hit, Medicare did release monies. For us, it was $11 million. And they just basically wanted to keep the doors open. And then instead of us giving those monies back, what they have been doing is they've been drawing down our remittance advices and taking them back. And we expect that the monies will be repaid back to Medicare by the end of this fall. So this is Joe. I just wanted to jump in. So in a lot of these charts, we are in a bit of financial distress. That's why in our strategic plan, it's the number one issue. It's really important. And you can't just immediately come out of this. It's going to take effort and diligence. But we are often listed right there with Springfield. And Springfield did file for bankruptcy. And I think that was a surprise to people. I think a lot of people in the state and regulators said we're really surprised we didn't know that was going to happen. They're getting help and assistance, which they did. And I think that's great. But Kotli is right next to it in a lot of these indicators. So I just want to make sure that's clear that we really do need some help and assistance. And I think a part of it is our rates are not at all helpful. They're extraordinarily low. And we're very busy. So it's a challenge. But thanks. Last indicator that I have is the debt service coverage ratio. This measures our ability to produce enough cash to cover our debt. Again, higher is better. And when I look at the five-year average from last year to this year, Kotli is actually looking much better than they have as compared to the peer group. This is actually helping us out because right now we are in talks with USDA. We're trying to get financing. This is one of the indicators that they definitely dig into. So it's good to be in the middle of the pack on this one. Moving to health equity. When I look at health equity or diversity, right now Kotli is working with his local partners to meet the community needs. We're using any and all grant options and funding that is available to us to further this initiative. We're developing collaborative DEI statements for our staff and volunteers. Once we do that, we will be introducing signage throughout the organization to reinforce our beliefs. And as of right now, when we took a look at it, currently over 80% of our employees have completed Elsevier cultural diversity training. I would love to add a little bit to that, Jeff, just because I think this speaks to what I was speaking to earlier and talking about how we work together with our collaborative partners in the community because it does just, we have to involve our community. And this is where we really strive when we're collaborating with our community partners to ensure access to care and removing those barriers and not neglecting the social determinants of health. So I think we all are very much aware that those impact our health and our well-being, overall as a human being. And so to not neglect those and to actually enforce and invest into these collaborative partnerships will only benefit the remote volunteers that we serve. Thank you. Yeah, thanks, Jody. And I just wanted to add to that, you know, we probably should have spent more time on this slide to reflect some of these things, but it's actually listed as one of our goals. And the strategic plan is one of the objectives. In fact, it's the first one under stabilizing and developing the existing workforce issues of DEI. So we are putting the time and the efforts in. So just wanted to jump into it. Thanks, Jody. Wait times was requested. You know, we did produce, you know, two slides, but I actually went back to our clinical managers, you know, who are dealing with us and asked, you know, their opinions and viewpoints and both of them kind of came back with a very similar story. And it's a balancing act. It's a balancing act and many different things with our wait times. The first that they kind of came out is they need to make sure that they got the right visit types by providers. They need to have slots, you know, for new patients, but they also need to ensure that they have enough slots for patients with urgent care needs available as well. Another topic that they brought up was recruiting. And that was something that they said, having the right mix of providers is crucial. You need to make sure that you get the right providers to keep those wait times low. And then to offset that, you need to make sure that we have the correct staffing to support those providers. And the last thing that we hear at Covley are experiencing is we need the appropriate space. We're tight. We don't have the right space. We're working on making that better. But all these things are contributing to our wait time, line time issues. Okay. A couple of discussions about risks in the future and opportunities. COVID continues to be a risk. You know, we all thought it was going to end. We all thought we'd get back to normal. Normal doesn't exist anymore. And there are still a lot of threats and themes that happened during COVID that we're still trying to appreciate. So whether it's a great resignation issue, which happens, it happens to us. People sometimes just don't show up to work or walk away from the job. It's really fascinating. We've had travelers, we had a traveler a couple of weeks ago who worked three days, and then she just decided not to come to work. And it used to be that the travelers would actually get a bit of a demerit, or their reputation would have a bit of a mark to it, so they couldn't just go get another job and another hospital. And I've been told that, oh no, travelers are in such demand that if they just want to end the contract sooner or leave, they can still be on the marketplace and go get another job, which is really fascinating. So we've had cases where people literally just turn in a badge, walk away. It's been fascinating. Previous to getting here, I was in Alaska for a couple of years. It was common in Alaska. That was pre-COVID. But Alaska is way out in the boondocks. But it sort of feels a little bit like that here. And it's been continuing, where people are just giving up their jobs. I know there's many cases where staff, nursing staff, and others, particularly in the emergency departments, some have given up their careers. It just said, you know, I can't do this anymore. I don't want to do this. And there's this word moral injury, which it's a great discussion. If you look into it, I think it's Dr. Z, isn't that true? Dr. Z has a video on that, but the moral injury that we've been putting people through in terms of managing COVID discussions, being sensitive to listening to each other, it's been really difficult. And so it causes us to have patients come to our ED for a variety of reasons that Jody talks about, but also our staff to just be very fragile. So COVID continues, and it's going to continue. Staffing is part of that. We're very small. So when we lose somebody of importance, if we lose a particular provider or somebody who's got a very specialized leadership job, it can really be debilitating. We don't wish that we were bigger, but when you're small, you really care about each other. You're really a family. And when somebody leaves, it can have a detrimental impact. It actually affects Jeff and some of his budgeting. So that's the good news, bad news. And the sustainability issue that we've talked about, you know, finances over time, looking at how we manage them and make sure that we're asking for the help and the resources that we need, I think is important, but that's a little bit different. Can I add something to a quick thing? Oh, please. Yeah. I'm just going to speak to the staffing. And I think this is something that I, and when we speak, when we lose a valuable staff member, no matter whether it's an LNA and nurse, when we are building our retention for our staff, we've been, we have to acknowledge that we need good staff to train on-boarding new staff. When you graduate as a new nurse, you're not prepared to take patients immediately to take a full patient assignment. You need somebody to train you appropriately. The same with the new nurse practitioners, positions, assistants. So we need quality people to train the people coming out of school. And the only way we can do that is by retaining the good staff that we have to train the young staff coming on. And that's the only way we're going to be able to do it. So it's the engagement of that. It's a whole nother expense because every time we look at staffing, we say, well, what's going on? It's like, well, these two nurses or these technicians, they're in training. It's like, well, can't they take assignments? No, they can't. They're not capable of just sort of working the bench. I have noticed, a lot of us have noticed that, you know, we used to talk about travelers with nursing. So we had low contendance, which is a word for physicians, which is Latin for very expensive. Just kidding. Thank you. And travelers were expensive. But now the traveler label, it's not nursing. It is lab techs, radiology techs. It is, there's a whole host of people now that actually are itinerant labor that comes through and it's not from an agency. It could be by themselves. So it's been pretty interesting. It's not wild. Some of the opportunities that we always see that opportunities are ongoing. You just have to look for them and see. So to have an attitude of being cautiously opportunistic, I think is important to be careful. But there's a lot of opportunities to improve and change, try different models. And we always think about those. So our clinical reputation around quality is important. We try to build upon that. It does result in us having wait times of people wanting to book significantly. Orthopedics is one of the mainstays of which some of our reputation exists. The orthopedics team has really driven quality throughout the organization helped us. And so we have a lot of demand that we continue to try to foster that. It's because of the clinical quality. That's what delivers master facility planning opportunity. We're really looking at how do we spend these resources to save money operationally, to avoid risk or safety issues. So we do need funds for the master facility planning. We've been working on that. And opportunities that we do coordinate our efforts. One thing about COVID that I'll say was very, for our sort of community, it really helped bring a number of us together in a serious way. So there's a list of the six people, the hospital, the FQHC, private primary care practice, the Boyle County mental health services, the designated agency, home health hospice, and then the nursing home. Like it drove us together. We sat around, we met two times a week. We really got to know each other to say, how can we help out? And that was a really good thing. Everything from policies to sharing staff, to figuring out what to do and how to transfer or how to manage. So I consider that to be a really good outcome when it relates to the whole COVID. So Jeff's going to talk about value-based participation. Value-based participation. So take a look at this. The payer that we will not be or we did not put it in our budget was Medicare. So we still are electing not to get into the Medicare. However, last year we did join Blue Cross Blue Shield as well as MVP. And we will continue that into the next year. And to start our journey into value-based care, we will continue with the Medicaid program as well. Looking at our capital, again, one of our needs is to invest in our aging infrastructure. Over the years, due to the limited cash that's been generated by our operations, our infrastructure has structured here at Copley. And we've seen a large backlog of projects. One of the good projects that's coming up for next year is we will be renovating our central sterile area. We feel that this will greatly enhance the patient experience. It will actually get us into a better situation to meet in the central sterile standards that are out there. And the most important for us, we're tight on space, and this will be able to allow us to promote efficient workflows. The diagnostic piece of equipment below, this was actually a piece of equipment that was budgeted in 2022. We weren't able to do it, so we're carrying this over to 2023, but extremely needed piece of equipment. IT is always at the forefront of our capital needs. But when I take a look at items four and five, our breast biopsy machine, as well as our MRI breast coils, these two projects are great projects, and we have set up a Copley campaign to fund both of these capital expenditures. So Dr. DePuy is going to sort of close this with a discussion about COVID sort of the impacts as well as quality. So really appreciate that. Yeah, so fiscal year 2022 has been somewhat of a wild ride with COVID. If you haven't been to Morrisville, you might not know that the LaMoyle Valley goes right through LaMoyle Valley. The LaMoyle River goes right through Morrisville and makes a rather grand oxbow right in the middle of town, and that forms a beautiful plateau where there are soccer playing fields, but also there are community gardens and a large outdoor amphitheater. And during the summer, we have regular outdoor concerts, which we haven't been regular during COVID, but they started again. And I was there a couple of weeks ago with my family, and I was totally taken by how 2018 everything really looked. It looked exactly the same. There were the occasional masks, but the kids were out playing, the band was going, there was dancing, people were buying corn in the cup. It looked all very normal, but it'd be easy to excuse people for having a short memory because this time last year Delta was hitting us very hard, and that continued well into the winter. And when Delta led up, then Omicron hit, and that has been very difficult to manage as well. So even though out in the community, things almost seem past COVID, the hospital, of course, is not the community. It is full of vulnerable people to COVID still. And so not a lot has really changed as far as the way we operate in the hospital. And that's really sort of lent sort of to a tale of two cities, where community life and hospital life is really quite different. Sort of from an operational point of view, we know a lot more about COVID. We have a lot more experience and a lot more expertise, and we're certainly calmer. But basically all the things that we did two years ago, we pretty much do now. But the only thing that's really substantially changed has been our visitor policy. We sort of worked out how to have reasonable visitor policy while still keeping things pretty safe from COVID. And the one thing that really changed a lot during Omicron is that in Omicron age, or the age of Omicron, which sounds like an Avengers movie, I guess, basically almost everyone is going to get or has already had Omicron. And of course, that's the same as the staff in a hospital. And that has been very challenging to deal with. And one of the things that we've done is that nucleic acid amplification test PCR is the one everyone knows. But there are also others that the CDC recommends for basically high reliability, high safety operations. And some of them deliver much faster results that we've been able to use, I think, very effectively in keeping the hospital as optimally staffed as possible during Omicron while still ensuring safety. The other thing that's really happened during COVID is that we've had to make a lot of lemonade out of the lemon that is COVID. One of the things was that Joe touched on earlier was this increased sense of community and tighter community. With our COVID response teams, even though because things are really not changing very fast anymore, and we basically have a much tighter handle on managing it, we don't meet as often anymore. The relationships that we developed and really the spirit of community that developed during that time has persisted. So that really feels good. One of the other things that we did when we were still very restrictive on visitors is we developed this communication program called EASE. This basically allows the operating room nurses to communicate with the families of the people being operated on. And so what actually happens now is that the families are much better kept informed as to what's going on in an operation than they would be even if they were out in the waiting room because it's just very easy to communicate. And the patients love it and it just seems to be a fantastic improvement that we may or may not have thought about without the impetus of COVID. The other thing that we really worried about a lot at the beginning was this issue of COVID and surfaces. Even though it turned out that the phone might transmission of COVID is probably not the dominant way it gets passed around, we were really quite concerned about it. And then hopefully we really took a hard look at how we clean things. And this is like one of those kind of esoteric things in hospitals that people really don't think a lot about. But the cleaning substances we used to use were largely quaternary marine amines and bleach, which are very hard on the people that are using it. And although they're pretty effective, we thought that both there was probably something safer for our staff to use, more effective. And it turned out we found something that was both of those things, but it was also a great deal more environmentally friendly. So during COVID, we switched to an acetic acid product called eradicate that really wasn't in mainstream use. And we worked with the company to figure out how to actually use it effectively in the hospital. And so we've actually been testing, we take swabs before and after the eradicate use and the quaternary of being used. And sure enough, it works better. It also kills the scores with C-dip. So we don't need to use chlorine and bleach anymore. So the staff is just ecstatic about not using that. And you can you can just dilute this stuff and pour it down the drink because it's essentially just a very fancy vinegar. So we have been able to make a lot of lemonade out of some lemons in COVID. The last thing I guess I want to talk about COVID is sort of like the more things change, the more they kind of stay the same. And really what I'm thinking about here is our commitment to helping the community get through this. And the two really big things we do was one of them was when monoclonal antibodies were still effective. We stood up really rapidly a way of safely giving it to people who needed it. And at least in our experience, that was it was almost an obstetric clinic as the vast majority of people we ended up giving it to were pregnant women. So it was both something that was useful to do and also felt terrific because in healthcare, new humans are a desirable thing. The other thing we do is as basically as the people in the community and around the state pulled back on their testing, we keep going drive-through testing. And a little while ago, we passed the 40,000 test mark. And as you may or may not remember, we have two Rionics, basically high-volume batch analyzers and two Cepheid blower throughput, but much faster PCR analyzers. So we've been able to keep all the testing in-house, which has allowed us to give results really quite a bit faster than almost anyone else. Going to the quality thing. Sure. All right. So, Jeff, if you could fire that up. So what cockley presentation to the Green Mountain Care Board would be complete about a little section on quality? Thanks. So there's three things I just want to talk about kind of quickly here. Go back, Jeff, if you could. Yeah, so you certainly heard from us in the past, and I think it's pretty well known throughout the state that we have an outstanding orthopedics department here that we're very proud of. And that's really widely known. However, cockley's not a one-trick pony when it comes to quality at all. And I just want to talk about a couple things. The first thing is this CMS overall hospital quality star rating system. And the CMS basically rates over 3,000 hospitals in the U.S. on a variety of measures from actual outcome measures, readmissions to administrative measures, like what percentage of your staff is vaccinated. And they come up with a zero to five star rating system. And out of the 3,000 hospitals in the U.S., 429 or about one out of seven are judged to have five stars. So in a state with 14 hospitals, you'd expect two. But Vermont actually has four. And one of these is a critical access hospital. And of course, that's cockley. Another really broadly held measure of quality that I think is also being incorporated into the new statewide system that Allie Johnson, so capably has been working on, is the HCAP ratings, which stands for hospital consumer assessment healthcare providers and systems. And basically, this is a survey of recent patients in the hospital. And the two I think most important thing, all the things are important, but I think the things that are generally held to be most important are the overall rating of the hospital. So the patients are asked to rate the hospital one to 10. And basically, if you raise it nine or 10, that's thought of as pretty darn good. And as it turns out that 87% of cockley's patients rate us as nine or 10, which is the highest percentage of any hospital in Vermont in 2021. Another HCAP metric is would you recommend the hospital to family or friends and 89% of cockley patients would in fact do that. And that's also the highest rating of any hospital in Vermont. So we're obviously quite proud of this data. And everyone knows about orthopedic surgery at cockley. And if you'll excuse the maybe apparent conflict of interest since I am the senior general surgeon here, I just wanted to share the Nesquik, which is a national surgical quality improvement program data. Nesquik is the gold standard in outcome quality measurements from surgery at hospitals. It's both in the US and around the world. And two kinds of data are produced by Nesquik. One is this raw data that you can see here. This is for the last five years, it's a general surgery. Cockleys in blue at the bottom compared to the Nesquik average at the top. Some Nesquik hospitals that you may have heard of or Mass General, Beth Israel, Dartmouth and even UVM. So the hospitals are generally pretty well thought of. So an average Nesquik hospital is probably quite a bit better than an average hospital. And on these graphs, lower is actually better. These are raw data. So this is what actually was observed when patients came to have general surgery surgery at cockley versus the Nesquik average. This is all complications. As you can see, our complication rate is very much lower. Next slide, please, Jeff. This is surgical infections. As you can see, cockleys rate is very much lower here. And the next slide. And this is our readmission rate. So basically, this is like any sort of problem you might have after an operation, as you can see ours is very much lower here as well. Now, some of the larger hospitals that deal with a wider range of people in a community hospital might will definitely have a yeah, but with these numbers, even though this is actually what happened to actual patients that actually came, it is true that not all patients are the same with their risk of having a postoperative complication. And generally, the larger medical centers have patients at a higher risk for complications. So Nesquik has obviously thought of this, and there is a way to normalize both for the pre-morbid risk of getting the complication and the caseness for the hospital at a whole. And that's using an odds ratio basically over the same things. So on the left are all complications in the middle are post-op infections and the right are readmissions, and it's color coded for the year. So the odds ratio of one means that things are basically the same. So that would be the Nesquik average. So this is taking to account all those things. So if a hospital is below one on these measures, that means that they're doing better than the great average Nesquik hospital, but with all those other things taken into account. And as you can see, you've seen similar graphs in the past for orthopedics, and now you can see it for general surgery. We are consistently at very high quality hospital. So as the CMO I hear a coply, I'm obviously very proud of this data. And I think it's quite remarkable that somehow we retain such high quality while being so low cost. That seems exactly the kind of thing that the board would want to support. And I certainly hope you support us in our effort to maintain this quality while being increasingly financially sustainable. Great. Thank you, Dr. DePuy. So I think this sort of ends our presentation. Helpful to have questions. I just kind of stop sharing, I think. Great. Thank you so much. Really appreciate it. Joe, I always appreciate your candor and your team's data-driven presentations and focus on quality. As you probably know and have heard me say, I've been trying for years to figure out how to incent all Vermont hospitals that perform surgeries to participate in Nesquik, and cost seems to be the obstacle there, but suggestions most welcome for how to get more hospitals on board with that. I also just want to say, I really appreciated hearing some of the innovative lemonade silver linings from the pandemic that Copley has emerged with. I think what we'll do now, if everybody doesn't mind, I've been doing this and I think it's been helpful, is we'll take a brief 10-minute recess so that the board can compile their questions for you, give everybody a chance to refuel with coffee or however you deliver your caffeine in the morning. So we'll come back at exactly 10 o'clock. A brief recess, so we'll back here at 10. I think Copley is here. So at this point, I am going to turn it over to Board Member Lunge for questions. Great. Thanks all. Nice to see you today. First of all, before I jump into questions, I wanted to say thank you to Dr. Dupuy and Dr. Macy for participating in the VPQHC hospital quality process. We really appreciate your engagement and your participation and also thank you very much for showing your quality information. It's very impressive, so I appreciate seeing it. So the first question I wanted to ask about is related to the utilization assumptions that you're making in the budget. So on page two of your narrative, you are expected and I do know that you have some slides. I will say my slides that I have do not match the slides that you presented, which quite frankly makes it a little bit tough to make sure that I'm going to have the right slide number. And it's my understanding from our staff, we don't actually have the slides you presented, so if you could send those along afterwards, that would be helpful for us moving into deliberations. So my apologies if my slide numbers are off, we'll muddle through I think. But in any case, in your narrative, you had talked about expectations around inpatient and outpatient decreases and clinic visits increases, and I do remember seeing that in your slides. Could you just talk a little bit more about what are driving those assumptions? Okay, so again, yeah, when we were talking about our volume increases, the two that we did touch on was the lab reduction, which is affecting both our inpatient as well as our outpatient. And that's due to the for-profit coming in. We were conservative with our ED. We did submit enhanced or the podiatrist paperwork in the winter, which is increasing our clinic visits, as well as we had an opportunity to enhance our cardiology services. So we're seeing additional volumes there. Just recently, we actually had the ability to open up a brand new MRI for this fiscal year. We have seen the pent-up demand actually realized. We're able to lower the lag times for that unit. So that's also in our budgets. And then the last thing that we do have is we have kind of an ongoing issue with provider retention. So we have seen that we have a possible provider leaving, and we accounted for that in our budgets as well. Okay, great. Thank you. It's helpful to get a little bit more color commentary. Yeah, I just wanted to add something. So on the MRI side, maybe it's just a choice of words, but it's not like pent-up demand that people are not getting MRIs. Most of this, a lot of this has to do with orthopedics. They do require extremely clear and well-formed MRI procedures. We had one of the oldest mobile MRIs probably in New England. It was 12 years old. I can talk about it now. I was not permitted to talk about it at all up until when we sort of got that replaced. Understandably, it was okay. It would be really nice to say it was okay, but we would actually send a lot of patients who came here for orthopedic surgery to other hospitals. So we were actually advocating that people would go. Our orthopedic surgeons would do that. So isn't that interesting? So even though they're part of the team, they're employed. They have a standard that says, listen, particularly with hand work in other foot to a lot of bones and feet and hands. So they would actually send MRI volume away. And it's not like where it's volume that should come to us because it's our orthopedic surgeons, but they actually really found our equipment to be lacking. And that's good. They're doing what's right for the patient. They're making that decision and saying, we don't care about volume's administration. We're going to make sure that we get the best. So it's not like it wasn't addressed. It's that it's coming back to us as it should. I don't know if that works. Yeah, go ahead, Dr. Capri. Yeah. So a couple things about the new providers. For the most part, they're not new to the state. So if we're thinking from a system point of view, these people aren't being added to the system. They're being moved around a little bit. There is one addition, however. There is a new general surgeon starting at Copley soon. So I will be the only guy in general surgery now. And we did kind of an odd thing here at Copley. I've been here for almost 10 years and I've been on call every other night for for all that time. And that's no, no, no other place does that. And you really, Dr. Olmsted, who joined this three or four years ago was probably the last person you'd ever get to join that. But our call has gone up dramatically over the time I've been here. We've averaged one to two cases per call week. My last week on call, I did eight. And that's not unusual anymore. So it's basically become totally unsustainable for two people to take call in sort of the modern, modern world. So that was there's no getting around that. But for the most part, you know, we're not adding to the system. We're just adding them to the Copley part. But the one general surgeon's from East Montpelier. Yeah, I knew her dad. She's gone off. She's a Vermonter. And she's going to be excellent. She's really sort of a proud moment to have people come back. It's great. She's got a lot of family ties. She's amazing. She starts in next month. Great. Thank you. Thank you. That's helpful just to get a little more color commentary to the numbers. So when I was looking at your appendix one to the narrative, it looks like both in the budget to budget and the projected to budget that that you can obviously there are ups and downs. But when I look at the rate compared to the total change, so in the budget to budget, there's a $10.4 million total change. And one way to look at that could be that 9.6 million of that is from rate. And from projection to budget, there's a 3.8 million up. So and certainly I appreciate your statistics around your prices compared to elsewhere. And that's very helpful information. But it looks like really when we're looking at the budget increases, it's not so much the volume. Utilization isn't what's driving the budget increase is sort of my takeaway from that. But I wanted to give you a chance, obviously, to speak to that and tell me if you see it differently. Nope, that is the way we were seeing it. And you know, in our presentation, you know, when you take a look at the volume assumptions, that's how we stated it, budget to budget. If I can go back to the presentation, not bring it up on the screen. Apologize just looking through my slides. No, it's okay. Take your time. Yeah, so budget to budget volume, we had going slightly down at 0.9 percent and then annualized to budget 23 we had going down at 3.8 percent. Thank you. So in terms of the travelers, I just wanted to have a little bit of understanding around what you've been seeing of travelers and locums, I should say over over the course of the ups and downs with travelers, because what we've been hearing from other hospitals is, of course, traveler, both numbers and dollars dramatically have increased over this past fiscal year. Many hospitals, it seems, are seeing both the number of travelers and the dollar figure per hour come down. So could you just, I know you said you went from $2 million to $6 million, but could you provide a little more detail and commentary on that breakdown, both like number of people and dollar and hourly rates? Yeah, absolutely. So right now, current travelers in our system is running around 28. You know, as one of our cost savings initiatives, you know, you got to like look at this and you got to understand we need to know exactly what's going on. And so we actually have been working with our travelers and they're swiping in and out of our payroll system so that we know at any time how many travelers we have within our system. We also are able to now use this data to accurately audit the invoices to make sure that we're paying appropriately. You asked a question about the nurses, you know, the traveling rate. And we saw that, we saw that rate being as high as $200 per hour pre COVID. We saw it around $80. And for the budget 2023, we're we're in at about $120. So let me sort of jump in. We had only a couple of people at that high rate, which gave me a heart attack. It should be everybody a heart attack. I mean, I think it has been to be fair. What's that? I think it has been to be fair. People have been quite concerned about that highest rate for sure. Yeah, I don't know why I don't hear the economists or the national leaders or pundits talk about how healthcare by itself is an extremely large driver of where the economy is going. You know what I mean? It's been interesting. They don't stitch these things together, but you know, $200 an hour, you know, that's a for over $400,000 a year salary, which is not technically correct. You can't just add 20, 80 hours multiply. But in essence, it is, which disrupts everything, every single thing in healthcare, any technical positions, any doctors like why go to college and become a doctor when you're looking at salaries that exceed what you would pay as a doctor. So we've had a couple of we had a couple of those, not many. I think we had two of them at that rate, which was really disappointing. But sort of with a gun to your head, you have to sort of pick and choose. So we deal with a lot of travel agencies, we're trying to get everybody to give us a rate at $100 or less. So we are trying to push back. We are and we have people saying, well, you're not going to get anybody. And it's like, well, we can't. I wish we had a collective group of all of us. And I wish that sustained the feds and people would sort of say, this is this is unsustainable. I didn't work post Katrina down in Wayland, Mississippi. And, you know, if you've charged a ton of money for a bottle of water post a hurricane, that's illegal. And you can't gouge because of that. But and I'm not saying this is a construct because it's actually eat its way into the lab of radiology and all sorts of positions. But it is the most disturbing thing I've ever seen in my life. And we try to ask the staff to figure out how to be more creative, how to work harder, which there's not much of that left. Jody will attest to that to working hard or even working smarter. But how can we help contribute to moving this in the right direction? So we're having those difficult conversations of saying, we're not going to get a traveling. We're going to have to figure this out. But it's really disturbing. In Vermont, we have people who are quitting hospitals in Vermont to go travel to another hospital in Vermont. I'm sure you've heard that. That is that should be a major wake up call like what are we doing? How are we helping? And it's been difficult and painful. So we're trying as best we can to manage and bear down and ask people. But it's all part of the great resignation and people just changing their expectations across the board on every single issue. Not going to come to work. I was talking to somebody last night. Great story who I met was a UVM traveler. And so she's from well out of state, but she's working at UVM. This was a great comment. She said, UVM is great. It's a wonderful place to work. I really love that. And of course, I smile and we had a conversation. I said, yeah, that's interesting. Some people when they do their same job for 20, 25 years, they get sullen and complained and all that. But sometimes travelers are very helpful for us. There's too many and they're too expensive, but they're helpful. They bring perspective. So this woman's perspective as a nurse was like, oh my gosh, they don't know how nice it is. Isn't that funny? And I'm like, yeah, that happens sometimes. And we use sometimes travelers to help train because they're already fully trained. So we don't have to actually have somebody who's a brand new nurse. But it's a two-edged sword and it's been cutting pretty hard in one direction for all of us. I wish somebody could help us, not our hospital, just all of us because it's still a bit out of control. Yeah. Sounds like it. So you mentioned that you're currently at 28 travelers. What would you say your traveler numbers were before this trend started and what are you budgeting? So yeah, I don't have the exact number. Like I said, we are tracking it now 100% in regards to what our travelers were before. But in regards to what we're budgeting, when we look at our budgets, you know, here at Cochle, we do budget for paid employees doing the job. And we assume no travelers in our budgets. However, we do budget a premium for the traveler expense and that premium was at 120 per hour. Got it. Yeah. And how many people? Basically, I believe our HR had us at 12. Okay. Cool. Thank you. That's just helpful because a lot of the hospitals express it in that way. So it allows us to kind of see what the trend is around the state. In terms of the critical access hospital cost report structure, so I've been asking all of the critical access hospitals to talk about if and or how they've incorporated future cost settlements into their 2023 budget. So for example, your fiscal year 22 cost report will get settled during your next fiscal year and will reflect at least some of these higher allowable costs and expenses that all the hospitals have been seeing during fiscal year 22. So if you could just speak to how you generally look at that and budget or not budget for it, that would be helpful. So Jeff's going to let me try this. So he can always correct me. So it's great. I got a chance to answer finance questions and he will correct me. So we're always looking at a continuous reserve amount on the cost reports that are done to our outside auditor to either adjust them up or down each fiscal year depending upon how open the cost report is or if there are residual issues. So we make estimates on what we think the reserve is based upon the volume because if you're busier or less busy, the Medicare process has a defined rate that they're going to give you generally. And if you're busier, then you're going to actually collect more money. So you're going to owe them because you actually collected too much or if you're less busy, they're going to owe you. So that's how we do it. And we're always looking at that. Sometimes it's a big dollar amount. We always want to get it correct because we don't want to be surprised. If you get surprised going one way or the other, it's like, oh my gosh, why did we not know that? Yeah. So it's the estimates of the cost report in terms of the reserves by year based upon the class. Yeah. Process wise, once we complete our financial audits, which are typically by December 31st, we then change gears and we then work on the cost report. We get that off by the 20, have to get that into Medicare for FY 21 by February 28th. And then typically you see communication back from Medicare a couple of months later. Great. Just give me one moment to take a look at a couple other questions I have noted and see if they've already been answered. Yes. Okay. So the other question that I've been asking most hospitals is to just speak a little bit to the cost savings initiatives that you have planned for fiscal year 23. Yeah. This is going to be a two parter. Jill's going to jump in. But one of the big things that we hear at Coughly, when I came to Coughly, I was hearing that that they had CPSI as their EMR. They installed CPSI as their EMR in 1988 and it has been going since 1988. A quick look at the system saw that the system was pretty inefficient. It needed help. And as you guys have been hearing, a lot of people are looking at different new EMRs and they're actually looking at going from one EMR to another EMR. That's something that Coughly had been in talks with and stuff. But one of our cost savings initiatives is that would have been pretty expensive. And what you hear is you're going to see productivity reductions. You're going to see payment issues, i.e., you have to remap all your payers. You have to figure that all out. And so one of the things that we thought that might be the more efficient way right now, given the times given where we are, was to do what we call a refresh. And so instead of a brand new EMR that all of the employees would need to have to understand and learn, we actually set up a new company within CPSI. We were able to then set up all our new tables. We were able to maximize on all the processes that CPSI said we should have been doing. Because when you're using a system that's been around since 1988, you can't change. It is what it is. It's too tied up and not. One of our big cost savings initiatives, we've become more efficient due to it. And we're getting our claims out more accurately and getting them paid more appropriately. And do you have any way to estimate kind of the financial impact of that? Can I just jump in a few things? Sure. Your information system is the lifeblood of what you do. If you change it, it's like changing a language. I'll just throw that out. It's like going from say French to Spanish or German, much more difficult language, but it's really a big deal to change your language. I'm trying to come up with an analogy that works. Most organizations can fall into this sales model where they think that if they buy a new information system, their problems are going to go away. And actually that's usually not the case. I'm going to say that it's like marriage. You want to fix your marriage after 25 years, you should both go to counseling and both realize that you are more than 50% of the problem. So I've worked in a lot of hospitals and have seen good, bad, and ugly. So I know CPSI, Jeff knows CPSI. This is the oldest CPSI site in America. This is the single oldest install in the United States of America, but we had not been using it very well. So we were sort of dropping the ball. When I got here, they were thinking about going to Cerner. Cerner's going to run between four to six million dollars all in to do a conversion. At the end of the day, if we're not disciplined and structured in the use of this, we're still going to have the same problems, right? So sorry about the marriage analogy, language analogy. I'm sure I'm offending some people, but you really got to say, how do we personally commit to using it, using the tables, the reports and doing our job? So CPSI, it's an okay system. It's okay. It doesn't cost as much as Epic. I was down as part of the mass general system during the conversion of the hospital. I worked at down there at that estimate was 600 million to convert the hospitals. When I left, it was at 1.8 billion dollars to do the conversion of the hospitals to Epic and the Epic price tag is staggering. So nobody does the assessment of like, wow, and there are hospitals in Vermont, I could name them, but I won't, that have gone through conversions that are very expensive. So we did something different. And the reason is we couldn't afford it. We can't afford to just spend that money. So we've changed ourselves. We recommitted. There we go. We got remarried. I don't know if anybody's done that. I've heard that. You sort of, you redo your vows and you sort of say, I'm going to commit, honey. And so we did that. So I'll give you some stats here that are somewhat helpful. Our charge master prior was at 36,000 items. I got this great sheet that I want to share with you. 36,000, we went down to 9,000. You get a 73% decrease in charge master items. We had 34 years of stuff just, you know, disgusting. Our pharmacy charge master went from 8,120 to 1,709. Our insurance tables went from 276 to 168. Our provider table, you can't imagine this. This is what happens. We had 9,399 providers listed. How is that possible, Joe? That doesn't make any sense. Your critical access hospital. Well, every provider had multiple provider numbers associated with different insurance companies. And then we did variations of each one. So it's almost like a never ending license plate variation. We were just making things up. We went from 9,399 to 946. 90% decrease. And our chart of accounts went from 2,114 to 913. So it's really a great testimony. CPSI was extremely happy that we did this. Nobody ever does that. They usually get angry and walk away. So we're going to continue to use CPSI for some period of time. But we're learning to flex our muscles, be disciplined, structured, clean up your tables, manage, look at how you're auditing. So we think it's been a great success. Very cost effective. It's all we could afford. So I don't know if that helps, but we're happy about it. Great. Yeah. Now it sounds like a good decision. And certainly I can imagine cleaning up a lot of that complexity will help with ensuring that your billing is more effective and you get less denials for weirdness and that kind of thing. And this is probably not possible. But do you think there's a way to quantify kind of how that has impacted? And it's totally fine to say no, because it does seem like it would be hard. But if you have any thoughts on that, that would be great. Yeah. Right now, when I look at the quantifier and I try to, I put just dollar signs on that. Again, you're talking about efficiencies and productivity with our billing staff, as well as the denials. There's so many pieces to this that... Yeah. No worries. Okay. And so I do want to give you, if you have other cost savings initiatives an opportunity to speak to those as well. So yeah, one of the things that Joe touched on we always do is making sure that we're working with our traveling companies. It's not just a simple, hey, we need a traveler and we'll accept it. We're always challenging them, making sure that like Joe said, this rate's too high. We want that rate. We're doing that. We right now, our managers, they review all the vendor contracts and as they come up for renewal, they're looking for at least 10% reduction. So they work with each and every vendor trying to ensure that we have initiatives to reduce our advertising spend. That one this year, it's coming in about a $15,000 loss. Another big one, there's a bunch of them, but is we're doing IT audits. Our IT system has been a little bit tied up in knots and we're starting to untangle that. We have pieces of software that we're paying for that nobody really even uses. And so we're making sure that we're going through checking all that. And right now the IT manager says that that's probably saving us about $70,000 a year. I can go on and I have others and stuff, but those are the types of things that we've been looking at. Great. Thanks. Some of them are embarrassing because, as Jeff mentioned, so it's to admit that, oh my gosh, we were paying for that. We weren't using it or we didn't look at that contract. We always try to ask people to negotiate and try to drive down that cost. And I have a funny story about Jody about a year and a half ago. I went to buy a car and she said to me, Joe, I don't have anybody to negotiate. You give me any tips on negotiating? And so remember that story? Yes, I do. So she went and bought a car and she talked them down and saved monthly like some pretty good money, but we don't. Good job, Jody. Yeah. She's embarrassed, but it was fine. I won, I won. But we try to do that. It's like if you don't ask every single contract and every single vendor, like I just, I need 3%. Minimally, I'll do it right now, but I need 3% or I need 2%. So we're trying to get the culture to say you've got to ask. People are going to ask. We just have to be 100% the group that always asks. Like, you know, just give us a break. We need a reduction. So we're trying to do that across the board. We're cutting back on food service. Our food service has actually gotten significantly better, but we're cutting back on weekend food service. We're not allowed. We can't afford to do that. So we're cutting back in many ways, but also improving in others. So there's a lot of stuff that we do. Yeah. Great. Thank you. Yeah. I did have one last question on your rate request comparison tables because there's a labeling discrepancy. So I just wanted to make sure I knew what was accurate. So in my slides, that's slide 24, 25. So in the top of each of the columns where you have the five-year, 10-year, 15-year, it shows the calendar years through 2022 that you were using. But in your average, it says through 2020 average approved. Is that just that label didn't get updated from last year? That is me. I apologize. No, no, no worries. This happens. I just wanted to make sure that we understood that you were using 2022 or 2020. Yes. Yes, you're using 2022 just so the record is correct. Yes, we're using 2022. We did not get updated. Great. Thank you. Okay. I'm all set. I'll throw it back to you, Jess. Great. Thank you so much, Robin. I'm going to turn it over to Tom Hallam, but I just also want to have a little time check and recognize that we have three more board members that have questions. So and we have, you know, until 11.30 on our schedule to do that. So I just wanted to let folks know that I'm trying to keep our trains running on time here. So board member Hallam, you are up. Thank you. Well, thank you. It's just interesting the contrast between the quality indicators and the financial indicators. One's a little problematic and the other is not problematic at all. So congratulations on the quality and let's work to fix the financial issues. So this is a quick question. I think you already answered it and I wasn't quick enough to hear the answer, but it follows on a question that Robin had about travelers in that, you know, two or three times during the narrative, you mentioned that you've seen a travel expense almost triple. And then I went to the budget documents, the income statement to try to find that. And I couldn't find it in the salaries, but maybe it's there or I couldn't find it, you know, in the other operating expenses. So my simple question is, you know, and I understand you're kind of a premium, the premium you pay for a traveler versus a regular staff person. So, you know, what was the premium, the budgeted premium for 2020 budget for 2022 projected and for 2023 budget, you know, the all in number. So, you know, we can see that in its totality. That's something that you can get. You might not have it right now. So let me just jump in, Tom. I don't go to the decimal point change. So sometimes I make these broad statements, but that that discussion was for contracted services, which is not only travelers, it's other contracted services that we were running around $2 million and it cut up to about $6 million. So travelers are a big part of that, but it's not just nursing travelers. It's travelers across the board, as well as low contendents, as well as consultants. So I just wanted to say that it's that just a general big bucket of people that we call upon and hopefully minimize that, but it did go from two to six, but Jeff can continue. Yeah. And to get those exact numbers, you know, I would, you know, I don't have those at my fingertips. You're just looking for the premium paid or the traveling expense. Yes. I mean, what I'm trying to kind of understand looking forward from where we are and, you know, if things work out well relative to disease in the community, we might not need all those travelers. And so the issue is, you know, is there a kind of a surplus growing there on a budgetary basis that can be used elsewhere, you know, in the hospital? And so I'm just trying to get a, you know, a sense of whether that's a big number or a little number. Also related to travelers is I'm just interested in over this last period, a couple of fiscal years, have you, you must have hired permanent staff at Conway Coffley, people that came in and they weren't travelers. They're people that are part of your team now. And I'm wondering how you got them. Do you have any programs to reach out, to establish a pipeline for people, you know, to come to Conway and work at Conway? And is it a random approach or is it a very organized and focused approach? Great. Tom, I would love to speak to that just briefly. So our Chief Nursing Officer, Lori Profata, has worked really closely with the Nursing Education Program and working with Vermont Technical College and really onboarding new nurses. So we are doing not only clinical resource pools to educate and take in high school students, 17-year-olds to get the LNA supports and building in those PCA's patient care attendance. And then we also are now, we have Jennifer Leather, who is our nurse educator, who works directly with the Vermont Technical College part-time both sides to bring on new graduates. So we are really taking the opportunity to build our nursing resource pool through the education program. So we're building them from scratch, starting from 17. And then some of our these lovely 17-year-olds are now going to nursing school. And we hope that in four years when they get their degree or two-year degree that they will again onboard with us. And so we're building those nursing resource residency programs here and really kind of steam lining an education program for new nurses and clinical resources. That's awesome. So we're going to add to that. So we just had an LNA graduation like a month or so ago with a tent outside and how much people showed up. So we are really pushing and encouraging LNA's and from there to become an LPN or an RN. So we're doing a great job. It costs us money. It is educators and resources, but it is really important and it's become very successful. So people get to know us. They work with us. So that's been really helpful. We used to convert travelers. So we used to have a general appetite for travelers so much. And over time, you used to get travelers who really would like us and love us and they would convert. But the problem in America is the traveler rate is so high that it really just becomes harder to convert people. So you know what I mean? Because the dollar amount is like, oh my gosh, people say, why are you leaving? I mean, we've had people leave us that have loved us, have been here a long time and they're like, I just have no choice. I have to go. This is just too much money. So we still try to do some of the travel and convergence as much as possible. We do advertise. We get word of mouth. So a lot of people that get to know Copley, which is great. They want to work here. So we've had cases. Somebody recently either gave birth or we took care of them in surgery and literally that's happened. There have been cases like that where actual patients who come to us to have worked on or nurses end up saying, I'd love to work here. We just got somebody from a very large organization. I talked to her yesterday. She just likes the style, the approach, how we manage the time that she has to do her quality work. And she's like, yeah, I was Pradeem here for a couple of years and I finally have made the move. So Pradeem is a very common pool too where people will work. They're classified as Pradeem, but they get to know us. And so we take over. That's good. So I mean, you get these permanent folks that are a lot cheaper than a traveler, I would think. Right. And so my next question was on Payor Mix for Medicaid. In the Payor Mix table, you have that with a 45% increase and obviously it's not rate related going from 11.6 million to 16.8 million budget to budget. And I'm just wondering if you can give a little bit more detail on what's pushing that increase. And so Tom, you're looking at budget to budget. And I will say that our overall collection percent that we've submitted in budget 2022, we're pretty much spot on where we are at with that. But when I take a look at how we spread them to the different budgets, we did have some discrepancies. And that's why you're seeing, we tried to realize those discrepancies in, I believe it was called change in accounting. If you were to go to your projected to budget, you'll see the more true picture that we're putting into our budgets this year. Okay, I can do that. Next question was on your capital spending where you mentioned capital spending for 2023 is proposed at 5.5 million. And as I look at your balance sheet, I see current assets at your 2022 budget, 7.8 million rising to 37.5 million for 2023. And I'm just wondering what the tensions might be in terms of your current assets and the ability to invest 5.5 million in a capital expenditure. Yeah, could I on that one as well, just I don't have the detail behind all the data, I'd love to be able to get back to you on that. Okay, great. Second to last question, I'm going fast, Jess, I'm doing fast like a is the I'm bad debt. I noticed and you said in your narrative that bad debt as a percentage of GPR will come in at 2.9%. And so I took that number and I compared it to all of the hospitals, you know, so, you know, all the hospital 14 hospital applications and, you know, to look kind of what systematic that ratio is and across all 14 hospitals for 2022 is trending between 1.3%, 1.32% and 1.38%. And so my question is, does COPD have a financial metric targeting the level of bad debt that you try to manage to? I have to take a look at the one point that you're saying the range is 1.3 to 1.38. 1.32% to 1.38%. And I think that would be equivalent to about $2.6 million in projected that bad debt. So that ratio was a big number and you're quite a bit of a field of kind of where other hospitals are at. And I'm just wondering, you know, how you approach from a budgeting point of view what level of bad debt you can carry? Yeah. And so what we do, you know, when we come budget our bad debt is again, we always look at our historical trends and we budget based off of our historical trends. And if you take a look at, you know, COPD at the whole that's overall, you know, where we're at as compared to the other organizations, I'd have to dig into that to see, you know, I think, you know, the relationship between bad debt, affordable care on the different buckets like that. Yeah. And then my final question is, I'm sure everyone's wondering, there were, you mentioned that you were one of the five star in CMS is a five star quality program, you were one of four hospitals in Vermont that were five star rated and I'm just wondering who the other three were. So you want to know the three behind Copley? Yeah. Yeah. I couldn't resist. Yeah, yeah. Yeah, Rutland's UVM and blanking on the other one. Where is blanking hospital? I haven't heard of that one yet. Yeah. Yeah. I can't remember. I think it was. All right, Jeff, back to you. Sorry. It was central. It was UVM, mothership, central, and Rutland and us. Okay. Thank you. Good company. Back to you, Jeff. And don't worry. I'm just trying to, you're, if you have more questions, feel free to ask them. Okay. Well, if you have anything, follow up. I'll give another opportunity at the end for anybody who wants to ask more questions. Board member Walsh. Thanks, Jess. No real questions. I wanted to extend a few kudos and a comment really. Really, really good presentation, well done. A lot of places advertise as being high quality, low cost. You presented data to back that up. That's very persuasive and impressive. A lot of places don't do that or can't do that. Your COVID lessons were very telling. I appreciated that and the kind of the innovations that you've learned and kept through a stressful time, your slowest growth rate in the state over 15 years. That's impressive. And your use of the price variation data that has been a big discussion point over the past couple of years, but you really dove into it and learned a lot about yourself and, you know, that's the kudos there as well. My one real comment is, even with all the really good stuff, a 12% increase is large. And I worry about the effect that that has on the community, right? Because we know even small increases in out-of-pocket expenses for patients, they stop taking their medicine, stop going for routine appointments and follow-ups. And downstream, that leads to more unplanned and oftentimes unreimbursed admissions, more use of expensive care locations like the emergency department, and rising bad debt. So I worry about these things. The people in our state like others have been under intense inflationary pressure. Healthcare has been in the last couple of years, but healthcare premiums for folks have risen over 50% since 2010. So the inflationary pressures have been steeper and going on longer to the people that we serve. So I want to try to keep that in mind as we're reviewing budgets. And I want to be clear about my concerns there. But I really appreciated your presentation and sharing what you've learned and being able to demonstrate not just advertise your high quality and low cost, really well done. And I'll pass it back to Jess. Thank you. And good to see you again, Jeff and Jill. Yeah. Can I just make one comment, Jess? Sure. So we don't get 12% in that, you know, we collect about 60 cents on the dollar, so it comes out to be 7%. And I appreciate that costs are going up. Healthcare costs are, you know, the labor component alone is just really insane as well as others. So it's 7.2% of a very low number, Tom. So you know what I mean? When you look at the prices, I mean, we don't talk about prices. We're afraid to talk about actual raw prices, which we shouldn't be. A lot of the stuff we tend to not talk about, but it's 7.2%, a really low number. You know what I'm saying? It's not 7.2% on top of the most expensive number, like, you know, the one MRI contrast without contrast, that's, you know, we could charge another $3,500 to be one of the highest. It's sort of interesting. And then when you look at it, I just want to make this comment. Somebody said to me, so you got a new MRI. This is a normal question that you would ask, but in healthcare finances, it's all crazy. They said, so you've got a new MRI. How much of the price is going up on those MRI procedures? Because you now have a new fancy piece of equipment that's very expensive. And I have to explain to the person, those don't correlate, which makes no sense. It's like, well, how could you buy a new MRI that's specific to MRI prices? Why wouldn't the MRI prices go up relative to what you spend on that piece of equipment? It's like, that's not how we do it. I mean, we look at what's allowed, we look at the marketplace, do you know what I mean? And so our MRI prices are not more expensive because we have no equipment. They just kind of sit where they are and they just bump along. But our prices are actually a bit of a problem for us. Isn't that interesting? I don't know how to solve that. I mean, we are least expensive, but it's not, it's a bit of a problem because we need capital to invest. But thank you for your comments, Tom. I really appreciate it. Thank you. Yeah. Thank you. Thank you for yours. And I really do appreciate the work you've done using the price variation data. It's compelling. I think it's important too that from the board perspective, we continue to think about what these decisions mean to the people we serve. So thanks for listening to that. And I appreciate the conversation. Thank you, Tom. Thank you, Jess. Thank you. And I think maybe, Joe, you might have answered my first question in that answer to board member Walsh. But I've been trying to get from each hospital the relationship between the change in charge and the effective rate that people with commercial insurance are going to experience. So in my understanding, it's accurate that your 12% increase in charge really converts to a 7.2% effective commercial rate given your portfolio of commercial contracts. Not for commercial, but if you just take any hospital like healthcare is so interesting, right? We have gross charges. What the heck is a gross charge? And then we have net. What's your net from your gross charges? So what we charge versus what we collect, it's about 60%. So on the commercial, they're going to pay more than that. They're going to pay probably closer to 8% or 9%. Actually, Jeff, it's 8% to 9%. Medicaid doesn't pay anything for the most part, unless they feel gracious. So there's that collection of who you're talking about and who's paying what? Well, I just, so I've asked this of every hospital. So every hospital has been able to give me an effective commercial rate. So, Jeff, if you can do that in a follow-up, that would be fantastic. But really trying to understand how does that change in charge translate into what the average commercial patient come in a coply will experience. If it's a follow-up, that's great. We're trying to get a number on that. Okay. So the stress of the system, I just want to say and acknowledge that we have been hearing about these bottlenecks and challenges and throughput from every single hospital. And it's really discouraging. And I just want to acknowledge that it must be stressful for you. It must be stressful for the patients. And my hope is that I've asked, as I've said in a couple of meetings, is that you'll work with VOS to try and quantify the unreimbursed costs of these bottlenecks and how it actually translates into these commercial rates that you're going to have to cover those unreimbursed costs with so that we can finally put a dollar value on the annual costs of these bottlenecks. We know there's quality costs if people are not receiving care in the appropriate setting that has quality implications, but it also has cost implications for the system. So hoping that one of my follow-ups after this is, ooh, and I talked to Michael Treco about this, but can we start to quantify across the whole system? But in the meantime, my question is, how much do you think that the Dartmouth-Hitchcock 65 new beds that are coming online in fiscal year 23 will help reduce some of that capacity stress? I'm sure it will. I mean, obviously, it's going to. They serve a lot of our monitors. They serve more than me, I'm sure. So it's going to sort of help us. So that's going to be helpful. My question, Jess, would be what kind of beds are they offering? Because are they critical care beds? Are they med-surge beds? Are they long-term care beds? And so those are the kind of questions that would help me facilitate that question because without knowing how it could offset that, because when I'm developing a transfer request to another facility for higher-level care or long-term care, those things matter. So if it's med-surge beds, absolutely because we need med-surge beds or cardiology beds or critical care beds. So having to sit on a transfer with a vented patient here in a critical access hospital for three hours waiting for a bed who can manage a vented patient is really stressful for the house supervisor managing that bed and that proper fall drip, but also waiting and the transport team. So yeah, without knowing. So I'd love to know what kind of beds they are. Yeah, well, I don't know the answer to that either. I'm just, you know, keep looking for silver linings myself and lemonade. Yeah, we're making lemons. Right. So wondered if that's something that, you know, you incorporated in your analysis of where there might be some relief from some of these unreal costs. So one of the things you talked about the revenue losses due to, you know, market capture by quest that's entered into your community. And I think in the narrative, or maybe in the presentation, I can't remember now, there was some mention that that quest was getting more referrals from the FQHC. And, you know, given the price variation that you showed and Copley Labs seem cheaper than the quest labs, I'm trying to figure out why they're gaining market share given that you're cheaper. And there seem to be getting more referrals from the FQHC. So if I'm missing something here, let me know. But just trying to figure that out. No, you're not missing something. It's a question that we have as well. You know, the study that you saw in our presentation was the study that was requested from the FQHC. The rates, you know, in regards to the lab, those rates, you can actually literally call quest and they'll give them to you. You know, the items that were requested wasn't something that we generated. That is on what was the FQHC said, hey, I want to see your pricing for these specific items and stuff. And so when we did the study, we actually threw in the other hospitals to understand where we were. Yeah, that's what we saw is our rates were much lower than the quest rates, which did come to me as a big surprise as to why then anybody would leave and go to quest. Well, hopefully you can have some continued dialogue with the FQHC in your community. If you are a low-cost center for these labs, it would be helpful to have that referral coming back, I will say. So I always want to just jump in and say, I always try to think about how to make the overall system in Vermont better, more healthy, you know, with some normal dynamics of marketplace still in play, but some stuff is like, well, that's not helpful. So we don't have a for-profit hospital in Vermont. I think we've done a nice job of trying to keep things at bay so that the dynamics are accountable and we have, you know, discussion and oversight. I would love this date to really limit the ability of for-profit labs to come in here because it's not just our hospital. I'm sure they have inroads in other parts of the state of Vermont, yet we've got great lab services in all these hospitals. We've got tertiary care center that does lab work for us and then we send stuff off to the Mayo rarely, but I mean, we can provide all this stuff. So the state, if it was creative, could maybe say, well, you know, at least for none of the Medicaid business that we have, none of it's going to go to a for-profit, you could probably creatively come up with a way of helping that in many other ways to have us not lose to for-profits, but I wish that was the case. It would be easier than just, you know, because it's throughout the state. I don't know how much they do. I think they probably do quite a bit of business, you know. Yep. Let me switch gears a little bit and talk about utilization. I know a board member Lunge mentioned this, asks some questions. I just want to dig a little bit into some data that I'm looking at the staff analysis that we have that I think is created from the adaptive data that you all submit and I just want to clarify if I understand this right. So on here in 2022 projected under physician office visits, what I see is a estimate of about 22,528 physician office visits, which is on par with actuals in 2020 and, you know, a little bit lower, but not much in 2021. And then I'm seeing in the budget for 2023 that 22,000 jumped to 40,626, which seems like an enormous leap. And I know that you have some new providers on, but I'm also looking at the physician FTEs and it's going from 19.9 to 20.4. So that would be adding a half an FTE. So I'm trying to figure out how you're almost doubling physician office visits with a incremental 0.5 FTE. Is the data that I'm looking at not accurate? It doesn't sound to be accurate. Again, our physicians, we are seeing increased volumes from cardiology and existing service. We did add visits for the podiatrist and yeah, that's pretty much it. So maybe you could work with the team just to sort of find out. Thank you. That's helpful. And the other related question, this may also be, I'm not sure, the non-medical MDs, I'm sorry, the non-MD FTEs, it went from 341 in 2020 to 355 in 2021, 398 projected for this year and up to 418 for 2023. That's, you know, in three years, that's 60, 70 extra non-MD FTEs. And I'm just wondering if that's an accurate assessment of the incremental amount of non-MDs and wondering where they are all, what they're all doing. 60 to 70 extra people over three years seems like a lot if that's accurate. Yeah, I think that's actually very accurate. We've talked about that. So there's a lot of things we have not been doing around here, haven't been staffing for, and I think we've done as best as we can in the clinical side, although there's always more need, but on the support side, whether it's the billing office, maintenance, staff, technicians, we really, yeah, we've looked at those and sort of talk about them and say, yeah, we actually need them. So we have made a lot of mistakes that have cost us a lot of money and we're trying to prevent those. So we had the IT system a couple weeks ago fail. We had two days of a complete blackout, no internet, no IT, none of the systems work, no phone system. And we for two days were in, you know, great distress thinking that we had a cyber attack and it cost us emotionally a ton, a ton of the rig. And it turns out it was faulty old equipment and our wiring here is my, here was going to be my show and tell around maintenance issues. So trying to see if it's even possible. Have you seen this? So this is a pipe that burst finally once again and this is the duct tape that was used for so many years that it's flayed out as if it is rings of a tree. So the maintenance folks, this is one example. I could talk about IT as well as other things where they collect these and give them to me now because they know. So I have a collection of things in my office. This literally dozens of wraps of duct tape over many years with this pipe and this process that was stuck way up in the ceiling. And the problem is this went for about 14 feet and it dead ended. This end is capped. So for many years we have not traced it back and we have things like this all the time and we have pipes that burst and we have issues. We have wiring closets that Jeff wouldn't allow me to take pictures and show you that are really snarled and so we have not been managing some of the basics. So the FTEs, we knew that would probably come up. Every one of them is justified and in fact is saving us money because when you have things that completely break, fall apart, safety issues, it's really expensive. So we're hopeful that the FTEs and all of what we're doing, as well as investing in IT. So we've had a very lackluster IT team. We've got a new CIO. We've got some really new staff and we are, these are appropriate investments. I wish they were all doctors and nurses but it's, you know, you need both to make this work. Health care is very complicated even on the billing side in collections and medical records. And so I would say they're all justified but that was one of my many show and tell. I appreciate the show and tell. It's a nice diversion or, you know, just something else to look at. Well, let me just ask you then a follow-up question. I know some hospitals use FTEs per adjusted occupied bed. Did you find that your FTEs per adjusted occupied bed were really low prior to these increases relative to benchmarks and now they're on par with where you would like to be if we think about that as a measure of efficiency? I haven't really looked at that. Jeff could probably comment. I don't, I don't think it's one, I don't think there is one single measure of efficiency. That's one of them. It's okay. It gets adjusted based upon your outpatient business. I mean, we've changed dramatically because we do so much orthopedics on an outpatient basis and health care has always gone towards outpatient at a variety of things. So even the word bed is sort of, so I don't know, Jeff, if you've got any comments. One thing that, you know, coming from, I've had the opportunity to work at different organizations and I find it kind of an interesting thing. What is an unoccupied bed? That's even a hard thing to have anybody tie down. Not to mention how you then bring in swing beds, how you bring in your, you know, if you have rehab beds, how you, you know, manage. It's such a difficult measure to just to look at just one simple, you know, measure, you know, to get to the number of stuff. No, and I can appreciate that. And I think it's something that we're, as we're going to be reimagining our hospital budget process, I imagine we're going to be looking at multiple measures of efficiency. And how do we, how do we start to think about that? So, again, just as your institution has done a wonderful job of helping us contribute to the conversations around how to improve our understanding of quality. I think if you've had some ideas around how to measure efficiency and what metrics and how to think about how you count beds, I think we'd really appreciate those insights. So, okay, I will, I think that is generally it for me. You know, I'm asking every hospital, I appreciated your efforts to bring in referral and visit lag. This is our first attempt to really tackle understanding both metrics. I know you were, I don't think I saw a referral lag in your, you know, in your submission. I suspect that might be harder for you to measure the date of referral. And that's why. So if there's any way, you know, in the next year, you can think about how you can incorporate that into your metrics. And the reason we've asked about it is we heard from a fair number of primary care providers that referral lags were real in different parts of the state. And people were waiting weeks and sometimes months for an appointment to actually even be scheduled. And then another month for the appointment happened. So, you know, our, my feeling is if we don't start measuring referral lag, we may not know where there's problems. So if there's an opportunity to incorporate that in your systems, perhaps with your new refresh, that would be helpful for next year. And then my last standard question is just a standard comment has been asking every hospital to share if they have any known or likely changes to federal or state payments, relief funds, Medicaid, Medicare reimbursement rates, they didn't anticipate going up or down. If you could follow up with an email to Sarah and the team, that would be fantastic. So I think with that, and I do want to just make sure if there's any board members that do have additional questions, we are now we're on great schedule. So does anybody have a follow-up question they'd like to ask? I did have one question that I missed that I'll just jump in with quickly. So in your medical office building certificate of need, you had budgeted in that project a nine percent commercial rate increase versus the 12 percent that you asked for. And I just wanted to give you an opportunity if you, if you know someone in Morrisville or Waterbury said, hey, you know, we, we understand prices are low, but you're asking for a big increase. And at the same time, you have planned this large capital project. You know, what would you say to that average Vermonter who, you know, is going to come at this from a common sense perspective and see that as kind of a discrepancy? Well, Jeff can talk about the nine percent, but I will just say that with, with anything, if you don't invest in what you have, so over time, you can, I mean, we've done that here at Copley. So we saved $12 million over 11 years, not putting it into capital. Good for you. You've saved $12 million. Even though you went through the deliberative process, you justified that, well, we're paying a price. We're going to, it's like you, you can't keep doing that. So I got busted pipes. We have the stair problems. We, we, we, Don, I showed Don last night we were here and I showed him some stairs that are literally rusting. I've never seen stairs like this in any facility in my life rust out, but ours are rusting out. So with any math, it's like, well, you have to invest. So I know it might appear that, that project or that new piece of equipment seems very expensive. How could you ask for that rate request? But everything gets, you know, depreciated over time. And so you have to sort of talk through that. I think when it comes to even prices, so there's a lot of uncomfortable conversations you have in leadership and you folks have all joined in the leadership ranks of helping the most important industry in Vermont. I appreciate that. It's tough because you get leadership questions. And one of them is like, well, how could you justify the expense of maybe a $4,000 MRI? And it's like, well, that's a really good question. And I don't know how to answer that for that price for that MRI, whatever the number. See, it's $4,000. But I can sometimes say, well, if it's, you know, a scan, if it's a scan of the brain with contrast, and they find cancer and a tumor, what is that worth? You know, what is it worth to find that, you know, somebody has cancer where they have some important ailments or issues that need to be addressed? Then it's worth it. Then somebody would definitely say, oh, I think that's worth it to help save my spouse's life or extend it for five years. So we all get confronted. You guys, we do. We all get confronted. It's like, how could you do that? So there is both sides of that. We're trying to cut back as much as possible, but we do need to invest for more efficiency, better quality, better access. So those are our questions. You know, what's the price of a contrast MRI of the brain work? I don't know. It's hard. I actually feel like I could speak to this as somebody who was an infection preventionist where we are a cost driver and it's hard to facilitate our return of investment. So when we have to meet these regulatory mandates by CMS or whatever body that we're following, making sure that we can offer the best care, providing that we meet those United States preventative task force initiatives that we're trying to do and these healthy drive initiatives. And as an older building to meet the demands of what other facilities, those things to make sure that we can access that care for our service area. And we serve other service areas. So it's really difficult to put a number, but to keep our care in our community, that's why it's going to have to cost us some money. So we can keep our doors open and keep them coming to us. So we don't have to make them drive to Chittenden County, which is so difficult for so many of our patients, especially when they depend on Medicaid transportation, who they can't bring their children in the vehicle with them. So how do we get them to that appointment? So I think that I would tell those people, so we can keep it in your community and give you the best care that you're going to get anywhere else. And it's going to be the evidence based practice, which is important for how we drive care. Sorry, I'm excited. Yeah. So there's sort of a concept that I think answers a couple different questions here. Tom earlier asked about how we're dealing with this with this traveler thing. And I just wanted to make sure you got the complete answer to that. But it also answers Jessica's question about like, what are you doing with all these extra people? They're good questions, both. So we're a clinical education site for two nursing schools and LNA program and a radiology technician program. This last year, six new nursing graduates signed on at Copley. And they all essentially live in the community. So now they have, you know, better jobs than they used to. Two of them actually used to work as MAs in my clinic. And so they have better jobs and they're serving the community at a higher level of their capacity as they receive more education and training. So it's obviously a good thing to do for the long run because you're going to save on the travelers, but it also supports the community in many different aspects. But we do need people to run the education programs. And so a few of these people, obviously not all of them, but definitely a few of them are here to support these educational things, which is clearly the right thing to do. And I don't know many of us were doing this five years ago. So it's actually the right thing to do. It is a little expensive, but in the long term, it's got to be the right play. Robin, are you set? I see a shake in your head. Okay, great. Thank you. Thank you for that. And I really appreciate the passion with which many of you answer the questions. It's really refreshing, obviously, see the care for your community. I think I'm going to ask our finance team if they have any questions at this point. Good morning, Sarah Lindberg finance team. Just quickly wanted to say thank you for your engagement and anything related to data and keeping us honest and helping us to understand how we might be able to provide more effective information to help you out. So I hope we can continue those conversations, but no questions from staff otherwise. So thank you. Okay, great. I wanted to then turn it over to the HCA. I'm looking, is it Sam? Yes, it's Sam. Okay. Was it your Eric today? Yeah, it's me. I literally just lost power and just got it back. So Eric, feel free to jump in. If I lose it again, there's been a lot of lightning storms around us. I live in Monkton, but we're good for now. Can folks hear me okay? Yes. You're in the dark. All the lights went off, so I haven't turned them back on. You can probably hear the thunder. Anyway, Sam, off to the healthcare advocate, health policy analyst, just a couple of questions from us. I want to start off by recognizing really the rigorous social determinant focus that you guys have undertaken, particularly with community organizations and with the health collaborative, as well as your emphasis on primary care. So I want to recognize that. The first question builds a little bit on Chair Holmes's question regarding wait times. I'm wondering if you can discuss, you reported that 48% of the visit lag for cardiology falls in the six month category, which is a lot higher than the other wait times. Just wondering if you can comment on that number. I'm sure you're aware that that's an important area given for most demographics and the importance of ongoing cardiology-based care. So I just wanted to hear you comment on that. You know, what efforts you're doing to reduce it. Yeah, it's a great point, and we agreed completely with your assessment on that, and that's why we have a new cardiologist coming. Congrats. That's awesome. So Dr. Kuhnen, who's worked here for many years, Adam Kuhnen, he's great. He's been our cardiologist. He's cutting back a little bit of his schedule and moving things around, and so we've actually hired a nurse practitioner and another cardiologist. So we're actually going to have quite a bit of cardiology support, which is great. So we're just lucky. And when these things happen, I mean, this is true for the medical center. It's true for every hospital. It's hard to get the right person with the right fit. You can always hire the wrong person. They're easy to hire. You know, there aren't people out there that you could hire as providers, but we don't tend to hire them. I think Vermont doesn't do that very much at all. I think we're very discerning. Other parts of the country do tend to pick them up. I hate to say that, but it does take us time. So anytime we have a provider opening, it's difficult to hire. It just takes a lot of effort, and it's Vermont. But in cardiology, that was a great question. Thank you. Sure. Thanks. Next question is, you highlighted in your narrative is on page 8, a decrease in the percentage of patients who reported they did not have a primary care provider from 46% in October 21 to 26% in June of this year. I'm just wondering if you could talk about what strategies you employ to achieve this reduction or what you attribute that reduction to. I think some of that is the information system and what we've been doing in terms of asking people because we weren't using some of the screens as appropriately. So some of that is actually an outcrop of the CPSI refresh. I've talked to Jen Holtklapp about that, our quality person. So that's a big part of it. I can tell you that in this community and county, there is not a significant increase in primary care physicians or providers in the availability. So it is not like, oh my gosh, you're doing a great job, and all of a sudden you've got a whole bunch of primary care capacity. We do not. So this is actually more of an accurate data collection methodology. We do have a primary care problem. I will use this moment to just say that primary care is the bedrock of everything that we do in healthcare. It is the first level of that pyramid of which we build upon. And although we talk about hospitals and hospital budgets, I always wish we would have those greater conversations. Some hospitals employ primary care. We do not have any significant primary care employment. We have independent primary care. We have FQHCs. We have some that are employed. But I always wish that we would talk about primary care because it is the most important step. It is how our hands are held through crisis or issues. It does alleviate people going to the ER. And we've seen in this community and elsewhere that primary care still needs a lot more support. They need a lot more care and attention so that it is the most attractive profession to go in. So I don't know how to get there, but I just want to express that because every one of us personally, it is key. And some old fashioned primary care doctors used to do a lot in their office. Just saying, you know, a lot of old fashioned primary care doctors would do a lot in their office. And in parts of the West, primary care would deliver babies. So that's what you'd have. You wouldn't even need an OBGYN. You'd have family practitioners doing deliveries. That happened in a hospital I worked at in Vermont early on a long time ago, but you can't find any of those. And it's kind of too bad. But we should all think about primary care regardless, whether it's a mental health issue, home health and hospice issue, nursing home issue, hospital issue, it's like the primary care fabric is in need of care and attention. Yeah, just one more thing about it. I think there are two elements to it. One was the sort of, we'll call it the wacky entry effect that CPSI had before the refresh. Because, you know, whenever you look at data, I mean, first of all, depending on how hard you're really going to get into the weeds on it, it's sort of going to pass the smelt test. And probably, you know, when it gets up toward half the people, as the gestalt is, that's just not right. But it probably is somewhere between 25% and a third. That actually does sound about right. So there was the refresh. Also, for quite a while now, we've been working very hard with our FQHC. We share the person actually embedded in the ED whose job was to get people who did not have a primary care to get them a primary care working with the FQHC. Of course, there are a couple of problems with that. You have to have a primary care person to give them to, and then they have to actually go to see them. And the last time we checked, which is probably about six months ago now, I asked a specific question of that person. And we were probably somewhere around 30 or 40% actual follow-up of that. So even though the FQHC would make three or four calls, they just never came. So it sort of has the feeling that there's a hard floor on that number that you can only do so well without really changing some important dynamic of getting people to see their primary care person. So you got to have the primary care which is difficult, and then you got to get people to actually do it. So I guess that's the whole answer. Thank you. Appreciate it. Those are all my questions. Back to you, Chair Holmes. Great. Thank you, Sam. I think at this point, actually, we are done for the morning. So I wanted to thank you for your presentation for all the insights and your time in submitting the materials and being with us this morning. It is 11.20, and we're going to recess for lunch, and we will return at 1.30 to hear from Northeaster. Thank you very much. Can you do public comment? Public comment. Oh, I forgot to provide public comment. So sorry. I'm away ahead of myself here, but thank people keeping me honest here. Yes, public comment. Is there anybody from the public that would like to make a comment at this time? If you just use your hand, raise your hand function, I will see you. Is there anybody on the phone that wants to make public comment? You can speak now. 24 people on here. I'm not seeing anybody raising their hand and not hearing anybody. Okay. Well, but thank you for catching me to make sure that I didn't miss any opportunity there from the public to comment on your budget. Okay. So with that, does that mean we're not loved because nobody's even asking the question? I mean, I'm feeling kind of bad that there's nobody I want, you know. We're throwing clear. Okay. Well, thank you very much, Popling. We will recess until 1.30, and then I will see everybody back here then.