 So good morning, everybody. My name is Jessica Holmes, and I'm currently serving as interim chair of the Green Mountain Care Board. So today we're going to begin the, I think, much anticipated Green Mountain Care Board hospital budget hearing process. For those who don't know, every year we are tasked with reviewing and establishing hospital budgets for 14 of Vermont's community hospitals. So to conduct that analysis and ultimately make our decision for each hospitals, we look to our statute and our hospital budget rule for guidance principles. Our review requires us to balance several often competing factors, for example, the need to slow the growth in healthcare expenditures, while also ensuring that our hospitals have the resources they need to recruit and retain healthcare workers and provide the high quality care we expect in our communities. So as we look to balance containment, access, quality, and health system sustainability, we must be mindful of this year's unique circumstances and the significant headwinds we face. We have historically high inflation rates, workforce shortages, and the continuing impacts of the COVID-19 pandemic. They're all at play this year. And both nationally and in Vermont, hospitals are facing unprecedented financial challenges as our businesses, families, and individuals. So board members, I just want to say what lies before us is not easy. And I want to thank you all and I want to thank our amazing staff in advance for their diligent work in reviewing these hospital budget requests. Our immediate task over the next few weeks is to set fiscal year 23 hospital budgets for our 14 community hospitals. But I want to remind everybody that the board is working closely with the agency of human services to begin the work outlined in Act 167, which aims to move us closer to a sustainable hospital system that ensures reminders of access to high quality affordable care. And that work is going to involve extensive data analysis and community engagement to identify options for a more sustainable path forward. With that backdrop in mind, let's turn to the immediate task at hand, which is hearing from the hospitals about their 2023 budgets. We're going to have to ask meaningful questions that aid in our decision making and we're going to have to arrive at budget orders for each hospital that ensures short term stability. So I want to thank each hospital right now. And I will again throughout the hearings for the time and effort taken to submit the documents for review and for preparing for these hearings. I especially want to shout out to those hospitals that submitted all the requested information and on time. We really appreciate that. A few housekeeping notes about the hearings for the next two weeks. This presentation is a public meeting. It's being recorded and transcribed. Thank you, Lisa. So there will be a publicly event effort. If any hospitals leadership believes that there's any confidential information that the Green Mountain Care Board should consider, either as part of the hospitals presentation or in response to board or staff questions, please let us know before responding. If needed, the Green Mountain Care Board has the ability to go into executive session and review confidential information from hospitals. Executive sessions would be limited in scope as provided by the open meeting law and limited to information such as contracts and information that would be considered confidential under the Public Records Act. So if there's an issue of possible confidentiality comes up, I'm going to call on the board's legal counsel to determine the scope what could be discussed in executive session and if deemed appropriate and at the appropriate time. I will ask the board member for a motion to go into executive sessions. So, Mike, if you could convey some of this information to your members that would be helpful as we go through the hearings in the next few weeks. But before we do hear from Southwestern, which is our first hospital up. I believe we have a lot of some time for some brief comments from both Mike Del Treco from the hospital association and Mike Fisher from the healthcare advocate. So with that, why don't I turn it over to you, Mike Del Treco, for your comments. Sure. Thank you. Good morning, Chair Homes, board members, members of the public and our hospital teams. As budget review begins, our hospitals are facing numerous challenges. Before I discuss them, I just want to take a moment to recognize some achievements and acknowledge the tireless work that Vermont hospital teams do every day. We have a lot to be thankful for. Vermont has an uninsured rate 98%. Our delivery system continuously ranks at the top class. Vermont hospitals have funded reform efforts and continue to support value based care. We've significantly bent the cost curve, reducing growth rates that were once over 8% to current averages just over four. Our teams supported one of the best campaigns against COVID-19. Our hospitals are innovative and they've expanded the definition of hospitals far beyond bricks and mortar. We now support housing, help manage food insecurity, solve transportation problems and much more. All of this work is in the spirit of building a stronger, healthier and more vibrant communities. And leading up to these hearings, each hospital has gone through an extensive review process evaluating revenues, expenses and the resources necessary to care for their patients and communities. Each budget has been reviewed and approved by their community board. This is important to note as these boards understand their communities, their hospital specific challenges and the importance of affordability. You've heard me say it before but I describe these budgets as need-based. They are about patient care, our staff and our communities and come before you at a time of great uncertainty. I've been working in healthcare for my entire career and I've never seen a set of circumstances so complex and so severe. The situation we are managing is not normal. A hospital business is not like any other. We operate 24-7 and 365 days a year. We cannot close if things are too expensive or for lack of personnel. We don't make products, we care for people that all have unique health needs. Currently we have a workforce challenge like none other than before. Approximately 65% of these budgets go to cover expenses related to workforce and operations. We are experiencing unprecedented inflation and supply chain issues that are contributing to skyrocketing costs. 30 plus percent of these budgets go towards purchasing medical and surgical supplies and pharmaceuticals to care for patients. All of these challenges is the fact that many of our patients, adding to these challenges is the fact that many of these patients are coming in sicker and need more extensive care. To be clear, our system is at capacity and running at capacity is never a good thing. It severely compromises patient flow and care. To provide some context over the past three weeks, our system has been running at between 93 to 96% capacity. And unfortunately this is becoming a trend, not a one-time occurrence. We have a stress mental health and long-term care delivery system that places incredible pressure on our hospital. This drives up costs as patients are stuck in our hospitals even when they don't need to be there. Last week we had 125 patients waiting for placement. And over the last three weeks, this number has ranged between 105 and 138. Again, not a one-time occurrence. We are managing a pandemic and preparing for the potential of COVID surges and no one can predict the next challenge. Caregivers at our hospital are experiencing verbal abuse and violent acts against them daily. And under our current structure, we have not grown at medical inflation. And as a result, today's inflationary pressures are hitting us harder. All of these issues are taking a toll. Our workforce is exhausted. Our communities are challenged. And for the current fiscal year, most of our Vermont hospitals are reporting losses. These budgets produce minimal operating margins and average of 2% for the system. And as you know, margins are critically important as they allow hospitals to maintain and improve their facilities, care for patients and pay their employees. I've said it before, we need strong hospitals in Vermont. Because these are budget hearings, we talk about margins, operating expenses, rate increases, financial ratios, and all the details that make up this information. But I ask everyone listening to look beyond these numbers and these budgets are about caring for our patients, our staff and our communities. These budgets are thoughtful, our needs-based, and I respectfully ask the Green Mountain Care Board to approve them as submitted. Thank you for allowing me to speak today. And I appreciate the time. Thank you, Mike. Appreciate it. Mike Fisher. Mike, if you're speaking, I can't hear you. I managed to cover up my mute button, so that made it hard. Good morning. I appreciate the opportunity to speak for a moment and bring to you the healthcare advocates perspective as we enter into these hearings. So, you know, clearly these are not comments directly that today's hospitals, but for all the hospitals. I want to recognize and appreciate the words of Mike Del Treco. We agree this is a particularly difficult time for caregivers and for families. So we want to pass on our appreciation and recognition to, you know, with all due respect to the hospital administrators who will come before us today and the next two weeks. We really want to ask you to help pass on our appreciation to your frontline workers. So thank you for your work. You can expect, you know, a couple themes that you can expect from the Advocates Office during this year's hearings with regard to free care policies and financial assistance systems. The HCA appreciates the collaboration we had last legislative session with the Hospital Association and with Vermont hospitals on the passage of H-287. Now, Act 119. We recognize that the law does not require hospitals to come into full compliance for another two years, yet we now have a standard to strive for on the details of free care policies. And we recognize that some hospitals have already taken steps to come up to that standard. We're happy to work with hospitals on these details and provide as much assistance as we can on plain language summaries and other details as hospitals work to come into compliance. We also understand that an excellent free care policy is not the end of the story here. There are people on the ground working with patients at each hospital, helping them navigate very challenging financial systems while they're dealing with serious health challenges of their own or for their loved ones. It's a combination of good policy and a highly functioning financial assistance office that we're all after here. The best policy ever is of little help to people who don't know about it or who get little help with the process. We believe that by looking at the relationship between free care, the free care and bad debt lines in your budgets will help us gain an insight into the overall functionings of these systems. There's a real range of functionings across Vermont hospitals through these hearings and discussions after we hope to identify some of what drives this range and seek ways to improve the functioning of these systems across hospitals. As in past years, you can expect from the health care advocates office a focus on health equity, particularly race equity and questions related to what is currently being done, what is planned and what remains to be done in the future. And of course, you can expect questions from us about affordability, about the relationship of the budgets before you and its impact on people's ability to get care. I want to go back and say I appreciate the words of Mike Del Treco with regard to the needs of Vermont hospitals and you won't hear from us a pushback about that need. But you will hear the advocate continue to ask the question of whether Vermonters, whether they be rate payers or people paying for out of pocket costs can actually pay the bill. Thank you for a few minutes to speak and look to the next two weeks with you all. Thank you, Mike. I appreciate it. Okay, well, we are literally exactly on target. So it is 845 and knowing that we have a tight schedule. I think what we'll do is we're going to hold all board and staff questions until the end of Southwestern's presentation. But if we could keep to that a lot of time and plan to wrap up your presentation by 10 that would be fantastic. So with that, I think I'm going to ask Russ McCracken, can you please swear in the Southwest witnesses. Sure. Thank you, Chair Holmes. Mr. D. Mr. Majetic, I think you said there was one additional or a couple of additional people who might speak. We have Dr. Trey Dobson here and also Jim Roy. Those four of us. Great. If I could have all four of the witnesses raise your right hand. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth to help you guys. I know. Great. I'm going to turn it over to Southwest whoever is kicking it off and thank you very much for coming. Okay. Well, thank you, Jessica. Thank you for inviting us today. It's good to be here to kick off the budget session. I also want to thank Mike Del Treco for his opening comments. He certainly capsulize my short comments with, you know, which I'll do right now, but also I want to also do a shout out of thanks to Steve Majetic and our finance team who put together this very difficult budget. Over the last number of months and, you know, the budget's already a little bit old in terms of, you know, when we submitted it back probably three months ago and what health things are impacting us even today. So it's a, it's a, you know, it's a document that continues to be organic and change and live and it's, it's a challenge you want and I will say in my 40 years as a health care executive, this is the most difficult time that I have faced. And I think our most team members would say the same. I think most people on the call. This is a time of great uncertainty for us and challenges and and the need to try to stabilize our situation. And, you know, Steve, if you're going to do the slides, maybe we can go to just the first one. Correct. I'll wait for you. Can everybody hear me. Yes, I think we can. Yes, just let me click and we're we're up. Right. Okay. So maybe Steve, you can just go to the next slide please. And again, I'm just going to take a few minutes here and talk about some of the major forces and Mike did a great job. I'm just going to go to the next slide and kind of clean it up. I mean, for us, Steve, on the financial uncertainty, maybe you can show that next slide on that. You know, we're coming into our budget year. And on really uncharted territories for us we have, we have strived very hard during my time here and Steve's time and the rest of our leadership team to keep our, our budgets balanced. And we've had 12 straight years of operating gains anywhere from one to up to 4%. But we're in strange territory 2022 looks like it could very well be the first time that we're in a negative operating by year and which is something that we're, you know, we certainly were concerned about. And as we put together our budget in 2023, we had a very slight operating gain, but as Steve will talk about later on, that operating gain for 23 is now being challenged with some new trends that we've just been incurring. So we are not feeling overly confident in our, in our financial situation that is uncertain and challenging us almost every day. So we start off with the financial uncertainty which is new to us and hopefully will not be a trend into the future. And then, as we go into the question of workforce shortages, that's this is probably our biggest challenge and you may be hearing inconsistent theme from other hospitals throughout the hearings is that at the workforce side of our operations is very difficult. And, you know, and we took a different path and most hospitals across the state during the pandemic we made a, we made a strategic decision that we would not be, we would not look to bring in traveling staff, especially in the nursing side. We made a decision to try to make investments in our current workforce and in the staff or operations by not bringing in external external workers. Time will tell whether that was successful right or not but we were we were glad to do it, but we've had to make major investments to handle that type of decision. We made unbudgeted decisions in terms of wage and salary changes, we accelerated wage and salary adjustments, and it impacted to a rate of over $4 million. And, and it's something that we struggle with even making the investments to try to keep our workforce in place I mean we had some success and we also have some failure there. So, our workforce challenges is, is something that we're very concerned about on a daily basis, and I have to do I have to make a comment here. Our nursing leadership team, led by Pam DeShane is our chief nursing officer, and her assistants, they, they really walk the talk they went and they staffed the floors themselves. And this is happening every day where our leadership is working on the floors caring for patients and really setting, you know, setting the trend in the tempo for other people to follow and we're immensely proud of them and appreciate it for what they've done. But we continue and as we look at our 2023 budget. This is a continued source of major concern. Next challenge. So next is our capital projects and, you know, you've heard this in the past when we've been to the Green Mountain Care Board every year and we talked about the fact is that Southwestern Medical Center has the oldest plant of all hospitals. The age of plants the oldest in Vermont. And we are in the midst of commencing major projects to update our infrastructure and you'll see in the picture there that is the start of the building of our major emergency room project we have an emergency room main floor project which is over 31 million and again, in my 40 years of being in healthcare executive positions I've never seen a market like this where the pricing that we've developed and we spend a lot of time doing is changing almost weekly and some major, you know, some of some of the major, you know, sub projects within this such as electrical and iron and steel is up over 40% and in this change on a continued basis. And that's if they can if the contractor can even find laborers. So we are in the midst of trying to do necessary upgrades to our to our infrastructure in a time of great uncertainty is as to where these capital projects will end up in terms of their costs. But yet we're forced to do it. So, again, that's in that is impacting our budgets on a real time basis. And then as you move into the area of population health, you know, our our biggest unknown in our budget for 2023 is what will be the impact of COVID-19 as we move forward. And again, we made a decision and I guess we could be criticized for it, but we made a decision not to budget for a major surge of COVID-19 in our budget. So we pulled out any expense related to COVID-19 on as well as revenue impacts. So that is that's a concern that we have that we really have no idea as to where it will take us, even though I think you live by Dr. Dobson who will be speaking later I think we had a remarkable effort to deal with COVID-19 in terms of our community. I think, you know, I'd say one of the best responses in the states and and treating many, many, many patients and and we're ready. We're going to do it again if we need to. But certainly that will impact our overall financial stability. We're also having impacts on the population health side in terms of mental health patients, which is significant, actually so significant on the mental health side that we're also looking at potentially starting mental health services that we're currently investigating. And we haven't actually we've responded to RFP just recently by the Department of Mental Health for for inpatient adolescent services. So we're taking our responsibility very much to heart with with you know, using our are are certainly our mission to meet the needs of our community. And even though we know financially if we do this this will have a negative impact, but we're still certainly going down that road. And then the next on a major impact is the issue of system wide system wide gridlock. You know, we have this maybe you can go back one slide there. We have a system in many hospitals are feeling this, but it's very difficult to to get our patients through our through the health system. There's throughput issues. There is major gridlock our length of stay is increasing. And that is impacting us on a daily basis on any given day and Mike Mike Del Treco talked about this we're we're seeing 567 patients who are in our hospitals with no place to go. And when I finally do get it, we finally are able to get a disposition a bed for these patients. Oftentimes, we're not able to transfer transfer them because the local ambulance operations don't have the staff to transport transport these patients. So you almost have a perfect storm. And on top of that, you know, we're dealing with increased insurance denials the insurance companies are are I would say being more predatory in terms of how they're handling hospitals and patients, and and many of them are certainly denying care, which we feel is really, you know, in this day and age very, very distressing for for patient care. So, and on top of that, we have a growing workforce violence problem that has been a major stress point for our system. And this this in 2022 we are trending to 100% increase the number of incidents of violence and abuse of our staff. And many of our clinical staff nurses and physicians have been injured on the job. And their lives are being threatened every day by by certain individuals. And this is not what they signed up for. This is not why they wanted to healthcare. So we are, we are very concerned about that we are spending more funds in terms of contracting with local law enforcement to protect our workforce and we will that we will protect them at the best of our ability. So these are all forces that are that are making our budget that we're submitting today, one which, to be honest, I'm concerned about. I'm concerned about meeting the targets that we've established, and in one which could easily turn on. And it'd be a need for us to come back and talk to you at the Green Mountain Care Board at a later time. So let me ask Steve Majedek to step in and start to go through the details of this budget. And certainly we're, we're, we're happy to answer any questions you may have as we go through it. So Steve. So good morning everybody. So we're going to start off with just an overview of our statement of operations. As you can see that our fiscal year 21, we had a significant gain from operation, mainly driven by our COVID-19 provider relief funds we received. In 2022, when we prepared this projection, we projected almost a million dollar loss. That projection was built off of the April financial statements. Since then, we have seen some trends that were not in our projection and we are trying to hold that projection as best as we can. And you'll hear me talk about several circumstances that have changed since we did this projection, as well as our budget. Our budget in 22 had a operating margin of $3.6 million. And as you can see, we are, we are not achieving that. I'll go through all the details. I did eliminate in the, in the budget because we talked at length about it, the loss, the, the accounting loss and the termination of the pension plan, which typically goes in non-operating activities just so we don't get sidetracked. The pension plan was terminated this year. We met all the targets and the final numbers will be reflected in our 2022 audit. The actuary is finalizing them now. We secured with an insurance company the benefits to our employees that earned them over the years. And we bought annuities and we took off about $750,000 a year of administrative costs off of our profit and loss statement by doing this. And the word termination, you know, that's the word they use, but basically we secured the benefits that our employees earned over the life of employment here with a A rated insurance company and the insurance company is now administering those benefits. So here's a, here's a graph as Tom talked about it over the past 12 years. You can see if you start back in 22 and the red line is basically our budget. And as you can see before the pandemic we were pretty consistent. We were budgeting a 3% operating margin most years. We went up a little bit in 18 and 19. 3% operating margin was our target. That's what investment advisors in the healthcare industry look for. That allows you to invest in yourself that allowed us to improve our balance sheet to be ready to go into capital projects that allowed us to fund our pension plan so we can terminate it. And as you can see the actual results, which is the black line, we were before the pandemic, all but for really 19 and 18, you know, the world was changing a little bit, but we were consistent with our operating margins then the pandemic hit and I'm not, I'm not proud to say, but it seems like every projection I do since the pandemic has not come come to fruition, both on the upside and the downside. So, and I think moving into the future, you know, as a CFO for over 32 years, 12 years here at Southwestern, you know, I kind of pride myself on and my team on being consistent and before the pandemic I thought we had a good track record and it's just been kind of a little all over the place and our projected loss for 2022 is the first time we're showing a loss. We did budget a small, see by the cursor a small operating gain, but those gains are in jeopardy as we move into the new fiscal year. And 22 are operating results are writing revenues or about $8 million over plan. About 5 million is directly related to the COVID-19 both testing. We tested over 100,000 individuals in our COVID resource center. We vaccinated nearly 50,000. We administered nearly 50,000 vaccines in our COVID resource center. Therapy services and inpatient services were also in our revenues. We have and so that was a big driver to our $8 million positive revenue. If you back that out $2 million, we would have been about $2 million over due to services really mainly in the emergency room being over our 2022 budget. Our express care, which is our physician service without appointments and imaging services. All those volumes are up. And then we also had about a million dollars worth of positive revenue in other operating revenue related to 340B funding. Revenues funding from our foundation some grants and there was also some monies in there for from a state contract related to COVID-19. So, you know, those were the drivers in our positive revenues. However, our expenses were over about $12 million over our budget. Salaries and wages are projected to be 6.3 million over or 12% over plan as Tom talked about it. We made a significant investments in our workforce. Instead of paying agencies, we paid our nurses to try to keep them here. And, you know, as Tom said, our nurse managers were outstanding. They worked side by side with the managers with the staff and helped us minimize our agency cost. We also had about $4 million worth of related to that $5 million of COVID-19 expenses. And this is identified direct cost while they're also are indirect cost. Our physician locum costs were about $1 million over budget and inflationary and other costs are over about $1.3 million to make up the $12 million driver. Workforce challenges in 22 and they're going to continue in the near future. We increased the hospital's minimum wage in this fiscal year and we accelerated our pay increases. Typically, we get pay increases in the May-June timeframe. We gave them in January. So that that that was a deviation from our budget. We created incentives and compensation to staff. We did some temporary salary increases. It's a permanent salary increases. And we also changed our shift differentials to meet what was going on in the market. And we provided shift bonuses when staffing levels were near crisis mode in order to keep the proper level of staffing. We also are creating an ongoing program for greater incentives for recruitment and retention because it's a lot cheaper to retain your staff. And then then to constantly have them turn over and also we need to create the pipeline. And we've been working for many years and we continue to add to our recruitment efforts with education loan forgiveness programs. We were we're giving additional compensation to individuals who assist in the recruitment and development of retention staff. Sign on bonuses, which everybody is doing and constant market review of our compensation levels to make sure we can recruit and retain individuals. You know, the hospital, we were pretty fortunate. We're near nurse traveler free for a short period about eight weeks. We had about four travelers. The question for 23 is, will will you be able to maintain this? And as Tom mentioned, Pam DeShane, our chief nursing officer, she's committed to doing it, but you can only, you know, the staff may get tired. Our end vacancy rates are between eight to 14% depending on service location. Overall hospital wide vacancy rate is 7%. They don't sound that high, but when positions are open for length of period of time, it does create stress on the rest of the workforce. And again, here are some of the education recruitment and we're working with both the local colleges and high schools to especially get the BSN high school grads to enter the BSN program. Just last week, we for the radio in the radiology area, we have an agreement with Hudson Valley Community College. We have also an agreement with existing community college for radiology tax. Because it's just not nursing where there's a workforce. It's everywhere. It's from the nurses to all the way down to the housekeepers to the food service workers and to materials management that we're having challenges. So we're trying to work with the local education facilities on getting some programs through the hospital. So hopefully the kids will want to come to work here when they're done with their studies. Hospitals, it's changing. We're creating an additional strain and unplanned and unreimbursed resource consumption. As Tom mentioned, just in the inpatient acute care setting, we're averaging four to five patients that we cannot place into a long-term care beds. We're spending a lot of patients that are in our emergency room waiting for placement. You know, a quick estimate of the cost without doing a whole cost accounting, four to five patients a day. You multiply that by 365. It's at least a million dollars with no reimbursement because we do have to staff them. You do have to treat them. You do have to document. And it's at least a million. I can make an argument that it could be upwards to $1.5 or $2 million with additional cost that we have. But it's, you know, on the low side, it's about a million dollars. And there's no additional reimbursement. We're looking at programs that possibly will help us there, working with the local nursing homes. We're looking at some swing bed opportunities and things like that where we can get some money, but it won't pay for the additional costs. As I mentioned in our emergency room department, we're seeing an increase in patients with behavioral health needs. Here's a simple graph that shows that we've seen a 40% increase in patients with behavioral health needs since the beginning of the pandemic. Also, the graph on the right side shows that our patients with mental health needs and behavioral health needs are staying longer in our facility because it's difficult to place them. Because those facilities are also being challenged with all the same challenges we have. Bed capacity staffing. We actually had a patient in our emergency crisis area with seven weeks. Emergency crisis area is in our emergency room. We dropped off by a local nursing home and that patient refused to take the patient back. So significant challenges and adding additional costs and resources. So, so that's really what's been going on in 22 and really, you know, fast 40,000 foot review. We submitted a budget of $188,000. That's that includes the fee for service and fixed payment revenues. And as you can see here, here's our budget, our budget is that we submitted now, just so the board and everybody understands. We start on our budget journey in March, April, we do a lot of the work and may we do some fine tuning. I got to go back. Got to make sure I can get back to you. So, since our budget was prepared, you know, in the journey, like I said, starts in March goes into May. We get our board of trustees to approve it in June, earlier in June, and then we submit to the Green Mountain Care Board at the end of June. Since the budget was prepared and approved by our board of trustees and submitted many assumptions used, believe it or not, maybe outdated. And this happens every year. Okay, there's just one or two things that that occur and we we have enough room where we can adjust. I can tell you things this year are moving much faster to the larger magnitude. And let me give you a few examples. Since our our budget was approved by a board of trustees and insurance companies approached me for a 30% rate decrease. In my in all my tenure here, I have not ever had that, you know, you get a few adjustments that people are asking for insurance companies negotiate and you meet in the middle and we usually have room in our budget to absorb it and make it make some slight adjustments. The 30% rate reduction is a $1.6 million hit to our budget. So that would erase that profit of 904 right off the bat negotiations continue. The insurance company made us a and an adjustment to their proposal that reduces it to about $1.4 million from the reduction. We also got an insurance company also gave us a new payment policy that they were going to institute. And after we reviewed it and talked to them, the review show that we were going to lose, you know, over another another million dollars, but after talking to the insurance company showing them, you know, the impact to us and and they they actually pulled it back. And we worked through it with the insurance company and it was not the intent of the insurance company to do what they with the word said, so we were able to dodge that bullet. As we do our budget each year, our professional liability insurance, we put a 15% increase in our budget. When we did the original croat was at 34% which we got the last week in June. And we actually settled on a 24% rate increase so we have a budget variance already. Another local vendor came to us with a increase for 23% we have now settled in. We budgeted 10% increase and we're now we settled in. I believe it was a 14% increase. So you can see things are just, you know, when we budgeted just as an example, a 10% increase for this vendor. You know, I was kind of like that. That's way too much but when we sat with him and he showed all his costs and showed what he was running showing what his labor was. It was a challenge. So we these are just things that are happening and every day. It seems like and I've never seen anything like it in my in my 30 plus years as a CFL. So we're going to stick with our budget. As Tom mentioned, you know, it's a challenge each day. But we are working to achieve this with putting plans in place to because we need as a health system Southwestern Vermont health system as a statewide health system. We need to be able to reinvest in ourselves because operating losses. We don't we can't reinvest in ourselves. We have an old plant. We need to do that. We built our balance sheet up over the past 10 years to be positioned to to, you know, bring our physical plant up to, you know, modern standards. You know, we have a lot of work that we're we're planning and without without operating gains. We can't do that. So it's going to be a challenge. So as Tom mentioned that I mentioned our revenues are $188 million. No revenues related to a COVID surge. We wrestled with that a lot. But how big is the surge going to be if there is one? Is it going to be, you know, 10 cases, 1000 cases, 5000 cases, 20,000 cases in our and nobody really could could tell. So I didn't want we didn't want to put into our budget a what I would call a guest in it. It's out there. And we will adjust and we will do the best we can at any level. There's no federal estate COVID relief funds included. And we pulled out all the 22 COVID testing vaccine therapy and inpatient out of our out of our budget base and built our 23 budget plan with with that. So there's not that the direct cost. You know, of course, indirect costs are always built in. So, so that's how we built our budget. There's no upside or downside risk related to the one caregiver model. You know, I take the position each year we're going to be smack in the middle. If we get some upside, great. If we get some downside, we'll have to make adjustments and the care. The care teams get reports every basically every quarter and meet with one care and where we stand. So we make adjustments accordingly over the past years of the pandemic. There have been no material downside from Medicare because of the health care emergency in the country. So our increase is 11,000 11 million sorry, or 6.35% over our 22 budget. It's an increase of about 2.33 over a projected remember a projected does have COVID revenues in there. And when I step back and I look at our 23 budget compared to our 19 actual, which was the last non pandemic year. We're up about 3.8% a year. Here are the components. Revenue rate priced what we get paid is $8 million compared to volume and services of 2.8 to get from the 177 to the 188. We're requesting a net charge increase of 9.5%. That's what we're planning on realizing from commercial payers. We did put in a Medicare increase of 3.2% at the time the budget was prepared. Recent the IPPS came out which may be about four to 4.1%. So there's a little headroom there. We've seen over since about February we're seeing a significant increase to Medicare and Medicaid patients. In our in our actual results. So we put a payer mix shift in. I believe this payer mix shift may not be enough. If I base it upon recent trends. We also put a small increase in for Medicaid and disproportion share and we increased our bed that charity care by $250,000 which you know in light of what's going on in the economy, maybe a not so conservative number. As I said, the charge increases a gross charge increases 9.5% approximately 65% of our charges. No across the board on our physician practice charges rehabilitation service and selected other services because we do look and do compare ourselves to Vermont hospitals as well as New York hospitals in Detroit, Albany area. And we look to the ourselves what people are charging in those areas in from Massachusetts. And the drugs and medical supplies is no across the board increase on charges. And the $7.9 million increase represents 4.2 of our total 23 that patient service revenue budget. The Medicare as I talked about the Medicare increase was budgeted 3% maybe a little greater, but the payer shift to government payers of 9,957,000 maybe a little light. So that increase in the IPPS to over 4% will be chewed up by our shift to governmental payers. And so overall when you look at the other rate increases ends up being a net of about $500,000. So that's the volume as I reported our emergency room is seeing volumes increase after the pandemic imaging volumes. We did put some additional revenues in for radiation therapy. That's that that that's a risk in our budget. Because we have had some volume declines there. Sorry, interrupting here, but whoever is not on mute, please make sure everybody has their audio muted, please. Thank you. Sorry, Steve. That's okay. Observation patients, we are seeing greater observation patients. As you can see, there's nothing for a COVID-19 surge. And then our outpatient routine lab volumes are going down and that has to do just overall with volumes as well as some of our COVID testing. That's this is all budget to budget. Fixed perspective payment. We're looking about $37 million. We participate in all the programs. These numbers were received from one care. I do believe there may be a greater shift. Once we get the final numbers remember the one care years are calendar years. The 37 probably will go up a little and the 151 will come down a little bit as more lives attribute to the model. But we used strictly what we got from the agreement care from the one care Vermont. When we asked them for a projection on what they saw. So to recap our budget, a 6.35% increase four year trend is about 3.8 no significant revenues and expenses for another COVID surge due to the uncertainty. A net charge master increase of 9.5%. And again, non non COVID related volumes were removed. And as we took the, you know, emergency room and imaging are the big increases to our 22 budget. Just moving on, you know, to the numbers again, you know, our budget showed a small profit, very different than our history. But again, that profit will be challenged and is being challenged. And if I have to submit a budget today, I don't think it would be a $900,000 gain from operations with what I know and what we're dealing with every day. High level cash flows with a $900,000 gain. Our cash flow is about is break even at $200,000. So does not show significant game cash. It will be a challenging year if we're if we're even able to hold the operating game. If we can't hold the operating game, one of the first contingencies and the first things that we have to look at is our is our routine capital purchases, which we have reduced this year from $6 million to $5 million. And we will have to look at other things as we move through the budget year. But you know, it each year, you know, while while the graph I showed earlier showed us relatively consistent. Each year we had our challenges and each year we had some things that we put in the budget go the right way, some things we had things go the wrong way. So this team, you know, from from the housekeepers, dietary workers all the way up to the EMT members, you know, we've adjusted over the years and met our targets. So Steve's audio. Is it just me? Yeah. No, I think I did too. Anybody else know what anybody from the Southwest team know what happened to Steve? No, let me check here. I'm here. Am I here? Yes, you're here now. Thank you. So I'm really some. Where did you lose me? At the beginning, Steve. No, I'm just kidding. So, so did we look at statement of operations? We were on the balance sheet when you lost me. Yep. Yeah, you're right here when we last year. Okay. Okay. So the balance sheet, a lot of numbers. I just, you know. You know, up here cash and accounts receivable are the drivers to this balance sheet. You'll see that our plant property and equipment, a lot of numbers on this page will be increasing. We're really, really related to our emergency room project. Other than that, not a lot of significant changes. A little bit change in our long term debt, but not not see no real significant changes. And so, so let's just turn, you know, we talked about revenue. I'm just going to spend a couple of minutes on our operating expenses. You know, our total operating expenses will be 196 million budget to budget increase of about 8.5%. When you look at our people costs, it's over 60%, nearly 60% salaries wages. You know, we, we, we, in 2012, 2012, 2012, geez, I only wish. On 2022, we put about $4 million worth of cost into our workforce. We continue to be planning on doing that this year. Benefits are going up accordingly. We expect increases from our insurance carrier and then our providers through our Dartmouth PSA also going up, you know, and there are challenges and you'll hear. I think you'll hear from Dr. Dobson talking about recruiting related to wait times and challenges that we're having in those fronts, but overall the numbers, you know, a good chunk of our expenses are, are related to labor and you know when you back out the you know, first of all, depreciation and interest, which is, which is, you know, kind of, you know, you know, first of all, depreciation is a non-cash cost in 196, and then you have your fixed cost of your interest and your provider tax fixed cost. Our cash, you know, when you take the 114, you compare it, it gets up to 65, 67% of what we do each and every day. Repeating, you know, 14% increase in our budget to budget, permanent compensation increases of 4.2%. And, you know, we did raise our minimum wage last year. We're looking at right now, you know, maybe that wasn't enough. Because, you know, some of our lower paid employees can go other places to get jobs. And we've added some monies in there for the, in the budget for that, but we may have to give more. And as well as the professional staff. We've seen an increase in FTEs. We've added some FTEs for the blueprint, and that's a plus minus revenue and then expenses. We increased some FTEs in the clinical areas due to staffing concerns. And when we're holding another four to five people in our acute care unit, because we can't move them to the nursing home or we can't transport them to the nursing home. We still have to take care of those patients. We still have to feed them. The nurses still have to around on them. The nurses are still administering meds. The hospitalists are still coming in to see the patient. So we've had to increase staffing because our census is up as well as the, I'll call it sometimes we want to call it the post pandemic. We have our census has been higher, not just due to COVID patients, but also due to patients just presenting and needing care. And we did budget, just a fraction of contracted labor, but and we're, you know, our goal and Pam's goal is to minimize the use of outside travelers, both from a quality perspective. And a cost perspective. Health benefits, as I talked about, will be going up. We're going to be sharing some of the benefit increase is with our employees. Workers comp is going up and talked about work workforce violence and workers comp is rates are going up due to that as well as our experience and regulatory benefits due to increase as, as, you know, as, as we increase salaries and wages. The regulatory benefits such as fight as such as unemployment and things like that go up as well. So overall, you know, again, up 8.6% supplies. You know, we did put it looks low, and it might be low at 5.3. But we challenged our hospitals value analysis team to come up with $750,000 with the savings in our budget. So there is an initiative there and the team is compiling looking for ways to save money. And we factored that into our supply cost. If not, our increase would have been greater. But one of the things that is really one of their missions is that, yeah, you can get lower cost items, but we cannot jeopardize the safety and the quality of the care we give here at the hospital. And in addition to the word safety, you know, we always try to give high quality and safe care to the patients, but we also have to make sure that our employees are safe. And so that's one of their initiatives and they're working hard on on producing a list of things to do drug costs. We put in 8.8%. And then in our other cost, and we put another $500,000 of savings. We're working with all the managers to find things that, you know, sometimes when you get contracts, you know, the example I use is and I use me as an example. I've gotten a report for years here that shows me information and is a trend and I use that information to make decisions. This year I'm shutting that report off because our trend has been very consistent. I will hold off. I will use the older reports. And I won't be getting that report. So, and that's a contracted savings that we can get. It's not a lot of money, but if everybody does that, we can save some money. And so everybody's charged with that and we have a team working on it led by Jim Roy. We're working with the managers to go through everything that we in other costs and purchase services that we do and challenging the managers and the team to find at least $500,000 of cost and that's built into our budget. Another inflationary increase is 5 to 7. You know, this will create risk in the budget, but, you know, again, we challenge our managers to find ways of not going if the cost of the product is going up 10%, you've got to find ways to find an additional 3% and challenge that. Some will be successful. Some won't. We'll win on some, we'll lose on others, but we have to challenge because we can't just keep adding cost to our cost base. Provider tax, I won't give my editorial comment on that. So, so that's the numbers. That's the concept on how we built our budget right or wrong. It's a budget. It's a guide. We know we're going to be challenged. And as I said, if I was submitting it today, I'd probably be submitting something with some different numbers because it's been, you know, at least 75 days since we finalize this and submit it to our board of trustees and things have happened. So, I'm going to let Trey go through the equity section of our presentation. Dr. Dobson. Sure. So, yes, I was asked to give some comments and just talk a little bit about diversity, equity and inclusion at SPMC. You know, I think all hospitals, I hope all hospitals are working extremely hard on diversity because without a real strong effort on diversity, we can't fulfill our mission in healthcare. And that's true in many other sectors of society too, including education. And I'm not going to go through all these bullet points here, but just looking at the first one. We have a very active and growing the committee. I don't, I don't really want to call it a committee because I think of a committee is 12 people that meet once a month. This is a group of over 40. I think almost 50 people now that do meet monthly, but also are highly engaged in educational activities throughout the month. And so maybe it's interest group, work group, really spreading the message and actually the ones that are doing the work to improve diversity throughout our system. In bullet three, you can see annual mandatory implicit bias training. I think many fields you're aware of you have to do your annual education things where you click on buttons for slides to try to get them to go away. We have a lot of that in healthcare for regulatory reasons, but many of them do have an interest. And really the way to get these educational efforts to be appreciated is to have the staff themselves participating designing them. And that's definitely what happens with our mandatory bias and diversity training to the point where we actually have a lot of fun developing the scenarios and then meet after each annual requirement to see how we can improve it. For next time. And then you can see the other efforts there linked again. I hope all hospitals have similar types of efforts. We do talk about them together. The hospitals are of course very collaborative and trying to learn from each other. The next to last bullet point is also incredibly important. And that's a community outreach task force to work with the community to see how we can better incorporate diversity, equity and inclusion in all the work we do. Our biggest barrier is probably the same and you would as other hospitals and you would predict this and that is just attracting candidates from diverse backgrounds, diverse racial and ethnic backgrounds to our area. And we continue to work diligently on that as do others. It's going to take time. And I think the awareness and the will are certainly here. That's a great thing. But there is an incredibly long way to go and can't overestimate that. I hope that we will be in a significantly better position within the next five years. But I know that this effort must continue, especially when you travel to other locations and other healthcare systems. You know, we are not where we need to be in Vermont. And I'll move on to the next slide. So now different topic there, wait times. I put this slide here, not for really the board, but for others in the audience to make sure we all understand what is meant by third next available. I know this is in the definitions of the packet material. We've been doing it here in our, mostly in our practices for about five to seven years using the National Institutes of Health definition. And actually, you're going to hear me talk about some of the limitations. And that's not the point. I do just want to point out to everyone, you know, where some of the barriers are here when we use any type of measurement in healthcare. You know, I worked Thursday in our emergency department at SDMC and yesterday at Dartmouth, Hitchcock and no matter any of the barriers I talk about here in the measurements, one thing for certain, access is not where we want it to be. So let's just call that the principle of the situation. Access is not where we want it to be for primary care or specialty care. I see it in the patients I take care of. You see it in the community or among your family or yourselves. And so it's something I think we can all agree upon no matter what measurement we're using, how do we get better access and actually how do we share that among our health systems so that we're all working together to improve that. So if you can go to the next slide, Steve, to some of the things, just quickly for people to understand, if you did look at an individual health system measurement third next available, you're going to see that it varies tremendously month to month and you may want to know why is that. That's because just when an individual goes on vacation or just when an office introduces a new service or actually excludes a service for a small amount of time, it causes these numbers to vary significantly. So I bring this up so that you don't focus too much on what is the actual number but looking at trends and looking at trends at particular health systems. It's really the only way that we can make the right effort to improve upon it rather than trying to like squabble on the different individual measurements. It also varies by individual physician. You can have a physician who has good access for a few months and then poor access or for another few months. It's hard to figure out why it has to do again with vacation scheduling with office scheduling and the types of patients that individual physician or advanced practice provider is seeing. And also just for some reassurance, there are many, many patients who get in under that third next available who have urgent needs. They do have to jump through hoops or they have to be referred by another physician. This happens to me in the emergency department all the time. I have a patient that needs to be seen again within a few days. I know that they're not going to be able to get in if they just call themselves. I have to make that call speak with the doctor or the front staff directly and just emphasize why this person needs to be seen more acutely. Next slide. So these are just some, these are actually true examples from our own data. This is the second quarter 2022. And it's not the greatest slide, but I tried to put together, we have five primary care sites in our system. You can see one is called Palinal. We have a pediatric clinic. We have one called Northshire Family Medicine Clinic. And then on the right hand side, there's Deerfield Valley and then there's internal medicine in Bennington. And you can see the third next available in Palinal Pediatrics in Northshire Medicine are actually not bad within a week to maybe two weeks that there is a third next available for a new patient to be seen. Now, the thing that's in common with all of these practices right here is we've had recent new hires, new physicians, new advanced practice providers who've come in within the fiscal year of 2022. And that is what has driven the access to be improved. Whereas the other two locations have not had new physicians where advanced practice providers come in and their numbers are much higher. You know, up into the 30s and 40s for getting patients in for a third next available new patient. Again, if I need someone or someone needs to be seen in one of these clinics for an urgent reason, we can generally do so within a week. And I think that's a, you know, throughout the whole state you'll hear that from other doctors offices. It still doesn't mean that there's no problem with access. In fact, there is an incredible problem of access. I'll go back to it again and say I face it every day when I work in the emergency department and I hear about in the community and with my own family. So next slide. The same is true. I just want to point out the importance here with new provider hires. These are our specialties, not all of them, but just a select group of our specialties. A lot of this information was, you know, put out in the digger when this came up, when this issue was really came to the forefront. And you can see that in general surgery and orthopedics, the third next available is very small within a week. And that completely has to do with new physician hires, new advanced practice provider hires, whereas in neurology where we couldn't find a candidate, another candidate, cardiology, dermatology, the numbers are much longer. And let me go to the next slide and just explain why I keep putting these up. It is true, like in any field, you have to have efficiencies and these efficiencies are going to help drive access just listing just a very few up here, reducing the length of appointments and making them standardized, having others do prescription refills and triage rather than the doctors themselves that are trying to see the patients or the front staff that are trying to register patients, getting scribe services and other initiatives. Telemedicine helps not near as much as we would all like it to, but it does help for some of the services and then developing same day walk-in clinics. But in the end, these efficiencies don't make the difference in access that recruiting in new providers does. If we recruit in new providers, then our access numbers improve significantly. And I think that people see that no matter if they're in a highly specialized clinic like urology or a family medicine clinic where you see a vast numbers of people. And I think that's where we have to continue to focus our efforts as of course we look at improving efficiency throughout the system. And I think that's my last slide, Steve. Okay, can everybody hear me now? Okay, just wanted to make sure. So each year we give high level risk and opportunities and in the past, we used to give you a list of things, but I'm going to be a little more macro this year. You know, labor. Labor is one of our biggest challenges. When I look at the budget, I see the salary number is probably, we're probably going to be over budget in 23. And, you know, what we budgeted isn't enough to maintain our stable workforce. And I'm leaning to answering that question and saying, no, it's not. Demands on the workforce. You know, Tom talked about workplace violence. So will that will that prompt more individuals to seek other opportunities, maybe retire early or just leave health care. We've had a couple of employees and non patient care support services just say, you know, it's too stressful in health care. So when some of the lower paid individuals will go to work at Pizza Hut or or Home Depot, and they get a little more money and they claim it's less stressful. So, you know, just to put it in perspective, if we're off 1% of macro level, it's it's over $600,000 and that wipes out our operating margin that we budgeted in 22. I'm going to say we were seven were probably, I think that number is going to be eight to 9% by the time the end of fiscal year off in our assumptions. Here's an example of a competitor offered a clinical professional over 50% greater pay. And then what we did was we looked at at at the whole group at all the clinical professionals in this classification. And we have, you know, we were, we adjusted the pay we didn't go up 50% for everybody. The annual cost of $300,000 and by doing this, we were able to retain that employee, which was going to get a 50% increase, but he was going to have to work nights. He was going to have to do 12 hour shifts. You're going to have to work more weekends. And he had been a long standing employee. So we were able to retain that employee and two employees that gave notice to go to other places were retained. If we didn't retain those three people, we probably would have had to go into the traveler mode, which would be over 100% increase in pay. So, and and a week doesn't go by where HR, the areas VPs are not dealing with situations like this. So it is it is challenging and for us inflation. You, you heard in just the high levels, what we put in our budget, the initiatives that we're trying to save money, trying to find ways challenging our team. But if we're off 1% it's between six and $700,000, which the likelihood is high recent reports show that inflation is declining a little bit so you can see. But I did get a slide deck this morning, which I did not look at from our group purchasing main vendor that the low light is is that cost will be going up between 8 to 10% and I got to go over it before I comment further about it so this is a second significant risk. What is COVID going to be. You know, I've asked Trey numerous times. Look in your crystal ball tray, you're the clinician, tell me what the surge is going to look like in the fall and you know I think he chuckles sometimes and sits there and says we know when the winter comes there'll be, you know, some but how much we don't know so we didn't take a real big stab at it because it's really a big unknown. It's a big question mark and I think if we said, if we said we were going to have a 10% surge or 20% surge. We're speculating so we did not provide that we will deal with it we will, you know, like this team, I'm very proud of, you know, anytime we have something like this, we step up and we'll figure it out. And we'll look, we'll care for as Tom mentioned, and Mike mentioned, you know, we have, we're here to take care of our community so we'll figure it out. During the last, you know, the past year, we, we, as I said earlier, we vaccinated over 50,000 we administered over 50,000 vaccines. We tested over 100,000 people. And we, we were on the leading edge of giving some of the therapeutics. So, we will, we will step up and we will, because our mission is really to take care of our patients in our community, and we will continue to do that. In the pandemic environment, as I talked about managed care companies, you know, the, the women said to me, we're losing money. I got I got to find a way to, to reduce what I pay you. So I went over all of these, but these are things that are happening every day, and they're not, you know, the old, you know, I'll say the nickel and dime. These are big numbers for our organization. So things are changing faster. I don't have sneakers fast enough to keep up with them. And we will keep adjusting and confident that this team will do the best we can. And we will continue to create, you know, have a safe and high quality environment here for our patients and we'll, we'll figure it out. So, instead of going through all of the individual items on the risk and opportunities, I think, I think that those, those slides really cover what's what's happening in the world today. Value based care. We talked about this earlier. I won't go too much more into that. This and our capital. We have a $5 million capital budget. It's down because we need to have a positive cash flow. But, you know, one of the areas if we, if we don't meet our budget, we probably will start chipping away at this $5 million from a cash flow perspective. We do have, we will be spending about $15.6 million in the 12 months of the fiscal year on our modernization emergency room project. And that is on track to open in a timely fashion, as we submitted in the, in our CON, however, costs are going up and are challenging. Our future CONs, we're looking, I think a year ago we said we were going to submit the Cancer Center CON around now. We probably will push that back. We just got the cost estimates in. It's north of the 15 million. And so we're looking at some design changes to try to bring that down. I think it's safe to say the $15 million goal that we put in this presentation. We just got the cost last actually two weeks ago. It probably will be north of the $15 million just due to the cost increases that we're seeing that Tom talked about it. Future possible, but these may have to be pushed back in the imaging area. Our CT scanner is 10 years old and we have a portable MRI. It probably would be advantageous to and also improve the quality and just having an MRI stationary here. Family medicine residency program is still on the table and modernizing our operating rooms, but immediately the Cancer Center is our next big one. So discussion, you know, just times are challenging. Things are changing at a rapid pace and we will do our best to achieve our budget as submitted, but there will be significant challenges. So I am done from a presentation point of view, Jessica. Well, great. Thank you. Thank you so much. And just to kick it off, you know, a sincere thank you to all you're doing to care for the patients in your community and your frontline workers. We really appreciate we know it's been a trying year trying several years, I would say, and appreciate those challenges that you're facing and navigating these turbulent waters. Keeping your head above the water to find cost savings still and to try and, you know, the efforts you've done to retain your employees and improve wait times and focus on equity and diversity and inclusion. So very much appreciated. I think what we'll do is we'll open it up for questions from the board and I'm going to start with Robin. Hi, everyone. Good morning. It's nice to see you and I wanted to say thank you particularly for looking for cost savings in your budgets as everyone has said these are challenging times all the way around. And I think, you know, it's really great to hear that you've included that as some target costs. Related to the cost savings, I was wondering if you could tell me do you think that these savings are would you qualify them as fully achievable a stretch goal somewhere in between I just wanted to get a sense of your thought in terms of picking those as targets. So I would say that I wouldn't call them a stretch, but they're kind of like in the middle of the road Robin. Yes, you know, you don't want to. You always want to challenge your teams in in when you set these goals so but you know with with the pricing increases we're seeing it may take away from some of it but we're not backing off on it yet. The team is is forging ahead. And I'm just to add what Steve said, Robin, on some of these initiatives we're also looking working closely with Dartmouth Hitchcock, who's our affiliation partners see how we can, how we can collaborate on some opportunities so I think, you know, something that it's as far from a it's a gimmie but we're going to work very hard to achieve them. Excuse me please court reporting Robin, could you please state your last name and the last person that just made a statement. Could you tell me who you are please Robin first. Yes, it's lunch LUN GE. Yeah. And yes, hi that was on Tom D. Thank you. Thank you. So the the other question. I had a clarifying question around the blueprint for health FTE's adding to the budget is that due to an increase in blueprint or could you speak a little bit to what's going on there and I'm curious to understand that a little better. Well, there were there were a couple of FTE's added to our budget, because we need to add some staff to maintain the services and to to continue the good work that the blueprint does. So, in the in the monies we get for blueprint, we let a contract. We added more clinical people. So we can go out in the community and manage the care and reach out and make sure that our community is served. Great. And but I guess what I'm trying to get at it is that because the blueprint contract increases or is this on top of the blueprint money you get. This is it's a combination of both. Okay, great. In your summary of your workforce challenges and fiscal year 22. You talked about incentives and compensation for staff to retain staff. And you mentioned some temporary salary increases for certain clinical staff. Could you speak a little bit more to that in a little more detail? When, when did you institute those? Have they all sunset? If not, when will they sunset? So in in the late fall of last year, when COVID was surging, and we saw some of our staff start entertaining to leave us and become travelers, we actually increased pay to all of the employees in that job certification in that department substantially in order to keep those employees here and other employees and to keep the travelers out. So some of those sunsetted, we did it for about three to four months. And then we actually kicked it, had to reinstitute it a couple months later. So we had some critical staffing shortages. So in order to, you know, manage our resources and make sure we had adequate staff, we had to reinstitute. So we have, we have pay codes set up. And as we, you know, the last, the last choice is to call a travel agency. So, so we have these things in our, in our, you know, game plan. And, you know, some of the things that were permanent, you know, such such as shift differentials. And, you know, some of the staff we actually, the example I gave in our risks and opportunities where, you know, we actually gave permanent increases. Okay, so, so those bases have gone up. So, and one of the other things that we did was, which was permanent was we accelerated our pay, you know, increase from last May to January. So that's a permanent. So, you know, and we're getting creative, you know, we will give, you know, and this is a temporary thing, but shift bonuses if we're if staffing is really critical. We will, on the spot, give incentives to have people stay on top of their overtime pay. So it's a combination of permanent and temporary. And Robin, this is Tom Dee speaking. The area that was, we were hit particularly hard last year as Steve referenced was the emergency room where we were facing. We lost four, four key staff people and numerous other ones were also contemplating leaving for a travel agency. So that's, that's an area that we focus very aggressively on, but we also had to target other areas as a year went on. Thanks. In terms of, I thought your utilization estimates were interesting because we certainly heard in our qualified health plan insurance rate review, some analysis around emergency department visits coming back as the pandemic. As surges fell off. So there seemed to be at least in the insurance company data, some correlation between the ED utilization and urgent care as well as imaging and those things. So it was interesting to see that kind of follow in your budgets. Do you, what are, are there other areas in the hospital that you are budgeting? Not that same kind of take up that you would say are still low compared to maybe 2019. I'd just be interested to get a little more detail around kind of the trends you're seeing in utilization and how that relates to pre pandemic versus pandemic. So, so Robin in our budget, we budgeted on the patient side, which represents about 20% of our business. We budgeted admissions very much in line with 2019. And late to stay, we creeped up a little bit, but not to where the current levels are. So that's like the state is how long people stay in the hospital during the pandemic, they stayed longer. We hope to get back to that to those levels. But the challenges with transferring patients to nursing homes is putting a damper on that. So, so we have challenges there in the emergency room. We are seeing, you know, one of the things that we looked at and and Trey, Trey probably will cringe, but we looked at diagnosis is in the emergency room. And from a billing perspective to look to build our numbers this year. And, you know, there's not. You know, looking at the data we anticipate our emergency room to continue to go up because the diagnosis that we're used for billing. We backed out all the COVID ones that we were able to identify but I know that COVID is a moving target. Even even in a stay so so we saw those go up. Imaging is interesting. We're seeing imaging go up and primary care and, you know, our primary care numbers will go up if we're if we're successful in recruiting. And as a result, there appears to be more imaging coming. But, you know, I think Trey will say every time we take two steps forward. It seems like we take 1.9 steps back when it comes to recruiting. So, we're making headway, but not as fast as we would like. So, imaging is another area where we've seen increases and we budgeted that and the other areas we're kind of holding back to pre pandemic levels. And the data is supporting that lab has been. If you take out the COVID processing lab has been up and down. And I'm not sure what the trend is telling me there at this point. So we went to the 19 levels that, you know, pre pre pandemic levels. Will that be right? I don't know. We'll be wrong. I don't know. It will it will pan out over time. And Robin, this is Trey Dobson and Steve's exact Steve's exactly right. Just a couple of really quick comments. Emergency department and and urgent care express care volume increases. Some of that is clearly due to access difficulties with primary care. And, you know, that's that's not just us. That's everywhere. Better primary care access reduced some of those volumes. The second is, since you asked the question, general surgery has not rebounded as much as would it be anticipated. And that's actually not just here at SMC. That's in some other places. It's a little bit, you know, it's little not certain why that is. There are some national trends on it, but it's starting to slowly go back up and it probably just was an aberration with how that clinical service works. Gastroenterology, I think many places around the country are seeing that there truly was a, in that particular field, a lot of delay in care that that still lasted beyond 2020 and well into 2021. In fact, it continues a little bit now. So I think the volumes there will increase around the state, depending on whether or not there's access at that particular hospital. And then finally, you know, particular to our institution oncology services is really, as Steve mentioned a risk, both with radiation and chemotherapy, because cancer rates are not impacted by the pandemic. But our ability to recruit in staff, both physicians and support staff is a little hampered. Thank you very much. And that's it for me. Great. Thank you. I guess I'll turn it over to a board member Tom Pellum for questions. Well, good morning and thank you. I just kind of want to start off by kind of affirming your very good track record coming into 2023. That I've, you know, with adaptive, you can kind of look at a an individual hospital against the entire population of 14 of the 14 hospitals and just as a couple of top topside numbers that for all hospitals, the NPR FPP growth since 2021 has been 9.2% versus the Southwestern's growth rate at 3.5%. And the budget over budget, all hospital population is a 10.2% increase versus your 6.4% increase, same pattern in expenses. So I think the track record is pretty strong that you are working very hard to meet the challenges of all day. My first question is happy to do with your value based program with Blue Cross Blue Shield. And I mean that's been in play now for a few years. And it actually occupies 99% of all of the value based efforts aligned with carriers and insurance carriers in Vermont. And so I'm just wondering if you can provide kind of a high level overview of how you view that program. And successful. Why do you think other hospitals and the carrier you haven't engaged in a program that you have again at a relatively modest level four and a half million dollars, but it's still the most significant program in the state of Vermont. So, you know, we join, you know, we're our organization early on Tom was very committed to the population health. So when Blue Cross, when we saw the opportunity after going into Medicare or Medicaid to go into the Blue Cross, a qualified health plan program, we jumped on it. And, you know, like with like with all of this it's it's very fluid. And, you know, our team, you know, we have a group, I'm going to call it the care coordination team that works very closely with one care analyzing the data and then communicating to the providers. So, has it been successful. I think we're seeing indications that it is but this is a long haul and the pandemic just kind of clouds everything it makes everything foggy. So, you know, we're committed to it. It hasn't hurt us financially from a CFO perspective. Has it helped us financially. I'm not willing to go there yet, but it's not, it's not hurting us. So I think we're moving in the right direction. And I'm not sure. I don't speak for the other CFOs in the state and the CEOs of the state but but for us. It's all part of that progression of moving forward, because that is, you know, a goal of the state and a goal of our organization is let's move. Let's move the bar. Let's, let's, let's make, you know, the cost of care more predictable and manage it but you know, with all these other challenges we got going on. I may have a different answer a year from now. Okay, but I don't know if that answers your question because it's kind of, you know, my answer is kind of gray right now. Non-committal but my gut tells me we're moving in the right direction. And if we weren't, I'd be in Tom Dee's office and Tray's office jumping up and down. Yeah, I just, I just think it's, it's one of the pillars of healthcare reform in Vermont, fixed perspective payments, value based payments and you're, you're the leader of it in terms of actually putting it in play. And so I, I think I read an article in digger or seven days or something three, you know, three, two or three years ago that basically applauded your program because it allowed you to move a lot of your care into the community and home and out of the hospital. So just the update is appreciated and I can fully understand how COVID has kind of clouded the situation. My next couple of questions kind of have our kind of topside questions, but I just want to kind of get your feedback. There's a part of me that feels that the provider tax, your, your favorite line that the provider tax is kind of an error in that they are taxing higher NPR driven by a pandemic. And it just seems, you know, that that hospitals now are are bearing that cost. I think your increase in provider tax for 2023 is over a million dollars, which is big money when you kind of look at what it might mean to your to your margins. And I'm just wondering if, if what your reaction be if there was some momentum developed for a cap on the provider tax say at the NPR levels of 2021 for the next two or three years to give hospitals a little breathing room to keep those resources rather than sending them into the state. So Tom, the provider tax, you know, it's a complicated issue for the state because it's matching funds coming in from the feds. But when you look at our PNL, okay, it's a cost that each month we have we send back to the state and in theory it's built into our rates. The word I said in theory. Okay. And the state, you know, there's matching funds and I don't want to get into I can skirt your question. I don't want to get into all the politics of funds. But maybe that's a question from Mike del Treco and the hospital association. But, you know, from an absolute dollar perspective, it is going up. So as a result, I need to be able to compensate for that because it's an operating expense and it's and it's going up so we need additional great relief there. So again, not a great answer Tom, but it's something that I think we need to take a look at as not just the healthcare industry, you know, the healthcare hospitals, the providers but I think the state and and I know there's always discussions about this and we got to find another mechanism I believe because there's there's really no increased budgeted and for Medicaid. So, and our disproportionate share funds are not going up so, you know, it's, it's, it's a political football that I guess I don't want to get into. Tom, it's Tom D we support your platform though. We're right there. Well, let's let's just then kind of migrate to Medicaid because that my next question was on that connection that there are some facts on the ground or a couple of significant facts on the ground. And I mean you in your budget presentation to us have basically said that your increase in Medicaid is minimal or non existent. And that's true I think across all hospitals you're not unique in that message being sent and so I look at that and I say but what are we doing about it or what could be done about it and so if you go to for example the budget and look at the numbers there for me. Hang on. I'm trying to be the global commitment appropriation. It's item number three, the citation I can give you is is be 307 in the JFOs of budget tracking document. That is down year over year by $18 and a half million. And the rationale for that, according to the emergency board was a drop in caseloads which makes sense because you know now there's, you know, people reaffirming incomes and, and in case those have dropped, but still it's 18 and a half million dollars that was in the budget in 2022 state budget. That's not in the budget in 2023. And I'm just wondering. Do you think we've gotten to the point where just the cost shift is accepted as a fact of life and it's just is what it is and, and, and hospitals have to work around it. Yes. How's that for an answer. We got to work around it. You know, one of the things that that I wanted to put in my presentation but I didn't, I didn't go there was if you if you take the population and let's assume that 50% of the population is Medicare Medicaid. And 50% of it is commercial. Forget no pay. And the costs to the hospitals are going up. Let's pick a number, 8%. But if the government side of the equation is going up, Medicare is going up the IPPS is going up 4%. Medicaid is going up 1% maybe. Okay. And the budget, you know what I submitted. The other side of the equation has to pick up more talking about the cost shift Tom. So think about it. If, if cost overall are going up 8%. But one half of the equation is going up only and let's just assume for that means the other side of the equation has to go up 12. Just to break even. Okay, so, so it's kind of, you know, I've said this now for a long time, the car, the car shift is a monster. And it, you know, but how do I pay that 8% increase and what we're trying to do with the fixed perspective model perspective payment is to try to manage the care. Okay, and try to move people into a, you know, so they don't come into the emergency room and see tray with 10 problem hopefully we can manage them in the doctor's office and manage care and and that's, that's sort of the secret. The secret sauce that we still haven't gotten to but when it comes to Medicaid, you know, and we haven't received any kind of real increase but I probably some of that reduction might be related to the one care initiatives and trying to treat patients in a lower cost situation and keep them healthier so they don't come into the ED where Trey has to see them with multiple health issues, which then they get admitted for which is one of the most is probably the costliest spot for care. I don't know if that was helpful, but it did. There is some out of balance going on. Well, I mean, the fiscal imbalance is clear and but the energy to fix it, you know, is is is what I was talking about, you know, just trying to trying to get a visceral understanding that I was fascinated by the fact that you have taken a no travelers route by and large that was the message, you know, that that I got that that and you can see it in the other hospital budgets travelers travelers travelers travelers inflation inflation inflation inflation, but your presentation is not reside on a lot of travelers. And I'm wondering and trying to prevent that money from leaving the hospital going to a traveler agency and keeping it in town, you know, to take care of your people. And so I'm just wondering if you've talked to any of your peers across other hospitals, whether in Vermont or not, you know that you can get a sense about your turnover rate. You, you, you did profile on one of the slides, I think a turnover rate. And I'm wondering if you have any sense that that turnover rate is more favorable than than the others that other hospitals are experiencing some kind of benchmarking about the course that you have taken relative to the, the course that other hospitals are taking. Yeah, Tom Tom day, I don't, I don't think we really have data on the other hospitals to be honest. I've had a lot of individual conversations with other CEOs. And it's just, you know, again, I'm not saying what's right and wrong. It's our strategy. It's yet to be determined long term, but it's the right move or not. But because we've, we've made adjustments when also a number of adjustments have been embedded into our salary structure. So we're carrying them going forward. But we just think philosophically, it makes more sense to invest in our staff. And, and it doesn't work, by the way, unless you don't unless you have a man, a nursing management team like ours that steps up and and fill some of the gaps. So that's, that was a tremendous show of support by our leadership there to do that. But, you know, can we do this all the time year after year? I'm not sure. But so far, I think it's worked well, our vacancies, you know, we're running about 8% vacancy, which is high for us. We don't usually, you know, our nurse vacancy rates one of the lowest in Northern New England. So, you know, creeping up to 8% is high. But so I think so far it's worked in our market for our hospital. I'm not saying it works up in Burlington or anywhere else. It's, it's, I think it's specific to the organization. And, and we have a history here through our magnet program of trying to continue to cultivate and build our nurse model. And it's been a positive one, but this is a real test. And so I'd say, you know, we have to still, we're still taking a wait and see attitude in terms of how it plays out. Well, I think, I mean, I'm glad we're starting with Southwestern. And I think as we go through the other hospitals, you know, I've noticed vacancy ratings and turnover rates, you know, in most every hospital presentation. And, but I don't have a sense of, you know, kind of what the spread is. And we'll kind of keep tabs on that as we go along. Finally, so your construction fund, I think that's that you've mentioned is not in your domain that's in, in this in the organization that you you're aligned with. I'm just wondering if, if that fund is under stress, you know, given, and that and that it's a stress point we can't see because it's, it's not on your books is, but do you have any sense that that that fund is holding up pretty well. If you're talking about the funding of the project, our fundraising has been, you know, we're over $16 million of fundraising related to the project. Some of the cash that has been received. We have transferred and we have kept as liquid as we can. But I wouldn't to be totally transparent. It did take some hits in the beginning of the year. But we have a cash drawdown plan. So most of those investments are sitting, not all of them, but most of them are sitting in short term investments. They're not taking some of the hits we took in June. And also to be totally transparent didn't get the pickup. We got in July. Okay, so, so, you know, wherever you have money, it's under stress today, compared to where it was a year ago. But we are continuing to fundraise. And those funds are available as well as the construction fund, because we did refinance our existing debt and took out some new debt. Those funds are all in short term. And so they're not gaining anything, but they're not losing. Well, thank you for that. And I'll turn the light back to back to Jess. Hey, Tom, this is just real quick to your question before that. I did want to emphasize it as as Tom said, it does depend on your situation, your circumstance and your location as far as staff turnover. But certainly a prime focus and priority on staff safety and well being is what drives retention. Well, I mean, I mean, I've heard stories about conflict between traveler staff and regular staff. So it's, you know, it's just an arena where you've you've taken a different course and it might be the best course and it's just something we should keep an eye on. Thank you. Great. With that, I'll turn it over to board member Tom Walsh. Thank you, Jess. Good morning, Tom. And we got the pleasure of talking. And good morning, Steve and trade. I haven't met yet, but I look forward to it's been a real pleasant opportunity to look through your budget submission and see the performance. You're over a year. Some of the fellow board members have said a few things already about how you've addressed workforce shortages. I think that's great. I also heard in your presentation about negotiating with an insurer who threatened a big cut and being able to explain your situation. And I think your approach to presenting today has just been clear straightforward and with humility. And I imagine that that helped in that negotiation as well. As others have said, other board members, I think your approach to finding savings with your contracts. And with suppliers and engaging the whole staff. That seems like a very wise move. I do wonder. Do you anticipate those lasting or are they, are you anticipating one time savings from those type of efforts? So typically there'll be some one times and there'll be some lasting savings. Okay. And some of the one times may just hit 2023, but we are, I would really like. Okay, but I will take the one time. I will really, I would really like a long term savings, but things do change. And so we'll evaluate each of them and we do put them, we do put them in those categories here internally. So when we're doing some forecasting, you know, and let's just say we get $250,000 at one time $250,000 of long term. You know, we'll put that in our financial model moving forward. And, and then, and then there's always something that comes out of left field. Yes, that you can anticipate. So both pluses and minuses. Let me just add in Steve's comments to and good seeing you again. I think part of our, our longer term strategy, which is not play out in this budget is that we are moving into a relationship with Dartmouth Hitchcock that we think systemically could create some opportunities that could create savings as we retool and reengineer our operations. And I think that's what we're trying to do now is work through a single year budget budget crisis, but longer term I think we have to figure out how we can run our healthcare system differently. And I think that's we're hopefully over time will generate some opportunities for the savings that could generate to all of our monitors. I appreciate that Tom and I think you talked about some system wide interconnections and collaboration to address access issues. And I think that that it sounded like that may even extend to some. It sounds like potentially collaborating with competitors. And I think that that's a that's a good thing given the crisis that we're emerging from that's how we get through crises. Similarly, I think it might have hurt, maybe I misheard, but it sounded as though there's an opportunity for folks on staff, clinical professionals on staff to work as travelers and then return. So you could imagine that some portion of a workforce moving to wherever the biggest need is in the state for a short period of time and developing a collaborative model for getting through surges, essentially, because we may be facing them once or twice a year for a long time. A quick note about the third next available appointment. I've worked with that figure quite a bit with some work with the VA and also at DH a long time ago. Yes, it's highly variable. The only thing worse is next available appointment with jumps around a whole lot more. So it's, it's, it's a weird measure until you start to think about how do we find a stable measure to monitor over time. So please keep up your efforts there. I think the collaborative approach, again, the humility that you presented with it's just impressive. And it all comes back to me and this is more a comment than a question, right? But we're seeing in our healthcare system rising prices, leading to rising premiums, leading to patients facing higher out of pocket expenses, and then foregoing care. And they're also facing rising prices across the board, not just in their healthcare. So when they do come to us, it's more urgent. They're more stressed, frustrated, likely to become angry with us. They're less likely to be able to pay. And so our uncompensated care rises, which we've tended to address, not specifically you all, but in healthcare, we've tended to address by raising our prices. Again, this is a bad cycle. And we need to weigh, I think, Steve, your approach, we might disagree on whether to name this phenomenon that you talked about with, with board member Pelham, we might disagree about whether it's a cost shift or price discrimination. But I think you really hit the nail on the head with the secret sauce you described. The way through that is to really look at the delivery system, right? And how can we look to keep care out of the hospital in less expensive locations? Organizations in different parts of the country do make choices to try to develop care systems and engage with the community so that they can predictably make a margin, even with Medicare rates. Right. So it's a choice to either play victim to a cost shift or to look at how do we address this reality that we're in. And I just want to commend you for that secret sauce you laid out. A lot of other people are listening because you hit the nail on the head, regardless of what we call the underlying phenomenon. Yeah, just, I'm glad that we started with you, folks. It's been impressive listening to you. You can tell that you're committed to trying to keep people healthier and your budget shows your internal efforts to try to keep the price increases to slow the growth. Right. And hopefully more people are listening. So thank you very much. Back to you, Jessica. Great. Thank you. So we have a couple of questions. I'm going to start out with the charge master rate increase of 9.5 and we know that the charge master increases don't necessarily translate into one for one increases and what we'll call the effective commercial rate, right? Since it depends on the payer contracts in your portfolio. So I'm wondering if you can shine light for us on what that historical relationship between charge master rate increases and what an effective commercial rate. Your best estimate of what the experience be for your average. So, Jessica, if you, if we look at the, let's use the 9.8% that we're asking for in this budget cycle, the effective rate probably would range between, I'll say 7.75 and 8.55. I just did it quick on my 10 key, Tom, because he likes that I use my calculator from last year's budget presentation. So that's a quick and dirty. And I'm going to sit there and say, and that's probably in the 90% of our contracts. Okay, that's perfect. Yeah, and you know, there's probably an outlier higher, there's probably an outlier lower. That's helpful. And can you talk a little bit about your leverage, your bargaining power in the negotiations with national carriers versus Vermont based carriers? I'm not sure I have much leverage with either. Yeah, you know, it's coming down to, I don't feel like I have, you know, in talking to this one, and it's a small managed care organization. The negotiators focused on one thing is their bottom line. They lost money last year, they lost money the year before, and they can't lose money again. So this is a, I'll call it a ground war almost, you know, weekly calls, trying to find angles. With the United Health Care, I didn't want to mention anybody's names, but they're a national, they have not been as unreasonable as sometimes people make them out to be. And our local, I believe the local organizations that are engaged with the One Care Vermont model are, they try to work with us. But they also have demands and bottom lines that they got to meet. And as Tom, I think said earlier, you know, it's just, you know, it has to be a balance. So, and I've never felt in my 30 years as a CFO that I've never had leverage on an insurance company, you know, when I negotiate with them. But, you know, if we focus on the patient and our customers, you know, I feel the pain at times of, you know, being a consumer when I see things go up with my plan. So, you know, that's the balance that we try to try to do. And we work with them. So I could probably put this to our world, Steve, that's the balance we're trying to achieve every day here. But I'm a customer, you know, I use healthcare, and I'm a customer too. And I see what's going on and, you know, I scratch my head sometimes. Well, I appreciate that you are both hats. So, when we we hear from carriers that those rates are applied, you know, sort of across different service lines in different ways. And in fact, you know, some reimbursements may go up rates may go up some reimbursement rates may go down to achieve whatever the overall average rate increase might be. And I'm just wondering how you choose, you know, that allocation of rate increases or in some cases decreases. Is it margin? Is it volume? Is it market competitiveness? I mean, just what is the criteria that you're using to sort of say, hey, let's, you know, increase X service by 10%, but this service by only five or something. So, as I reported, many, for many years, I try to pull down all my competitors, charge masters and try to do comparisons. And I try to see where I'm high and where I'm low. And what I try to do is for the high ones, I try to pull it down. And then for the low ones, so if I come down 10 points on a high, this is an example. Okay, I may pull two lows up five. Okay, to try to try to balance it, because I don't want somebody leaving my market, okay, going to get care, because they're focused on the lows. Okay, and, and, and they're leaving, because care given, you know, outside of our service area for services that we do, I know at the end of the day, ultimately, it'll be more expensive. Okay, but if there's a, if there's some service lines that I'm low, that I'm low on, I want to pull them up. And if the ones that I'm high, where the people are leaving, I want to pull them down to keep them in. So we look at, you know, I get as much data as I can, and we try to do comparisons. Is it perfect? No. Okay. And sometimes it's onesie twosies. Sometimes I find out that a procedure done at Troy was $500 and we're charging a thousand. So I'll go to that one, look at the volume. And sometimes I mainly do one or two of them or five of them. And, okay, you got to make the decision. But other, you know, so the big volume ones, I try to balance. And in the One Care Vermont model, overall, I am 100% confident, let's say 99.99% confident that if we do the service here in the One Care Vermont model, 99% of the time, it's cheaper than when people leave to go to New York State or they go to Boston and things like that. If we can do it home, I can almost guarantee that the cost of care will be cheaper. Okay, for the services we do, and that's a real important thing for the services we do. And if we can keep it home, I think we also deliver as an organization high quality care. And Jessica, you know the answer here, but where we face a real challenge is the freestanding centers in the New York area that just, and many times can cherry pick, and they have, you know, we, they don't provide a 24-7 coverage that we do. I mean, those are tough to compete with. I mean, be very honest, those imaging centers and others that just have high volume and they have, you know, limited access. And what's important to know about what Tom just said, 25% of our business are thereabouts depending on how you want to measure it, comes from New York State. Okay, another eight to nine percent comes from Massachusetts. Helpful. So one of the, at some point, maybe, but not today, it would be interesting to know what the Medicaid reimbursement rates are for those other states relative to Vermont, but I don't want to do that today because it's not going to, we can't change that. One of the things that struck me actually about your narrative, and I really wanted to ask about this, was because most of the, it was 340B. So most of the hospital narratives referred to tremendous potential for lost revenues from all the manufacturer restrictions on 340B. And, you know, I know there's been a recent Supreme Court ruling that may, you know, mitigate some of that, and I know Biden's trying to find some manufacturers for their restrictions and all that. I don't have uncertainty around that, but what struck me about your narrative was you were the only one of the only ones that maybe the only one highlighting improved capture of 340B revenue. So I wanted to know, talking about secret sauce, what is your secret sauce? And is there something that we can, you know, that other hospitals might benefit from given all that uncertainty and downside potential for revenue loss? So, Jessica, we have stressed in our last three presentations, the downside of 340B. Right. We also are under a special, when in March, the bill was passed that we lost our qualifications for 340B, if you remember last year's presentation. However, legislation came through, I believe, was in March that extended through December 31st for us. We now re-qualify because the pandemic had, you know, the mathematics of the formula had knocked us out because of the pandemic. We're, as of today, if the fiscal year ended today, we would re-qualify into the 340B program. So, all of the, what the other hospitals talked about about the manufacturers is still here for us. However, I didn't stress it. The re-qualification that allows you to recapture, it's not something about how your data, I understand there's data reporting and there's different mechanisms by which you can still. So, all the issues with the manufacturers and the attack on 340B are all still relevant. But they were in my past three years presentation, so I didn't dwell on it. And we are re-qualifying, but what we were able to do this year is get more with some data cleanup, working with a new intermediary that helped us. But this is, you know, that's a one-time pickup. And there's, you know, we'll pick that up, but then there's going to be the manufacturers chipping away at it again. So, I probably was, I probably should have put it in my presentation and put it in my narrative, but I felt like I was beating a dead horse because it was in, you know, the previous years. So, we did have an increase and we're hopefully going to hold that increase, but that's another risk. And the 340B is, you know, it's a $5 million benefit to the hospital each year. Okay, at least. So, 340B being under attack constantly, it's a constant risk to us. And the manufacturers pulling things out is another risk. Yeah, totally understood. I was just hopeful that you had found some path forward that might shed light on. No, not much as Tom put it, secret sauce. Well, you've got secret sauce with travelers. I thought you had secret sauce with 340B. If you go first, this is wonderful because we can share the secret sauce. I appreciate that. Another question, and I also understand the throughput issues and we're hearing it from all of the hospitals this year, this issues, continued issues, this is not a new issue. It might be exacerbated this year, I think, probably related to workforce shortages and the nursing homes and all of that, but the challenges and costs related to mental health borders and also transferring patients to post-acute settings. And I think just as I'm going to put this in a parking lot, but it's a request of you to help us think about as a state, I think we need to start tracking those costs as we move towards long-term sustainability planning. And you had given in your presentation an estimate of, you know, the $1 million simply for the transferring of patients to post-acute settings. That $1 million translates into a rate request, right? I mean, we can track those dollars. We can start to see how much is it increasing commercial rates, how much is it increasing, you know, premiums because we're unable to solve these bottlenecks in our system. And that's where the long-term sustainability planning has to come in, is to understand where are those bottlenecks and what do they cost. So I guess what I'm just going to stick a little pin in is it sounded like you've already kind of got an estimate of at least the back of the envelope estimate of the patients trying to seek post-acute care and not being able to place them. But there's also the boarding issue of mental health and all that. So I just want to ask, you know, would there be some momentum from all the hospitals to do that, is to quantify it on an annual basis and also tell us what is that translating into commercial rate increases that we might be able to, if we fix the system, bring down. So is that possible calculation? Obviously not for today with your calculator in front of you, but is this something that is possible to quantify? I believe it's possible. Okay. And I would maybe it's something that the Green Mountain Care Board, the hospital association and some of the CFOs could get together to come up with a methodology and to do it. I would suggest that we keep it high level and different hospitals have different systems. So we've got to do it at the macro level because if we get too micro, then you get too many variations. Right. Yeah, definitely for a future conversation, but you sparked my interest in trying to figure out how to get around that. So thank you for that. I'm just about done. I have a couple quick more like follow up and I guess I would just say this is what I'm going to ask every hospital. So just asking you even you touched on it in your presentation, but I'm going to standardize and ask all hospitals, which is, you know, since the budget submission, if you could share any known or likely changes to federal rate payments, relief funds, donations, grants, anything unexpected in Medicare, Medicaid reimbursement rates, if you would follow up with our hospital budget team with just anything that falls into any of those categories, looking for both known and likely changes. So that. So Jessica, I'm going to, I'm going to take your question and make it a little bigger. Okay. So, yes, I think the IPPS from Medicare came in higher than I budgeted. Okay. But I will tell you on the downside, as I said earlier, the government pay or shift looks like it's larger based upon my past three, four months. On the other side of the ledger. I do know that I had to, I had to, I have $300,000 worth of additional cost of my salaries that we executed just the other day. So, I'm sure everybody will have pluses and minuses this year. So we just can't focus on the pluses. Okay. Okay. So there's, there's both sides of the ledger. And, you know, we need to be fair and balanced. But yeah, I can, I can put together something for the, for the team. And I would suggest maybe, maybe I can put something together, but maybe with the team and Sarah and her team, maybe kind of put together maybe a little template, what you're interested in looking at. I may send it to you in one form, another CFO, put it in another form and, and I'm just, yeah, so, okay. Yeah, no, that's, is that, is that fair? Yeah, I'll talk to Sarah about that. Yeah. And I'll be willing to talk to Sarah about my thoughts on it. Yeah. And I guess the last thing that I just noticed was in the budget guidance, we had hoped for some information about occupancy rates for both license and staff beds as well as average daily census data. It was I think in section under utilization, I don't have the guidance in front of me. I didn't see it in the narrative. So I'm wondering if there could be follow up on that as well. And then the other piece, and this is actually probably Dr. Dobson, I appreciated your wait times information. Didn't see anything about referral lags. And I recognize that that may be something that your systems don't have, you know, currently in place this year to be tracking. So I just wanted to kind of put a, probably more for future reference, but that's a really, in my mind, really, really important measure as well as the visit lag in the sense that, you know, I can personally my own experience. I waited three months for somebody to call me after a referral was made just to schedule a procedure that then took another three months, right. So we may measure a three month visit lag from when the appointment is made to when the appointment is scheduled, but there actually was three months before that, before that referral was made or actually scheduled. So I just want to throw out there that I think would be really helpful as we look going forward, you know, for next year's budget cycle is to start to think about how we can track those referral lags as well as the visit lags and in our processes. So just wanted to throw that out there, if that would be helpful to think about for next year. Is there any questions from board members that you just want to circle back to is there anything from a board member that's everybody is good. Okay, then given that it's 11 o'clock. I'm just going to, if there's no objections, say, let's take a 10 minute recess, so that folks can have a bio break as needed and we come back our staff will open up an opportunity for our staff to ask any questions and then we'll turn it over to HCA questions. So why don't we say we'll be back at 11 o five, if that's okay with everybody. All right. Thank you. So at that point, I'm just going to offer it up to our staff. If they have any questions. Sarah. Team. Hello. Good morning. This is Sarah Lindberg, head of the hospital finance team. The team has consulted and we do not have any questions. Thanks for a very clear presentation and transparent process. Wonderful. Thank you. So Jessica, can I just make a comment since Sarah? You know, Sarah, I just want to commend you and your staff lines of communication have been excellent during this whole process. And even though and and Sarah, it has my email address. She has my office phone number and she has my cell phone and we've had a good lines of communication and thank you for your efforts. I know it's the first year, you know, but thank you. Thank you. Well, that is great news to hear. I'm glad those communications are going smoothly. With that, I think I'm going to open it up to Mike Fisher a little earlier than the intended, but or Sam, I suspect Sam, I see you on screen. So are you the designated healthcare advocate person today? Yeah, I will start us off with questions that I will transfer over to Mike. So yeah, good to be with all of you, Sam Pish health policy analyst for the office of the healthcare advocate. So yeah, I think we're ahead of time. We'll do our best of course to keep within the time. But our first question is for Southwest is please describe your plan to come into compliance with the provisions of Act 119. As a reminder, this is the patient financial assistance bill that was passed the last legislative session. What obstacles do you expect to encounter as you begin these required changes? How do you plan to address them? I know in your submission, you said you hadn't changed your policy recently, so just wanted to ask you to respond to that. So, you know, my mic, yeah, my mic's on. It passed just a little over a month ago. Our revenue cycle team has been reviewing it and will be making recommendations to myself and then the board of trustees modifications to the plan. And a couple of the things that the team identified currently our policy talks about our service area. We need to update the policy to the entire state of Vermont. We also have to, you know, we also do give free or discounted care to residents in Massachusetts in New York when they present themselves. And probably use the same standards and the same levels, you know, and our teams are pretty proactive. There'll have to be some changes to the household threshold, the household income thresholds in our policy. And our team has outlined those. And, you know, so, you know, they're they're on top of it. I think we've demonstrated in the past that we're usually early adopters. We did not provide in the 2023 budget additional funds if necessary in charity care for early adoption. So we may have to hold off on some early adoption, but we will evaluate that. And like I said, our team is on it and we will we will proceed and be in compliance by implementation date, which I believe is July 1 of 24. Yep. Thank you for that. Related to your DEI work, I'm wondering this is a different type of question more in the health equity space. I'm wondering if your hospital conducts any training focused on racial bias and testing and treatment protocols, specifically those related to pain treatment and pain tolerance. Sam, I can't recall that that that specific narrative is actually in our training. I can certainly look. I think that's a great idea. We definitely look at bias across all of the treatment actually from the from the door to the treatment. I can't really say specifically whether pain is not pain is in there and I will look at it and get back to you and incorporate make any changes. I'll bring it to the to the huge, huge committee and have them do it because they're so good at it. Okay. Thank you. Appreciate it. This isn't more of the affordability and access space. So given what we know from the Vermont household and health insurance survey. 67% of the adult Vermont population is either commercially underinsured or uninsured. And I'm wondering if your institution calculates or estimates an inflection point under which the community you serve begins to no longer afford the care they need or they seek deferred care or less care. Well, I don't think there's a actual calculation. What I'm going to try to do is try to, you know, going back to Jessica's question earlier in the presentation. I like to keep our charges and our cost below other Vermont hospitals and definitely below New York hospitals because of where we are. Is it perfect? No, but I think I know that if we treat the patient, there's a good chance it's a low cost option. So there's no fancy formula, you know, I can I can start pointing to benchmarks on where we are compared to other Vermont hospitals where we are compared to other New York hospitals. But, you know, it depends on the individual as well. But I'm confident that most of the time we have high quality and low cost, which is kind of like the formula that we're all striving for. Thank you. And based on identify community needs, some of which you document in the last community health needs assessment that you did in 21. I'm wondering if you have any plans to work with local organizations to improve housing, food access and or transportation for folks. I know this is, I mean, Mike told trackers spoke a little bit about a hospitals are going, some of them are going beyond just the kind of direct region of care model, which I think is good. I don't know if you could speak to those activities. So, so yes, yes, yes. Housing housing is a big concern for us in our area, both for our employees recruitment, as well as the general community. So we have in the past before the pandemic, we had a program where we were, we renovate some houses and then work with either employees or outside people to buy the house who couldn't afford housing. Who couldn't afford houses and work with the local bank and do things like that. When it comes to food security, I know we're actively involved in that. I don't have all the details. I don't know if trade do you have any firsthand knowledge, but I know our planning director of planning and is involved in food security trade. Do you have any specifics? You know, just that we have a coalition as do many communities of over 60 groups that work on various aspects of community health and certainly food service and food scarcity is a part of it. Bittington College has also been doing quite a bit. And so we've been engaged in their efforts. I mean, it's really not something just the hospital works on, but we all work on collaboratively. I don't have the specifics or stats to present, but I can say that there's a high interest and it's good to keep it on the radar and appreciate you bringing it up. Well, just to add to that too, I mean, as Tray said that the Bennington College initiative we are working with for part of 10 different groups that got a $2 million grant to work on to work on food and securities. And it's really developing a number of case studies there right now. And of course, as Steve alluded to, Healthy Homes was the initiative that we did in terms of taking the stressed homes and renovating and going back to the community through our workforce or others. And a very big initiative is the Putnam Block Project downtown Bennington, which first phase of it created an additional 35 homes and apartments, which does an allocation have to be for people at need to address their problems for housing. And then also we're doing Putnam Block too, which the plan is for 50 additional apartments we've been creating online. So, you know, we've been both a partner in that investor and now we're also a tenant. So we're very engaged in that process and in our Bennington region. Thank you. Appreciate that. Oh, sorry. Did you want to add to that? Just to follow up to that, is OneCare Vermont involved in any of these efforts? And if so, how are they involved? Hmm. That's a good question. I know our care teams talk about with the OneCare Vermont care teams talk about food security and some of the social economic issues that some of the patients have. So I don't have any specifics, but I do know it gets discussed. Okay. Thank you. Last question for me before I turn over to Mike, I just wanted to provide an opportunity for you to respond to our question regarding if you had a high level contingency plan about how your hospital would amend your business strategy if the board reduced or denied your charge request for this year. So, you know, as I mentioned earlier, our budget is already at significant risk. So one of the things that we'll start making adjustments, we'll look at some services, we'll look at our capital budget. But, you know, the most important thing that we got to keep in mind is the people we serve. And I think Mike Del Treco said it, we don't make widgets, we treat individuals. So we have to maintain our level of high quality and a safe environment. So we'll figure it out. Okay. We may not have a profit. We may not have the 3% operating margin target we wanted, but we will figure it out. Because our mission here is to make sure, you know, we treat our community and provide services to our community. So we'll figure it out. And it's probably going to be a combination of things. It's not going to be just one thing. We will figure it out. Tom, would you like to add anything? Well, I think it's just important to note that, you know, we don't provide a lot of esoteric services here. I mean, we are a community hospital and I think, you know, we do a pretty good job. But when you start to see budget erosions, you start seeing an overall degradation of services. And that's kind of the insidious part. I mean, when you don't get the level of reimbursement you need, you can see you can start to do a gradual cutback, which impacts many, many people, you know, and service, you know, the service that we provide is not as stellar. And, you know, it impacts our community and you start to see in our health care indicators of equality. You see it in serious safety events. You see it in how we do with our patient satisfaction surveys. And we watch those very, very closely. You know, Trey and his team are on top of that on a constant basis. So, you know, what's it mean? It means that the overall level of care starts dropping. And that's, you know, I guess that's our concern is that I mean, we can't go out when we're not going to go out and we're not going to, you know, close down our OB service, for instance, something you hear all the people talk about. We're not doing that because, you know, if we did that, I mean, there would be people at a tremendous risk. But our overall level starts to get degraded. And that's problematic from us, from a mission standpoint. It's very problematic from the community standpoint. So, as Trey, as Steve says, we figure it out, but there is a point of, you know, really impacting our individuals in our community. And, and I'm concerned that I'm concerned about this budget. I'm concerned about, you know, how many more rabbits can we pull out of the hat to make this work. And this is a real, this is a real, real challenging budget that we've got. We've got to, you know, we've got to figure out and we need help. I mean, we don't usually ask for help, you know, and willy-nilly we ask him when we really need it. And this is one of them we have a need for. Thank you. Sorry, I have to make. Well, good morning still. I just lost, can you guys still hear me? Yeah, we hear you. I just lost my ability to see you, but I'm going to trust you can still hear me. So I want to start with, well, just a recognition that when we look at the 2021 actuals, the range of free care to bad debt is between 1 to 1.1 and 1 to 4.7. SBMC, by the way, it's sort of in the squarely in the middle, 1 to 2.3. And I guess I just want to start with a question. And I know we've had some of this conversation before, Steve. But is my presumption at the beginning that looking at this ratio between free care and bad debt, a way to have an insight about the overall functioning of not only the free care policy, but the functioning of the financial assistance system? I think you can. But one of the things that I always stress, when you look at free care and you look at bad debt, free care is really for people who can't pay. Okay. Bad debt is really people who won't pay. That's my definition according to Steve. Okay. And we work very hard. And, you know, we have a couple of real, real advocates for the patient that we try to get everybody into free care if they qualify. The problem ends up being in the people that don't want to be compliant, that we know they can qualify for free care, but they don't comply with the documentation requirements. And that's the people that end up in bad debt that are sort of in the gray area that are people who really should be free care. Yeah, you're, you're back. We see you now. So, so, you know, I want to say yes, it's a measurement, but it's unfortunately cannot hear you. Okay. Can everybody else hear me. If you can hear me, I think you should just go ahead and continue. I'm in having technical problems. Sure. No problem. So anyway, so, you know, is it an accurate measurement? I'm not sure. But, you know, we work real hard here to, you know, whenever we identify somebody, we try to get them in and if they're compliant, they get into free care. If they're not compliant, they end up in the bad debt bucket. So, thanks for that. I'm wondering related to that, what are the obstacles of shifting? Maybe this is part of the same answer, but what prevents your hospital from shifting more of that ratio to shift more towards free care as opposed to bad debt? I think it's compliance with the requirements by the people are intimidated by it. Okay, even though we have a very, you know, personable person, very, you know, down to earth person. I also think resources, but, you know, do I want to do, does the hospital want to bolster up our financial counseling just to transfer from one line item to another? Okay, to be frank, I'd rather put a nurse on the floor than bolster up my free care staff, especially when we're having challenges with clinical care people. So we work with what we got and we try to keep, you know, as they say in baseball games, keep the line moving without spending a lot of resources. Thank you. This is our last question. In response to the board's follow up questions, specifically one about affordability, you wrote, quote, affordability is an interesting concept. It's well documented that high quality usually drives costs lower, thus making it more affordable for patients. I'm just wondering if you can elaborate a bit more on this response and how it takes place in the community you serve. So, so I think I've said it, Jessica asked the question. You know, we look at our, first of all, I look at our overall cost structure at SDMC and we're on the lower side. I compare ourselves to other hospitals in Vermont and New York and Massachusetts. When I look at our charge structure, as I explained earlier that, you know, we try to keep people home. When I say home, meaning in our service area, and that will drive costs lower. And then our individual charges I try to keep, as I explained earlier, try to keep them in balance with our cost and what our competitors are charging. Okay, so, you know, an affordability affordability to a person carrying a blue cross card that has 100% coverage is different than a person carrying a blue cross card that has a high deductible plan. And I think affordability is actually in the eyes of the card holder and the individual and affordability is very different from, you know, in the eyes of the person who has that goal, I'll call it the gold plan versus the bronze plan or has Medicare or Medicaid. So, affordability is a lot of times in the eyes of the holder, but we try to, at least the team here, we try to manage that and try to be respectful of all of our patients and understanding who we serve. And also, Sam, just to add to that, I think we also have a philosophy here and also a strategy of becoming a high reliability organization, one that focuses on doing things, reducing errors, doing things effectively, doing things right the first time. And as you create that culture and systemness, that ultimately does drive down costs because you're not repeating and hopefully reduce the utilization and other things that drive up the cost of health care. So I think it's a philosophical system approach that we're driving from our board on down at the health system here. So I'm back. Thank you, Sam, for taking over and perfect timing. Everything has worked completely perfectly until I started to speak just now. So thanks, Sam, and thanks. I didn't get to hear your answers, but I won't go back. I do have one clarification question in follow up to Chairwoman Holmes's inquiry about cross border Medicaid. I think I understand, correct me if I'm wrong, that there is relatively less cross border Medicaid. People coming from New York or Massachusetts over to your hospital on Medicaid. Do I have that correct? A proportion of less, Mike. A smaller proportion. So small, small proportion. There's some barriers coming from Massachusetts because they have a, they have a one care equivalent, which they try to keep their patients home. The state does try to promote keeping the Medicaid patients in New York State, but we do get them. And there are differences in reimbursement, which is my notes is a placeholder that will probably talk about it another time with specifics, which I don't have. You know, it's one of those things that I think there's winners and losers in the services when we look state to state and things like that. Okay, then one last one. The new global commitment agreement has a interesting provision in there that gives the state some ability to increase provider reimbursement rates Medicaid provider reimbursement rates outside of the budget neutrality cap. And further, I think we have a waiver from the upper payment limit in the global commitment cap. So I think what that means is that we are limited by the state's ability to raise the local funds. With respect to increasing provider reimbursement rates. And so I guess my question to you as somebody who is also very focused on commercial rates, commercial insurance premiums, whether if if we we the state was able to do a real honest effort to increase some Medicaid provider rates, whether the whether you believe that that could be translated, and whether you could support translating those new dollars those those drawn down federal dollars into a just go all the way a dollar for dollar decrease in commercial rates. So I'm going to I'm going to hedge my answer. Let's see the numbers. Let's see what the impact is. And then I can probably comment. Okay, I think theoretically, yes, but specifically, I got to see the numbers, because if we get a 1% increase, you know, and everybody's going to say you got an increase. So so we have to we have to see the impact. But but but conceptually, Mike, that was that was one of the drivers behind us going into the whole one care program and was moving towards equalizing the reimbursement rates from all the payers and hopefully taking some of the pressure off the commercial side. If the governmental payers kind of ante it up appropriately. So I would say, very yes, but as Steve said that the devil's always in the details, but I think it's, we would certainly sit down with interest and look at that with you guys. Talk about it. Well, that's good. I think I'll just say, you know, as from the advocate's office perspective, I think it will be easier for us to fiercely advocate for that with an agreement that there will be a dollar for dollar transfer of those monies into reduce commercial rates. Thanks so much. So the questions I have and thanks for thanks for the interesting morning. Great. Well, thank you. I think our last item then is just to open it up for public comment. So are there any comments from the public? Yeah, I see your hand raised first. Welcome. Can you hear me? Yeah. Okay, so I just had a quick list on your macro trend, just a little bit of clarification. Your overall trend is a plus or minus. I know you can balance it out in the budget, but a little more on where you see that trend going on your workforce. I was wondering, you have traveling, while people that are traveling nurses, whatever that come in, but you have traveling teams, because I thought I heard you say like mobile. Is that teams or is that people on your wait times? I was wondering as you work this through, can you actually get more in person visits or are you going to diminish wait times by creating virtual visits. I know there are pressures in there. So I was looking for more information on that. You're bad that I want to push back. I think it's an assumption to say that people with bad debt can afford to pay if you've got a bronze plan and you max out over a medical event that maxes out all of your out of pocket expenses at once. That that isn't necessarily I can afford to pay. That's a bad debt that you're so fast and so hard that you can afford to pay it. So I just wanted to push back on that a little bit. And I'm sorry. And I'm sorry, this is the reporter before a response is given. Could I please have your name who asked the question. Oh, deal. Sorry, I never did my name. Could you please fill your last name for the record. A. C. K. E. T. T. And you can put a he on the end if you want to make me from Canada. Thank you very much. You're welcome. Food security when it comes to food security, I was concerned about people especially that have certain medical conditions and has special diets. That's where I see there is a major factor in terms of sure I can hand them food, but based on their medical condition. That doesn't mean that they can actually use it. Well, that is last across the last one off. So sorry. That's kind of a long list. I went through it as fast as I could. Thank you. And I couldn't keep up with the list. So hopefully we'll we'll I'm going to go to try first to talk about wait times. Yeah, so I mean, the short answer to that, Dale, and thank you for pointing that out is that our desires to have patients seen in the right place, whether that's virtually in person in a specialty center or in an office. So we work to we were working to improve access in all of those areas again to what's most appropriate, you know, telemedicine has a strong role, but it is not by any means people hear me say this all the time. The answer to many situations that require inpatient relationships further with telemedicine. There's some idea that you can make magic providers and those people serve on, you know, telemedicine. That's not true. You still have to get the position and advanced practice provider involved and many of them don't want to sit around and do telemedicine visits all day. There is they lack some of the knowledge that they would gain by the in person visit. So, you know, in short, we'll put the patient physician relationship where it's most appropriate to improve access. So I got a couple of other things related to the travelers. That's a term that we use Dale. When we bring in outside contracted nurses or or professional staff. So we we try here at Southwestern, you know, as we explain the presentation that we're trying to maintain our staff and use our own staff, but if the need arises, we can go out and get travelers and bring travelers in. So just to add to that, again, Dale, this is more future but in our discussions with Dartmouth, we have talked about the concept of creating a cadre of travelers that could go around to all the system hospitals that help in their their workforce needs. So that may be that kind of goes to your terminology of a traveling team that can provide assistance. So not in place today, but certainly being actively discussed. I really like that idea. Thank you. So going to the comment I made about bad debt knows who can't pay and won't pay your example of a person that has high deductibles and and can't pay. If they show up and they can't pay but yet they have insurance, there are ways for us to get them into a program. So, you know, the the terminology I use isn't isn't isn't applied to everybody but it's just a high level classification and the people in bad debt that that that can't pay. And a lot of them don't comply with the documentation requirements we have to do sliding scales or provide charity care to and if we got more people. And I think this is where Mike and Sam and and I think act 119 and just good business practice. As we as we talk to our patients who may have a challenge meeting their coinsurance and deductibles, making these programs available to them and maybe they have a $5,000 high deductible plan, and maybe they can afford $1,000. Maybe we can get them into the free care for the other four for the 4,000 as an example. So working, you know, conversation and discussion will help us move people into charity care and and I'll call it sliding scale. So, I don't know if that that helps you understand why I classify those in the two buckets. And food security is, you know, we're involved in that and one of the things that I do know are our teams that go out to the homes. We do try to help secure. We have nurses that go out and follow up with patients in their homes and we make sure that they have the right food. If they're diabetic, we make sure we help them get get food if they're elderly and they need special needs. They help. It's not perfect. And it, but it is a start and I do know that they they do secure some food for, but it's not for every patient. Thank you. Yes, it does very much. Thank you. Great. Thank you for your questions, Dale. Are there anybody else? Is there anybody else from the public that wishes to make a comment? If you do, you can raise your hand. You can actually speak now since I don't see anybody with our hand raised. If somebody's having a hard time raising their hand on the teams, feel free to speak up. Chairwoman Holmes, can I just like for sure here? I just want to say out loud that due to my technical problems, I've had a hard time hearing some things, but I very much appreciate the answer that seem to judge and just gave. I think it's important and we look forward to working on that. Great. Okay. Is there anybody else? Is there anybody else from the public that would like to make a comment? Hearing none. Hearing none. Tom, Steve and Trey, I really want to thank you very, very much for your clarity for your candor as always today and but most importantly for all that you're doing for your community. It really came through in your presentation and I really appreciate your approach and that commitment. I want to say, you know, I agree with my colleagues on the board. They've said this, but I really think it's true by going first. You have really set the bar high for the hospitals that will follow you. Not only with the innovations you have going on, but your proactive steps that you're taken to retain your workforce and to, you know, find cost savings and to build a real culture around delivering affordable care to your community. And the other innovations that you do are, you know, admirable and really highly valued. So also if you can share my thanks to your staff, because I know it takes a village to do what you're all doing. So the three of you are here, but I know that there's many, many, many behind you that are that are helping out.