 Good morning everyone. This is our fourth and final day of hearings on hospital budgets. You might want to say that we saved the best for last year. I'm going to start out, Pat, if you could give us the normal drill. Sure. I'll take you through the agenda for today and then a brief timeline of the hospital budget process, and then just a word about the role of the board. So after we do this timeline, we'll hear from National Scott & Nate Hospital Health Center, and they're all, let me pick up OIC, and then Springfield Hospital will join us as well. And then Vaz, Jeff Teeman from Vaz will then sort of do a wrap-up after we hear from Springfield. And then time permitting, we will begin the Green Mountain Care Board's discussion. In terms of the timeline, we received budget submissions in early July from each of the hospitals. Our small but mighty hospital budget team, and I want to really call out Kelly, Mary Perry, Tom Crompton, Harriet Johnson, and Christina Gloplin as well for really pulling together during this extremely digital time of the morning. But July and August really are devoted to the detailed staff review. We provide each hospital with our staff analyses on July 30th, and then heard back from the hospitals in response to our questions by August 10th. This is our last day of hospital budget hearings, and the deadline for public comment on the hospital budgets will be September 10th. The Board will pretty much immediately begin discussion that is in public meetings and will ultimately make decisions about each hospital's net patient revenue, and it's rated by September 14th. That meets our statutory deadline of September 15th. And then written orders will be provided to the hospitals by September 28th. Again, that meets our statutory deadline of September 1st. So that's the timeline. The next slide shows some resources that are available, links to the hearing schedule, but since this is it, that's pretty irrelevant. In fact, today, each hospital's budget information is also on their website, and that's linked as well. And then there's a link to provide public comment or can also be emailed to Christina Gloplin. Just a quick word about the role of the Board in this very complex process. The approach of the Board is to establish broad parameters for hospital budgets. And that includes net patient revenue, including the aggregate amount, the rate of growth in net patient revenue, and also includes for the last couple of years the Board has provided an allowance for eligible healthcare reform investments. And then in terms of rates, it's what the Board decides on as an overall rate increase or decrease charge to payers. The Board doesn't set individual salaries, it doesn't set wages, it doesn't set charges or prices for individual hospital services. That's really the role of each hospital's leadership, but rather the Board engages in broader decision making around hospital budgets. So I'll turn it over to Susan at this point to talk about the public comment that we've received today. Yes, thank you, Pat. To date, we have received over 350 comments. The vast majority of those have been related to the nurses' contract at the University of Vermont Medical Center. We have shared all of those comments with the Board. We have read them. And I just will reiterate that open comment is until September 10th, and you can do that either by emailing us, by calling Christina at our main line, or electronically, as I said, in L.A. And that's the update on the public comment, so I'll turn it back to you, General. Thank you, Susan. At this time, I'd ask that all the people who are going to testify, and I'll discuss if they can raise their right hand, and of course the Board will swear about that. Do you swear the testimony you're about to get shall be the truth, the whole truth, and nothing but the truth. Yes, I hope you got it. Thank you. And Dr. Harris, whenever you're ready, take it away. We're ready. And everyone, yes, go back. Okay. Thank you, Chairman, and the rest of the government, the care board, for the opportunity to testify to tell our story about what we're doing with Windsor and Woodstock in Hanover. It's more than just presenting our, I think, our budget, our financial performance. It's telling our story about what we're doing in the community. I'd like to introduce my team up here. To my far left is Wendy Fielding, who's Vice President of Financial Planning for Dr. Pitchcock Health, which is the health system that I'm understanding hospital health center is part of. We have left this piece of paper, who's our controller. And to my right, the example, many of you have had a lot of histories with Dave, and I'm thrilled to have him on my team. Most states. So we really want to see if he will stick to the agenda and the kind of questions that were posed by the board. Last year our discussion, I think, went far afield. So it's quite long, knowing that we're the 13th of 14 hospitals to present. I pledge to not take quite as long as last year knowing that that is equal to our. So we're right into our overview and our mission is to approve the lives of those who serve. A quick comment on that picture. That is a rehabilitation patient in our vector gate training system. This was a significant investment for us as we renovated our rehab a couple of years back. And one of the only health systems and more than one of them that allows us to help skilled patients and multi-trauma patients learn how to walk again. Our board chart, as you can see up top is Dr. Pitchcock Health, our health system of which we are a system member. This is Dr. Pitchcock Medical Center in Levin, which is our nutritionary partner in care, our AMC, Alluspec Day Hospital, Herculeactus Hospital in Levin, New Hampshire. Oss is with your hospital for co-operation, otherwise that is not a step in. Visiting the nursing hospice of Vermont, New Hampshire is a recent member of the health system. They are in a web of rejection. And Cheshire Medical Center down in Keene, New Hampshire, which is a medical center that the health system is setting up as kind of the in-between center. Not quite an academic center, more than a critical access hospital. Added capacity for those folks that are too sick for critical access, not but don't require the level of care at Dr. Pitchcock. And then we have to squeeze into London Hospital as well and London, New Hampshire also a critical access hospital. And just a quick point, historic homes that run these is our assisted living community in downtown Windsor. So on those nine glasses, I show this slide in every presentation I give. Regardless of the audience, it's our 416 employees and 192 volunteers from across our three clinical sites, Windsor, Woodstock, otherwise known as the AutoPitching Health Center, where we have primary care pediatrics and cancer services such as therapy in Hanover, New Hampshire, where we have an ophthalmology and optometry practice. Since our DHA's affiliation in July of 2014, we've had over 6,000 referrals for post-acute and web. It has acute rehabilitation patients down to Windsor. In that time, we've had a web over at this point, 1,600 admissions for post-acute care, who are sleeping in acute rehab units, averaging somewhere between 5 and 600 admissions per year from Dartmouth Pitchfork. And a quick note on that, that really is one of our strongest niches within the system. We're able to decompress Dartmouth Pitchforks some of their, and we are I think known in the system as taking their sickest post-acute patients. We have a robust hospitals program that allows us to take all of those folks year after year in that increase of tertiary and primary care beds at Dartmouth Pitchfork. In 2018, we've been pretty busy. Our average daily census has been about 22, I'm assuming in the acute unit. But at 8.5 in the acute rehab, oftentimes it's all 35 beds in the hospital or apartment. We view ourselves as the test pitches for all things integration with DHA at Dartmouth Pitchfork Health. There's a wing of our hospital that has not engaged in ways to manage expense, to increase service line activity, and otherwise try to benefit from being part of a larger health system, which I'll add to editorial lines a little bit. I think it's really challenging as a particular access hospital in the world, or that we're not being part of a larger health system and I'll get into reasons why I think that soon. But we've integrated our finance teams. We've done a lot of work in supply chain and materials management. I think Dave will comment on a few of the real significant savings that we've obtained by doing that. We've integrated our pharmacy. We're part of a regional lab service. We have DHH as well. All of our radiology is managed through Dartmouth Pitchfork as well. That was a recent change that's in January of this year. We're part of the system prevention committee, and I sit on the system prevention committee for Dartmouth Pitchfork Health, so we are moving toward one medical staff for DHH Lebanon and all the member partners. The hope is that at some point get to a time where physicians, other providers, nurses can move throughout the system freely to fill holes in staffing when needed and help hopefully ease some of the workforce stresses that I'll talk about in a moment. We have coordinated all of our specialty service lines. I've got a slide coming up which will exhibit that. And we're involved in system-wise strategic planning. The health system at large is undergoing a, say, robust and prolonged strategic planning process. And I call that a hoop, really a hoop does what I've been aware within the system. We feel pretty strongly that we are fulfilling the roles that DHH would like us to be doing. That said, I think some of the other partner hospitals or affiliate hospitals are a little bit more of a struggle when Dave and I were up here a few months ago to talk about critical access hospitals. We shared some of our sentiment around the challenge of the boom-bust cycle of small-hospital finance and budgeting. And if any of you recall, we talked about the glory days when you have a few orthopedic surgeons doing a ton of cases and your bottom line looks great, but eventually those folks get tired of taking a call every other night and they bail and the finances have a tendency to crater after that. We have consciously moved away from that model in the last number of years. Our role within Dartmouth Fish and Health being 20, 25 minutes down the road from the Academic Center and we really don't need to have a neurosurgery program or even we've gone to that orthopedic program over the last few years as well. And what that has done is put pressure on us and the management team to make sure that we can still keep the lights on doors open, pay the bills by not having those high-reverse specialty services. So our current service lines are listed there. Everything you see in red font are services that we're able to provide because of our affiliation with Dartmouth Fish and Health. I'll point out cardiology as an example because that's a brand new service line brought on over the summer. We have the volume or the deep pockets to support a full-time cardiologist. We're really even a half-time cardiologist. We're a small community, and we identified a need based on the number of patients from our Windsor Health service area just by studying ZIP codes, all of the folks that go up to get cardiology care at BH. We identified the need for a day and a half of cardiology services by working with BH. We're able to get one of their cardiologists to come down the day of the week and that's been a great addition to our services. But everything from pathology through GI to our telehealth programs and emergency medicine and psychiatry, we're able to pursue those because we have to, again, work part of the affiliation. So I'm often asked what keeps me up at night, and I would say last night there was no exception. It's workforce. And it's not just MDs and nursing. We often think of traveling nurses, but we have travelers in our tech positions, lab techs, radiology techs, respiratory therapy. These are mission-critical positions where we currently have travelers in high-end dependence on those providers, both in nursing and physician roles. And I put some DH data up there just to emphasize the stress of our region and really we're moving around workforce issues. DH has at least 700 vacancies right now throughout the institution. We have about 40 plus, but that roughly represents about 10% of the needed workforce at both institutions. And I know that other partner hospitals really struggle as well. So I'll give it to you a little bit more of why I think we're having... The acuity of the workforce issues has come about with that in a few minutes, but this is what keeps me up. This is what dominates our discussions and seek a leadership level on a daily basis. And just to bear that out, our travel costs have increased from $275,000 this year to 2017 to a projected total of $1.2 million in fiscal year 2018. That hurts. Generally, now that we've been deeper into the workforce is our issues with primary care. We've had a significant amount of provider turnover over the last five years. I dug a little bit deeper with digging into the primary care literature and some recent studies have shown that the average length of your first primary care job out of training is about three to five years. So the days of moving to a community, to a community, hanging out at Schengel and practicing for 20 to 30 years, at least in our negative woods, that has passed. Looking at ACGME, that's the American College of Graduate Medical Education, serving data for new residency graduates and where they want to go work. This is a survey data that's published every year showing that the vast majority prefer urban support for practices with a population-based gradient of $100,000. Certainly, it's not wings or wind stuff. We suffer with training partner. Our spouse stresses of relocating to rural areas. We run into situations where one partner loves the job, loves the area, but is wondering where their partner or spouse is going to work, whether they be an attorney or an engineer. We have a little bit of a buffer because of our close location with Dartmouth-Pashtock and Hanover-Levin region. We have a little bit more industry than some of our colleagues or glasses hospitals, but it still remains a stress. It was a stress when I did all the hospitals for recruiting for Dartmouth-Pashtock as well. And then we're going to be in a position to provide a burnout like all of our hospitals across the state and across the nation that have electronic medical work or work that are turning trainees away from primary care. Other hospitals, I'm sure, we've grabbed back a financial and operational uncertainty as far as the ACO, the all-fare level. We've been in Medicaid for 18 years. We were the first hospital to sign our contract to go into Medicare and Medicaid to do cross and shield programs for 19. So we're at full risk. We've had a little risk creep. And I'll explain that when we, none of this data was available for our budget submission, but as the summer progressed and we got more information for one care of a month, our estimated overall risk was only about $990,000. That was the estimated maximum downside risk for entering programs. That seems to be creeping upward, now closer to $1.2 to $1.3 million depending on which hospitals enter. As you all know, our risk depends on the risk of the whole system. And full disclosure, I'm on the board of one care of Vermont as a DH pointee. So it's one of the family members so depending on which hat I'm wearing, I'm trying to recruit as many hospitals and practices into one care because when I put the CDO, my scouting hat on that's going to lower all of our risk. If folks decide to bail and I'll pay a model, then the folks that have committed to it, our costs or our potential risk is just going down. And I will add to that about $260,000 in one care fees as I sometimes say, paying for the opportunity to take some risk. But we're ready. I've described it to our board as this is an incoming time. We can keep moving our feet chair because at some point, you've got to let us watch over you. This is what's coming. And I'm going to leave it as an internist before we're primary care done. We have a predictable Vermont revenue down because of this entrance into the off-air model but we still live in a future service world around our handshift patients which around 30% of our businesses coming from New Hampshire because we're a border hospital. So the communities in New Hampshire Cornish, Plainfield, Merritt and Claremont, we get a fair amount of our business from there. And then back to the risk side of things, all of our high-cost tertiary care is provided outside of our health services. It all goes to the government hedge fund. More than a round of oral retreat, when we dove deep into our high-utilizers, it's the patients that need a new cardiac valve or a bypass or have a long misadventure in ICUs at other hospitals, usually DH. Or it's honestly we identify pediatric psychiatry needs that are happening down the brown world. Now thankfully, both of those institutions are generally low-cost compared to a lot of other pediatric centers across the country. But we have a very low control over what happens there. Last of my list of issues is really the opioid crisis. I said we, maybe it's just me underestimated the effectiveness epidemic on our workforce. I, after holding an opioid summit at our hospital, and believe that's the hospital that did the same in their region, I think we have just woefully underestimated both the effectiveness of the work that we're doing, and the anonymous folks that are not just not really contributing to society, but are just not in our workforce right now. While our HSA does not have any way to list for patients looking for or have us looking to get into recovery, to get MAT, and our primary care doctors if you look at the BKMS data, that's the Vermont prescription monitoring service data. Our most recent reports in the Latinx over 2017, we're actually the lowest prescribers of opioids, of new opioid prescriptions in Vermont, and the second lowest in new prescriptions for benzodiazepines. That's all great, no waiting list, we're not prescribing opioids, but we are still failing, and the beauty of pulling a side together that has law enforcement, management, actual addicts, and folks in recovery together is you get a real accurate picture of what's going on in the community, things like the Narcan party, so I mean, designated drivers when folks are actually using intravenous opioids that are not using the data that they're learned up with Narcan, so they can go around and provide the Narcan as needed. Here are first responders that are saying we're going back to apartments seeing, you know, 10 to 15 empty Narcan delivery prices in the apartment, so I feel like personally it's a fail-in that I missed the boat here, so I'm going to turn fiscal year of 19, calendar year of 19 into a hard reduction year, and that's going to take a lot of work because all of the stakeholders in our community are not on the same page as far as prescriptions, there's still a number of folks that they're going to substituting an opioid for another opioid, and we're just propagating, we're extending the problem. It's going to be my job to focus on hard reduction, and I think those are things like needle exchange, which I think will be a tough sell in our community. I can put, you know, pie to sky, observe the injection centers that are probably way down the road, but a real concrete example of moving toward hard reduction would be starting an AT in our emergency room, so folks that show up in our emergency room would be either looking for an opioid or in mild withdrawal. We need to have our providers giving the first or second dose of Suboxone and getting them into a community partner the next day to start therapy, and that's fine, you can do it. I'm not exaggerating when I say that our stakeholders are not on the same page, but it's going to be a project, and I have to convince folks that yes, we're exchanging their needles, but what that does is it reduces the risk of HIV and reduces the risk of hep C. I've had a number of young patients this year, there are 20 to a few diagnoses of hep C because they're in real use, and that's something that I think we can really get impact on. And then we have to talk about direct outreach acts. I'm handing them off to David. So we're going to talk for a couple minutes about some of the risks, and I know you've heard a lot of this already, so I don't want to say I'm going to gloss over it, but there are things later in the presentation that I would rather spend time on, but certainly you can direct questions or even now, as far as I'm concerned. So risk, well, we signed up for the three risk programs, but we did not have the numbers at the time of submitting our budget beginning of July for you folks, and so that by itself was fairly risky now. We threw in about $250,000 of potential reserves in our budget, and plus the $70,000 that we are carrying currently for our medications now. We estimate that our additional risk that is not covered in the budget we submitted to you is somewhere between $100,000 and $500,000, as the needle continues to move during the course of the summer. Our biggest concern is that we have a small end, and we don't have a lot of covered lives, and so taking risk on 4,000 lives is probably not an actual way of making decisions, so but we're going to make our best efforts. And the other issue that's hanging out there relative to the ACO is that the critical access to the awful cost settlement piece has not been ironed out yet. I think there's a theory to get through the first year that I think is valid and will work but the data coming from CMS that's been tested recently with another facility has not been even close to accurate so there's some consternation there and likely to cause some additional issues going into year two which we have to elaborate on later if you'd like me to. Staffing recruitment, Joe has already talked about that and then generally as a small institution we have a small end we manage a small end so when we have 13 visits to the ER a day one or two visits starts to change our metrics pretty significantly our average daily census on med surge and swing is 22 it doesn't take much two patients is 10% and so we really on a daily basis struggle with managing staffing to accommodate the current volume and then uncontrollable inflation, pharmacy and those things which we've heard in other presentations for short. One of the things that we've really struggled with the last few years I think we've done this very well I think the results have been pretty good the Dartmouth Fishtalk Health expectations of your member of hospitals our needs for our community and our employees getting ourselves ready for HCO and all payer model and at the same time trying to accommodate your desires for our performance and none of those things line up by the way they're all different so we're trying to find ways to mitigate the differences and try to serve in this case four masters we're also bumping up against nursing home medicaid census limits we're as the largest subcube recipient from Dartmouth we're having a number of patients who are unable to get into a nursing home in Vermont or New Hampshire and many of the for profit nursing homes are now having the percentage of medicaid beneficiaries that they will have in their facility which causes a backup within the acute and subcube census Dartmouth Fishtalk Provider staffing as Joe referenced earlier we've had a reshuffling of the gap for services throughout the system some of that was positive some of that was negative but ultimately the tertiary facility needs to be adequately staffed so at the end of the day it falls short in cardiology for example our day of cardiology could be at risk because it's most important that the tertiary facility maintain the level of quality and staffing that they need we have the individual mandate we talked about that at the Blue Cross meetings and the ongoing increase of out of pockets for short patients as always and I mentioned this in April when we were here I'm always concerned that other operating revenues is a growing percentage as a contributor to the bottom line 340 people have talked about that being limited or move every single year meaningful use funding we have one more significant payment coming for Medicaid and then we're kind of done that's going the way that's been a couple hundred thousand years grant funding as we all know he's always at risk and has always been at risk so we try to use grant funding to support many of the initiatives that we've been doing before all payer model in the ACO but we're finding that more and more necessary to provide those services that aren't reversed in any way, shape or form opportunity so this is probably something we're probably not going to be happy to hear from you we're doing a capacity study at Dartmouth-Wishaw Health in the United States it's a great plan and we're looking at capacity as it relates to a lot of Scottie we're looking at primary care operating limitation as potential avenues of capacity that we can offer to the system the good news is generally that is bringing in adults that are going through out-of-state providers into the model or back into the model operating in particular we have a great deal of capacity on the inpatient side it's making one or two patients at a time it's about what we can effectively manage and primary care we continue to operation and address primary care and get back to a stable place in that program there's probably some capacity there unfortunately all of that leads to increased revenue now from my thinking and we talked about this in April when we were here I'm super concerned about our pricing levels and this would provide some opportunity pulling some money in from some other places meaning over the line across the river that we may have an opportunity to do some price adjustments in the future ongoing integration efforts we have as an affiliate member hospital of Dartmouth-Lichfock Health we essentially get Dartmouth's discount there's pure discount levels with GPOs and for much of what we do because we are a member hospital and essentially owned by Dartmouth-Lichfock Health we are getting the maximum discount on most supplies and pharmaceuticals what we've really approached this year is taking advantage of group buys for a capital product and I'll just give you a couple quick examples we bought a favorable emulsifier we had to replace our the unit we had normally the market is about 120,000 for that item I beat them down to about 110 and then we had Dartmouth step into the discussion and price dropped down to 85 so fairly significant gains on a lot of capital for them because of that relationship and then regional service pricing one of the things we're looking at is where's not only the best cost from an expense perspective to offer services within the system but also what's the reimbursement cost where's the best place to have that patient so those are some opportunities that we're looking at currently with Dartmouth-Lichfock the this next item I'm going to get to a little bit later and this if I'm going to editorialize on anything it could be on this particular subject it's my hobby or subject for the moment and we a part of a buying group from NIA that Dartmouth has led for a number of years include member hospitals as well as other regional hospitals they have no real affiliation with Dartmouth and they access to the buying group we build the overall stand with increased discounts for everybody from Dartmouth on down and a few years ago we get much more benefits through that I broke from the herd and I moved all of our mail orders for our pharmacies pharmacy benefits for our employees to a free 4 to 8 mail order model which is the only one in the year doing that and we saved about $100,000 a year a year out so it's been a couple of years this year and going through our new process which we're actively involved in as I sit here I really push hard to change PPMs for the entire group and establish our own formula and I'll get to why I push on that later but we estimate that that's going to be another $100,000 coming off benefits for the young coming year additionally we've got a little small here in Washington about $75,000 to maximize our free 4 to 8 benefit within the four walls of medications to administer the patients and that is really the last area that we have not maxed out and we'll be working on that we just started actually next issue is access and this slide requires some explanation in general we have the wrong kind of access we have a shortage of what I call panel level providers so doctors and nurse practitioners who can manage panels of patients in a classic primary care physician model we are still rebuilding after a significant exit over the last few years we're getting close I think we're one or two providers away from what needs to be but that WL is a waitlist if you are a new patient never been seen by anyone in the last company a system previously if you're not an employee employee family in front of the family we have a lot of exclusions so it's a very it's a vanishing small number of patients actually going on the waitlist but it's accurate to say we have the wrong kind of access we've got plenty of same-day access if you if you're an existing patient in our panel of folks and if you have any issues typically it's the same day but the latest by the end of the next day we actually added capacity in our Woodstock clinic and general surgery is the same story and I would say this is for non-urgent, non-acute referral to general surgery if you have an acute or urgent issue we have standard access for our surgeons as well there's a lot on this slide and I know in the budget now that this was an area of investigation by the board so I don't want to walk into my real visual response of our blueprint data I'll walk it back a little bit but we don't have full confidence in the accuracy of the data that we get from the blueprint as part of our HSA profiles I've been a physician much longer than I've been in the industry and the joke that I have to say is our operations data is something that no physician said ever but we measure our the quality of our care through data and when we get a profile of our care practices that clearly does not have accurate data I've been finding an optimal value for doctors to trust any data and the example I'll use is when I first got to non-study five years ago I sat in a meeting where I had to discuss our blueprint profile and it said that we didn't measure the VMI of any of our care practices which with our DMR you can't walk in the door without your VMI so there was data that we were trying to send to them but because of IT related issues we had to walk out of the door and we couldn't get in and instead of footnoting the data and doing a profile it just looks like we're terror we're not checking VMI we're not doing depression screenings and the problem is the areas where we could identify yes this is accurate we need to be active on this from a quality improvement standpoint it just becomes much harder because the other provider is saying again I was one of them this is true and we've got a couple other examples about the Medicaid while child visits when we looked at real-time chart reviews we felt that the data didn't accurately reflect what our pediatric practices were doing again it was EMRs and IT issues not talking with each other but upon further digging into various issues that the Medicaid quality measures did reveal are to improve our referral to treatment for folks that are presenting to our health center whether it be in clinics or EV to alcohol drug dependence issues so we initiated SBIR which is screening re-intervention of referral to treatment programs and both our ER in our primary care clinics we support a full-time laid-back, a licensed alcohol drug of use counselor in our clinics as well we have grown our psychiatry practice so that we can provide a third day follow-up after just starting from mental health we are now exceeding state targets through education efforts directed to other providers and staff around control and high blood pressure and it was often a little bit of a question about the prevalence issue around diabetes and hypertension in our health service area I think that data is accurate I think we have a lot of hypotensives and antibiotics so that is why we are focusing resources on improving the control of those folks and frankly through increasing prevention efforts through 3-4-15 to prevent the progression to actual hypertension and diabetes the appropriate asthma medication management I want that to better control of our COPD in asthma patients because of the asthma medication management quality metric is a little bit of a question from a physician standpoint I'm not sure that's a great measure of quality and I think keeping patients out of the EB and keeping patients out of the intonation setting is a better measure of quality for those patients we started a QI project 18 months ago and since we do start we've been visiting inhibitions for this cohort but I think that's a better metric as I said the percentage of adults with PCPs don't report yet we're below the state average and it is directly related to our challenge in recruiting primary care physicians some of that challenge in recruiting is compensation related and I can't even blame DH like I always do if I say we can't continue with wage pressures that DH competes with Boston for talent especially on the physician side and then all the hospitals around DH are competing with DH for that same pool of docs but it's happening everywhere I in discussions with a primary care doctor right now we've got an offer of 50 grand more from a hospital in North New Hampshire and 100 grand more in the rural area of Minnesota and we just can't compete with that even if they did graduate from Dartmouth and went to Dartmouth Medical School and believe reading like a lot of our both of the docs do I I put the next two slides on here just as a reference I'm not going to go through them all because of time which I'm sure everyone was thankful for but the general take on being is that our primary care practices are at or exceeding the quality measures in most of these categories and where we're off, we're not off by much and focusing efforts to get up to at least the state average of my exceeding one thing I will point out that Davis have focusing on pharmacy benefit managers and I'm focusing on opioids for currently overdose deaths is simply too high and that also helped to change my mind that we were doing enough for the opioid identity again that number doesn't jive with no waiting list for MAT low opioid prescribing I feel like we've hit a couple it was a little bit like black wall where we're hitting a few of them but if folks are still dying it's not on production and as I said that's going to be a big moving forward I'll get it back over to David so again we've provided you with the P&L cash flow and balance sheet as requested I'm sure you've looked at that and Nazian the audience highlighted really on the P&L that we need to do things one is the 756,000 it was the best estimate for fixed income associated with Medicaid program for Canada 2019 and our operating margins essentially for human on the cash flow we actually couldn't really reconcile to this and I'd be happy to discuss with staff and whoever to kind of clean that up but essentially our increase is basically zero because it's a very even budget and our capital spending which is the depreciation it's really not going to increase four million dollars the balance sheet actually we're going to have some methods we're going to talk about in a second or couple minutes but I did a book on how to respond to this so basically we've got a total book of business so that would include the physicians inpatient ER all outpatient services where we're generating about three quarters of our business from Vermont in about a quarter from New Hampshire and so that's changing by a couple percentage points over the last few years and it's interesting if you look at it as a department level for this our our OR, laboratory radiology ophthalmology those are more like a third comes from New Hampshire and two-thirds comes from Vermont rehab inpatient rehab is starting to leave that two-third to one-third ratio and it's starting to head towards closer to a 50-50 and part of that is the result of our additional census that we were able to take in from our CON project we did number one, number two those patients were typically going to the health south down in Concord, New Hampshire and other states in the region so I think it's better for everybody involved so expense drivers and cost team again we've talked about workforce issues and the primary care issues in the ACO we have put a lot of time into our energy initiatives we were the first hospital in the state of Vermont to qualify for their highest award and we're in the 25th percentile nationally for the amount of adoption and implementation and installation of energy efficient mechanicals and much of our capital investment over the next few years is roofing replacement of roof units we've been tackling and lighting and these things to continue on that track we've done an excellent job with that it has net us a ton of money on the bottom line no but we're probably saving tens of thousands of utilities a year and we've maximizing the rebates along the way we have a great partnership with Efficiency Vermont and we're looking to maintain that and to finish the strategic plan that we've set up again I'm going to talk about that a little bit group purchasing we've talked about system integration and reduction of overhead I do want to talk about one thing some of you folks haven't been around as long as I have at least in this setting we've done a great deal of locking off of appendages so when I arrived at the end of the fiscal year 2012 and my first act of duty was to announce a $4.3 million operational loss and start work we closed the nursing home we looked at the contributions of various departments we looked at what our mission was we looked at who we needed to be when we grew up and we made some hard decisions so we've done a lot of if you go back to 2012-2013 data which I know you folks have you would see there's some very significant changes and we had a number of years where our net patient revenue didn't grow at all mainly because we were making some very large-scale adjustments in how we did business and what business we did and so as part of the system integration process again we're looking at managing efficiently and efficiency is getting rid of things that you shouldn't be doing getting rid of waste but it's also using the resources that you are paying for better or to a greater degree and with a large percentage of fixed costs that we have in the critical access hospital we do have capacity in a number of departments and in order to be efficient it's not just cutting costs it's also looking at how you use resources in total so we're actively involved in that I do want to mention insurance, we're part of the capital insurance program through Dartmouth we've had a cost avoidance of $30,000 to $70,000 a year on that program for a few years now we also initiated a program and the other member of hospitals have shattered capital stock loss for our health insurance this has lowered the premiums has allowed us to increase our cash report to $25,000 to $750,000 and then we have an umbrella policy that covers it after that we've had this in places this is our third year the first few years we were actually able to capitalize and take that benefit upon the P&L as a reduction in benefits and also build some reserves for the future so that's been an excellent program and it's one of the things that we should be doing as a system I've kind of talked about this through person and we want to touch on standardizing one of the things as part of our capital process and trying to leverage group buys for equipment not just supplies and pharmaceuticals is we're standardizing equipment so we have a number of part time providers a general surgeon who works a couple days a week at Dartmouth and a couple days a week at our facility and so what we're trying to do is as our equipment needs to be replaced and we're trying to adopt the technology wherever possible that's used at Dartmouth so that the docs are using the same equipment in both ORs that the BioMed folks are dealing with the same product in both facilities and they've been leveraging their deeper discounts that we're not able to get Joe touched on lab and RAD both of these one significant thing that doesn't get talked about a lot is that with the laboratory the radiology where all of our results are being stored in their system as well as our own system whether it's a PAX image for a CT or it's a result of a lab test and so now when we're referring patients to Dartmouth for sub-session to your tertiary care those providers there are able to see the studies that we did and not a study and not have to do with the testing issue that we've all hated for so many years the benefit of this aside from the obvious is that folks are able to get care quicker because they're not waiting for another test to be ordered and having to wait for that all of the protocols and procedures that we use within the laboratory and within our radiology suite are all Dartmouth protocols and procedures so it's totally consistent the quality is there and we've been consistent reads across the system so that's been a huge a huge benefit and Joe's reference shared staffing opportunities that we've talked about so here's my hobby horse subject for the day this is started as a consumer it drove me crazy and I've never had the opportunity to influence a change for this and I'm on the hunt now so there are three PBMs that control 80% of the market in the United States and a PBM is a pharmacy benefit manager and so when you sign up for Blue Cross or Harborville or whatever you're insured is they give a formula and it's a package formula and they say these are the drugs that are on a formula and our beneficiaries you know can only get from these and if you go off that then you need pre-authorization or you pay a co-pay penalty and that would be great if the efficacy data and the cost data justified pushing people towards certain medications but it actually does so I'm going to pull a little bit of Tom Cruise from the firm thing I may be the proud of Vicks out in the park and a lot of the smoke last probably when I'm done but I think it's an important issue that we all need to understand is basically the study we just completed a couple of months ago out of the $500,000 and send for our employees and your dependents it's about $500,000 we're projecting to save $120,000 and this is on top of the 340D leveraging of $100,000 from the other couple of years ago right off the top now the trick of this should have been well how do you make sure people are going to have better outcome it's not just saving money what's the outcome so this was entirely driven on 3 principles same outcome, less cost better outcome same cost and ideally less cost better outcome this is all FDA standardized data sets and so we went through there this graph gives you some indication of the more the guide is to the right is the better statistical outcome for the patient and then going down on the chart the vertical axis is what's the cost and some goals to push everything to the right to the bottom so we by the way only affects about 19% the $120,000 of savings only affects about 19% or 20% of the people who are getting coverage to us and it only impacts about 18% of the total drugs being prescribed in our corollary so it's not an insurmountable item to manage so I just provided a couple of quick examples this particular medication the annual savings is $20,000 a year by itself there's 14 people who potentially be impacted so we're going to go from and I want you to understand if you look at where these dots are there are two brands that are typically prescribed for this particular condition notice that the efficacy is not getting any better in other words the generic A is not moving to the right so people are going to have the exact same medical outcome that they would have with regards to A and B by going with generic A the differences were going from $57 a pill to 11 cents per pill so the formulary that we have currently is pushing people to brand A and B people aren't going to have the better expectation or the better result they're going to be hitting way too much so by changing our formulary to what's passed to the patient we're actually saving money as an organization the patient is saving out of pocket and again with the exact same result this other medication is actually going from a branded generic and I don't know if you've ever heard that before I'll explain it later if you'd like to purchase a generic and going from $515 a month to $10 a month the exact same outcome statistically speaking so these are the things we're looking at so I have published very hard to get the formulary for the NIA benefit platform change last week we made significant improvement on it the government has partnered with PDM often which is one of the big three but the condition was the formulary that we derive from this data set and we estimate for the system in this case we're going to be millions of dollars and we're going to be the same for better outcome so there's my copy of yours I confer I'd be happy to talk about this later your day reconciliation as we come up on stretch here so we have increased volume and I think that would like to point out out of this is even though we've had increased volume that volume is not something we have generated we're not running boutique services we're not pulling in some specialties we're not doing things to make ourselves bigger we're just doing a better job of being ourselves most of the volume favorable volume increases are in departments you don't market for you don't market for your emergency whoever shows up shows up and while we've had increased volume in many areas the flip side of that is that we had a decreased commercial volume as a percentage so medicators up four or five points a year today this year and Blue Cross and Immersion go down four or five points this year Medicaid is about the same a little higher but fairly close and so that's a big issue we unveiled a little bit this year because we had a favorable variance in our dish name FY19 that's being cut in half other revenue generally again we've got $162,000 that came in for the meaningful use of EHR incentive we've got one more payment coming in after that and that's gone and that does not reference in our FY19 budget so we've had some favorable 340B experience and so we just continue to work through that our expense management we're often half a percentage from July from our expenses so we're doing a really good job managing our expenses even though volume's gone up and this goes back to our discussion about what percentage of our expenses are fixed and how much capacity we have within the system or within our system Expenses Joe talked about the increasing need for travelers essentially our travel and local expenses has quadrupled since 2016 and that continues to run away from us we have some variances and salaries as we try to become a little bit more market common and offers to people and managing volume in a couple smaller areas and the benefits are growing kind of commensurate with the salaries we've done a great job of managing control we look at FTEs every single week in senior management we analyze it every hire do we do this job can it be done part time can it be done by somebody else and that's a weekly discussion in senior management that has been for a number of years and then other operating we're going to try and impose through this nothing terribly exciting here we're sure expected because we were raising this budget to be a loss of over a million dollars in operations we were because of the assistance we provided to the government by taking their subacutes and some other folks that are not money makers the government and the budget for allocation payment for those services and since we are now operating above or even we have not received any of that and that's okay for all of us this is brief history orange is what we actually did and blue is what we thought we would do it goes back to 2000 and you can see 2012 was my great first day of you guys just lost 4 million bucks and actually it was a great evening 14, 15, there were some losses 16 we made a few bucks and 17, 18 we about performed this is a great thing we look at it in context as cumulative budget actual the budget is about orange and that's how things should have grown from our operating margin over time and the blue line is what we actually did what we've done in the last 6 years is to steady the ship and I think again I'd like to remind you folks we closed a nursing home we cut out services got our full backs in services part of the system allocation process and through all of that we've kind of kept effective wheels on and through a lot of adjustments when I looked at us how healthy are we I looked at a couple things one, how would we compare you to other hospitals which is the same thing that you folks do but I also look at who are experts in the industry we know where they think we are and so we've kind of gone through small hospital ratings we're actually small in the small hospital and so we're looking at about a triple B we're a little bit low in days cash some of that is related to the fact that we've been hovering basically over the last 6 years and our CON which we funded a lot of that through cash and so we've done a pretty good job if you look at this 5 years ago we would have been speculative in almost every category so we've done a good job of trying to steady the shift in the midst of all the other changes we're dealing with turnover turnover has improved based on state averages and wages we have been really working hard to make sure we hit the margin we expect so we can give better market increases to our staff who went without spending many years and even when they got they did very much we've looked pretty good on adjusted FTEs and based on adjusted admissions of discharge our occupied bed loads to it we're closing the gap our age plan looks pretty good our recently closed out CON and we've done all this weathering all the integration changes and positioning ourselves for ACO and all payoffs I keep harping on this because I like to drive Joe crazy every day the weird prices the weird hot prices need work I've talked about this last year's period in April and I really wanted to submit a 2% or less price increase this year and we just couldn't make the dog bark we just couldn't do it and we're finding out that there's a problem under reserve for ACO as well but with our constant dish we've lost almost 400,000 in our dish payment year to year and the changes in the payor mix reserve which is proving to be inadequate there was no way I could do less than what we did for the 2.94% average so I'm very sensitive to this I have a sense about this the ACO 53 day comes out and I got the job for work for 3 days this is a consumer and a taxpayer this is really what I want to work on this next year is to leverage every opportunity we have which I do every day in any place but we really need to lower our prices and that's really important for everybody involved I'll look through these slides with some of the haste we were asked to comment on our response to whether community health needs assessment we are in the process of analyzing the data from our 2018 needs assessment and one of the reasons we've been saving a little bit longer is we made a conservative effort we started the process this year to reach more people and we have somewhere between 300 and 400 new responses in our 2015 health needs assessment we hit social media we hit 4th and July queries general stores post offices to hand out our surveys and we got about 1100 responses to the survey at this point but the things that we did in response to our 2015 survey are substantial many of you may know I'm a general board who is my director of community health she's a legendary in the state of Vermont of all the work that she has done so we can see with our the number one we identified was around alcohol and drug misuse of good heroin use and pain meds a long list of current and ongoing activities and we included a bullet at the bottom that is the overall cost of the program and I'll explain that as we move through the survey response all of our work as far as access to mental health was number two issue of the highest concern and part of that included high risk psychiatrists embedding that person in our PCN patient our access to dental care continues to be a significant problem for us Windsor doesn't have a dentist so we provide vouchers to go elsewhere we beg and plead with an area of dentists to take care of our patients we have made significant interventions in the school applying fluoride sealants directly to the kids while they're largely working in patients' vouchers and then just to provide care it's a huge issue I've offered to pay and how to subsidize practice to attract a new trainee allowing some of the changes and provide statute around dental assistance to provide more work in the community will help us but I think it's a it can be a challenging community of providers and our piano mix has been talked to attract dentists access to affordable health insurance costs for drugs we have a very reproductive person in our CHP teams whose only job is to get people on to exchanges to get people on to Medicaid we've brought in for our employees which is a grant program to help folks navigate a little bit of the healthcare maze insurance as well as affordability nutrition access to affordable food we were early adopters and 3-4-50 we show over 300 children in schools and over 1,000 adults in our community around prevention activities we wrote and distributed a cookbook it's fantastic a quick note that we want to make on this slide is Rachel's Kitchen which serves free community breakfasts which we have helped support over the years suddenly closed a certain lack of breakfast on a Friday sent a note to the community saying you have to keep this going this school was laying out for the summer so we stepped in and helped raise money provided funds and have Rachel's Kitchen back up to running on Monday morning we also provide lunches at three different sites around Windsor over the summer basically packing back bags and serving lunches for kids that wouldn't otherwise have access to reliable sort of the day when the school gets up and this built on the last slide on work with 3-4-50 and again adopted working implementation lines for bond as part of our work there and their ride for bond is really a vital part of the population and help on our ACO you know Windsor is a community that has access to economic stress not just the deal-fueling issue but a lot more than women towns when large industry closes it becomes a little more hard scrapple over time but thanks to Jill's good work we provide a lot of services and support a lot of services in our community access to primary care continues to be a big problem for us despite our challenges we get re-designated as a level 3 PCMH I recruit every day for primary care we develop a quality dashboard that is posted on our internet which allows real-time recording of and display around our access around our patient satisfaction with our primary care teams we are working through our list of high-risk and very high-risk complex chronic patients on our treated lives that are medicating now we do the same for Medicare test patients for next year we coordinate as part of our work in the HSA multiple meetings monthly with our over-designated agencies and other supporting agencies in the community to help provide care for some of these more complex folks now volunteers are over 15,000 miles in 2017 to get patients to their medical appointments to be studied or done with Hitchcock or transported or run out of our food clinic the population community health is really our overall concern about study we provide leadership for a number of organizations locally as listed there if there is a need we act to fill it if anything I sometimes have to put the brakes on Jill Lord with her correct writing and proposals because we often have a bandwidth to actually operationalize what we're promising and we're going to do but that's a good problem to have to rather be deeply embedded and working along those lines on summary of those costs we have all that up, it's about $1.5 million and about 900,000 of that is ranked donation and gift supported and 600,000 plus is direct support from the hospital whether that be covering salaries benefits grades and cumulative can underestimate the value of grant support and the work that we do in the community some of our hospital investments in health reform we also reported on what was listed as a reform investment 2016 and that was around our addition of psychiatry services at our hospital we had a contracted relationship with a nurse practitioner that frankly went out of that quality perspective, it was real maintenance and not real care our patients with psychiatric needs so we a full time psychiatrist embedded that person in clinic our team and 19 all three programs my non-clinical background my position work is in care management which for lack of a better description is the way we support and move patients through a system pre-hospital care, post-hospital care that also involves contracting with payers some arguing with payers about the service of care we're providing the dirty job that no one wants to do but I affirm with you that the build up of nursing care management resources is how we move the need of a population health standpoint so we are we call this a one care analyst but we are going to be hiring an intercollegial care analyst to look at the amount of data that we do get from one care that I believe is valid as well as reliable we are hiring a social worker to embed in primary care we've also we have hired a quality analyst a nurse informaticist to help our nurses better use the EMR as a tool to help manage our complex and chronically ill patients we're covering half of our the compensation for community health team nurse manager and we have our one care fees but all of those positions listed above in that graph is in that table that's new cost new positions in the hospital investments that I think we needed to make for a pretty significant downside risk far downside risk is 3 million on a breaking budget we need to make sure we're prepared for it I mentioned the people investments went over in that graph table we also support FGE of a couple of positions for our one care and one QI efforts as I mentioned earlier we focus on COPD patients and we actually work hard to reduce re-emissions Q2 and Q3 emissions that should be how complex is the patients I guess we're moving into that in Vermont as well to less than 10% which is a pretty remarkable re-emission and the care of our patients with CHF was identified as quality improvement so we invested in the 0.2 FD cardiology support for CHF and I'll hand back to Dave for the flight to his last year if you want to make one point that I missed in going on my hobby or for a couple of minutes and that is that one of the reasons that we're doing this with our employee benefit is if it's good enough for our employees and effective enough for our employees maybe something we can roll out to some of the other panels of patients that our doctors are managing because our doctors are managing the care of many of our employees and their dependents if we can make this thing work and I don't know why we would be pushing that towards any other panel of patients whether it's all a care model a count of care, the Medicaid program I don't know why this wouldn't be applicable to virtually every patient within the Vermont system so relative to capital this is going to be the most boring thing ever we don't have a single sexy item in FY19 at all we have nothing, it's rooftop units, air handling hot water exchange I mean it's just the mechanical stuff that should have been done routinely over the last 25 years our COO was sitting in the back and he and I had some boring discussions about what we're investing in because there's everything literally every item that is in our capital budget for 2019 is routine replacement so there's no building projects there's no new machine that goes pink in the OR it's all replacement of existing mechanicals and equipment there's no CON there's no material change there's no scope since we submitted the budget we've had to move a couple items up because we had a rooftop unit blow up two weeks ago so we're doing that one early and this is basically how it breaks out building improvement, land improvement major removal of land improvement is really parking block management because that's been very little resources at that for the last several years so we were about $700,000 we're not going to get to in capital we anticipated this year we're going to roll into next year basically our issue is we can only get so many projects and so many purchases done with our limited staffing so but again, fairly boring discussion here long range financial outlook we really need to work on our wages a bit we need to maintain our main infrastructure we're trying to keep the capital spending so we keep our Asian plan as flat as possible we need to continue to work with the standardization programs to maximize discounts for the government we're going to continue to effective the expense management and we're going to try to work on that to the expense percentage by using current available resources differently we'll continue to work with DH integration as many as we can and again, as I have on this issue we need to reduce pricing how does this relate to the all-parent model of the ACO our current management style I'm saying that over the last five or six years incremental consistent change over time this makes us more and more more predictable as time goes on we're no longer dealing with yesterday's crisis we're now working on things we've got to do today and looking to tomorrow positioning ourselves with people plan procedures to improve access costs and quality and really working on some of that controllable inflation and to reduce that we're trying to keep ourselves in mind our inflation in line with the all-parent model 3.5% growth over time that's going to be difficult when you look at the percentage of salaries and benefits as a percentage of our expenses and knowing what the market is forcing us to move to and then maintain some gas positions to go through the uncertainty over the ACO and the all-parent model budget compliance this is easy to be compliant and I did want to maybe do something I haven't done in my 20 years of oversight here in the state of Vermont so I think we put it together a pretty good budget we really challenged ourselves we pushed ourselves and I think we put together a good budget if there were two disappointments in the entire budget process and this is not considering your concerns as a CFO, a taxpayer and a consumer I would have liked to have had the smallest rate increase possible and I challenged Theresa some of our other folks let's go back and take a look at that let's rerun that data because that was really something I want to bend that curve on the other piece of it is that we have dealt with an incredible amount of change this is the third CEO I've had in the five years I've been there Dartmouth has had leadership changes and strategic changes through the entire system and we've kind of stopped to the other things we need to do for those external groups but what do we need to do internally how do we manage ourselves so we don't need to be damaged I know our net patient service revenue growth is greater than what you would have liked to have seen from us but when I look at things like the slight change in the payor mix and I look at our dishing cut in more than half and in some of these other things there's your percentage point that we added that's what it accounts for I can point to specific issues I would like you to approve our budget as submitted obviously I would like to not do a bunch of rework and reset for October 1st but I would also promise you as an individual and Joe and I have talked about this I'm not springing this I'm calling it audible the line of scrimmage I feel like because we've been doing incremental change consistent over time and every week that goes by we're a little bit more predictable every week that goes by we're getting to things we need to get to that we couldn't get to for five years I will manage to that margin I think that means price decreases in November however it takes to keep us with a breakeven margin and to do the best I can for everybody involved and my moral and ethical compass is far more stringent upon me than any year I've ever to show and Joe and I have talked about this these are things that should have been done years ago we're out of place, we've gotten stable, we're a little bit more predictable and we're willing to commit to working to that end so right now we're asking you to update on our projections for FY18 we submitted a budget for $130,000 of July came in which is usually a very slow month and we actually had a really good month so now my projections in the year is more like $500,000 well I looked at the stats yesterday for a month to date in August and guess what we're having another good month in August so I don't know if the $500,000 is a good estimate it might be a little bit higher than that the point being our continued improvement in financial performance is what's going to give us the ability to go back and deal with the pricing issues and deal with some of these things and I would prefer to manage that on an ongoing fluid basis as opposed to be regimented to an annual discussion about it I would like the flexibility to say I'm cutting my lab prices by 5% because I can and still make my financial goals so for whatever that that's it that's it a little shorter than last year go mad why is the presentation much shorter so we're going to start our questions with Robin one thank you I have a couple questions around that healthcare reform investments it looked to me in your submission that you had not requested the 0.4 NPR but I see from your slides that you clearly have 0.4 worth of investments that are new and quite frankly easily approval so I'm just wondering if you could speak to that and if you'd be willing to make that request so when Kevin Donovan was here the CEO we had our first year of off-range we called him back then and we really felt like many of these healthcare reform investments are things we just needed to do and because we're so small a lot of those investments were like 0.2 FTE it was really harder to figure out what was associated with that than just putting it in the budget so basically other than psychiatry in 2016 we have paid recovery reform into our budget much of what we're doing with the community health needs assessment has been baked in our budget for years so we're highlighting that because you asked a specific question but these are things we need to do regardless of the 0.4 or we just need to be doing them we need to have data and we need to have data that's usable and we disseminate it to providers to make changes personally I don't hear what you call it but these are things we really need to do and a couple of them we've already hired the staff to people because we just need to do them we're not getting to it and it's important I appreciate that philosophy and certainly that's where we want all hospitals to be but quite frankly your NPR is high so it helps you and it helps us so I think what we may request that you fill out the form if other board members are on that same page I think actually that's my only I'll pass it to Tom never know how close you get to this thing thank you for your presentation thank you new board member before we started the advisory process I was able to tour most of the hospitals in the northern tier and I'm heading south when this process is over I look forward to coming to your operation and spending a day with you if I could great couple quick questions I'm looking at your Medicaid projection for 2019 and it's not a lot of money in Medicaid in your hospital but it's looking like a 59% drop in your projection and I'm just wondering where that comes from what is your thinking two parts the first part is that as a percentage of our business Medicaid eroded during current year projected FY18 as a percentage of business and Medicare has gone down as I testified earlier and so that's part of it part of it is also the service mix so where the services what services are being done for folks in comparison to each other and then the second piece of my response is that we did get a call from Lori Perry yesterday afternoon we had a subsequent phone call and when we looked at it I looked at it in detail this afternoon yesterday afternoon I felt like it was a little bit overstated the network's out in the P&L but it was overstated and we probably could have done a better job what I came to learn was that what's an adaptive and then what was done and some of these other spreadsheets that are not linked to adaptive we did it based on our internal numbers you guys slice a little bit differently than we do so I'd be happy to tighten that up over the next couple days we've sat in that revised version but it will get better than that but it won't go away Lori and I did spend some time on that yesterday it was a good observation in terms of bad debt in the narrative it said I have a quote written down here somewhere but it said I think that it was basically bad debt and free care work basically tied to change when you entered another area it was not significant but there again you were looking for bad debt to go up by 29% and free care by 13% and those are big numbers percentage wise can you speak to that a little bit we're expecting some unfavorable results relative to pockets and individual mandate rollbacks I think you guys talked about that across the internet so we're expecting to get hit on that if you look at our percentages over the last several years you'll see that we've had some years bigger than that and some years smaller than that so we just fell with that mandate and some of the other pocket issues I think the total dollars is $253,000 in total between the two and certainly we prefer to categorize and process sentences with the financial assistance and free care versus bad debt but we do look at the two of them as a percent of gross revenue and so we are going up as a percentage it is actually lower it was just a few years ago we were budgeting a total of 4% for the two volumes and we've ratcheted that down but we're expecting to have a bump up next year regarding trappers do you find it hard to get a trapper when you need one is all the hospitals are having a hard time filling core positions when you need a trapper are they part of it? so I manage some clinical areas as well as financial areas and so the three really busy departments that I manage are clinical we have somebody who one moved to another part of the country and they wanted to relocate and we literally could not get a traveler in for respiratory therapy could not get one for any amount of money for a month because they're just not out there that's like the worst example and then on the nursing side we did a very good job for a number of years when I was first I got there in 2013 basically fiscal year we did a good job managing that especially in nursing areas and now with the way the market is we're having a harder and harder time and we used to have one company we went with now we've got four on contract and it's radiology tax, lab tax RT tax nurses it's a growing concern and we haven't changed how we're managing that problem we're really looking at all the creative solutions we looked at in 2013 14 and 15 and 16 when we just had a couple hundred grand a year not a big deal, really good result and now we're going to utilize a 1.2 million and we've improved wages during that time we've improved the work environment during that time we've done all those things that should have made it better but in fact we're caught in the same harass as everybody else on the on the provider side you can find locums positions they cost a fortune and I always say there's a reason why most become locums we're either welcome after six to eight weeks wherever they are and in the world of non-consistent EMRs we can't come and play positions unless you're using CERN on a community works platform we use it half of their locums assignment is spent trying to learn how to use the EMR and as I said they cost a fortune it's incredibly disruptive to bring in locums the way I dealt with it is I recently retired Docs from DH who I know from my prior life in Lebanon haven't worked in half time and that has worked well bringing in the locums from Wisconsin and we've never been to Windsor for eight weeks, three months it's a tremendous challenge in the same building with nursing where there is a flex pool of nurses or DHH for the whole system but again amongst the five partner institutions will make progress on how to consistent EMRs but there's still being four EMRs and one of the reasons that we actually brought on nursing informatics is to tell them that as well to help nurses at the level of who are doing the system be able to rely on communication but that's obvious the reason why I ask that question is I'm just wondering if there's a price point between what we're willing to pay for a person on staff and the travelers and if they easy to get a travel between where you are and where that travel cost is like a price point but I'm getting the sense that for non-physician folks in positions we have provided some incentives for staff to pick up additional shifts or why not that's good for a couple weeks but then it's a huge dissatisfaction we're providing that opportunity for some folks we're limiting that opportunity so that people can burn out as you but sometimes when we're waiting to get a traveler in that's what we do for a week or two so we're incentivizing and trying to minimize that but it's not a good ongoing solution to just work your staff no matter how well they be paid or whatever bonus money they might be getting and my last question is in negotiating the universal rates with the commercial insurers does Dartmouth, Hitchcock do that for you or do you do that on your own? so great question so I do so Niga they have some relationships with the Durham Helms & Company on a concrete New Hampshire and they provide some data analysis for us and some negotiation support and it's really being a border hospital I have to know all the New Hampshire payers and I have to know all the Vermont payers and so I meet with them once a quarter to give me a brain dump of everything that's going on in New Hampshire and then I know what's going on in Vermont with the hospital association up here I've had Dartmouth there's not one Dartmouth contract that I am a party to and there is not one contract with a payer from our shop that they're a party to we have looked at that and that is probably one of the things down the road but it's extremely complicated because they're larger they have much more aggressive terms and I'm not talking about dollars I'm talking about complicated pre-schedules and things that we just don't have to bandwidth to monitor or manage within my shop but over time as the integration continues I may be able to utilize their support and move to a higher percentage of fee schedule driven models and incentives and things like that but right now we just take care of our own stuff and so far it's working out okay thank you I'd say to talk a little bit about your relationship with Dartmouth-Hitchcock I mean obviously that's helped a lot in bringing patients and kind of shifting across the border I just wonder so for 2018 you talked about you kind of take higher acuity patients you bring them in and you have a forecast for a subsidy from Dartmouth-Hitchcock and you turn out your financials works better and it may not just be from that area or the things you're doing in other areas and so that subsidies was taken away about 800,000 and as we move into 2019 I don't know if you have much of a subsidy from them and I'm not saying that Dartmouth-Hitchcock should be picking things up I'm just saying if we are taking these higher acuity patients and maybe subsidizing them through this network and we're taking a rate increase next year of 3% and you really want to push the prices down how do we work to say what should we be getting from Dartmouth-Hitchcock because for instance if we got a $19 million from Dartmouth-Hitchcock that's 2% of your rate increase we wouldn't need and so I'm not trying to say do something unfairly but I'm saying we're used as this hospital to help offset that probably lose money on some of those patients and because you ended up making a lot more money in 2018 you didn't get your subsidy so how do we work through that? So there is no subsidy budget for FY19 The second thing is that Dartmouth's expectation of a critical access hospital would be a 2% operating margin which I don't think is underneath silver but they also recognize what we've been doing over the last few years and the benefits of the system so they were they said if you guys didn't get a break even a nail it we're happy but the second piece of it is we've gotten really good at taking these patients and managing them from a pay or reimbursement standpoint the first year or two we didn't really understand how all the mainstream Medicaid program worked and since then we've gotten really smart on the every week of care management we go through individual patients and scenario and try to come up with a good discharge plan that will minimize our pay so I mean we look at this we talk about Joe talks about it at Dartmouth in his regular meetings I always look at it because it's the area the highest risk from day to day and I think that Dartmouth would do whatever the right thing was for the system and for the patients and for us but right now we're able to stand on our own with the types of patients who are sending us and we're making it work so less interaction is somewhat favorable to me because I just don't have any more meetings I want to start with you and then the last thing that was really on the ACO was kind of the accounting of what you have to do for the ACO because you seem to have a bit of a mixed bag so you have you have about 700,000 that you're showing on your FPP for the ACO right because you're not showing the commercial or the Medicare payments but you're talking about a reserve of a quarter of a million dollars you have ACO fees of a quarter of a million dollars you're talking about a miss potentially you know up to half a million you know a reserve a risk issue of a potential up to a million dollars so I'm having trouble a reconciling that and the other question which we as a board are kind of struggling with is how should hospitals be accounting for the ACO should they be putting in risk reserves because that could go plus or minus right and we're booking everyone if they're booking is booking on the downside where it could go either way and if in fact you are booking a reserve that's impacting what you ask for rate requests if you work the math right if you put something in and we're working the math and you specifically talked about that so I guess we may need to take offline specifically how you're recording for things but in your FPP of only $800,000 that you put in and all the risks to talk about is a disconnect and maybe because of your late signing or you're signing now and getting the other payers together can we talk to that a little bit? I think we're booking it entirely correctly and again I'm happy to have an additional discussion by fall or reverse and so on this issue the $750,000 represents what we understood to be our Medicaid fix payment for the year and so because that fix payment is not associated with any specific encounter of patient care it is not according to the accounting interpretations of the standards in this case PWC was the best white paper I've ever done that is booked as other operating revenue when the patients actually come in who are attributed to us we take care of them like we normally do we book the charges and send the bills like we normally do and that goes into gross patient service revenue we get what we call on our shop fake payments back and so on our example Medicaid for this year we book gross revenue we send the Medicaid for bill there is a fake payment that comes back electronically that calculates what we normally would have been paid in cash and the contractual that we would normally receive but they're both non-cash transactions and so that increases contractuals and that increases the gross revenue okay now for the reserve how we would book that so we say okay what's our off-sides for the Medicaid program for FY 18 it's 70 grand so that's only for nine months of the fiscal year because it's a calendar year program and we start in October so we would take the 70 grand divide it by basically 12 multiply it by 9 so that's our risk for that fiscal period and we would start booking those increments in January year goes on and we see how we're performing against the expectation we would either adjust up or down that risk on an ongoing basis to get to the finish line that we think we're going to get to which may or may not be plus 70,000 or minus 70,000 so we're not booking 70 grand in January we're booking 70 divided by 12 times that's what we're booking for the month of January and in February we will the biggest issue we're having is the lag in the data just got marked so we're going to be closing August in a week so it's really difficult to manage where you're going to go and what you're booking but that would be done incrementally in January and as our performance is better or worse against the target we would be adjusting that monthly reserve booking that runs to the P&L until we got to where we thought we were going to finish up it's the same exact exercise we use for the cost report honestly it's not that we can take off some of your numbers in here you talked about $500,000 or reserve estimates understated and that was because we had no we had no idea how many Medicare lives we had in July 1st we threw in a placeholder we knew it was going to be at least $250,000 we threw in a placeholder of $250,000 into the actual budget because we had no numbers and so now since then we've got two iterations of attributed lives for Medicare Group Cross and Medicaid and now we're seeing that instead of 70,000 for Medicaid FY18 now we're looking at a potential $1,000,000 maximum risk and those aren't even final numbers and just we are considering an FPV as a tournament even if there's a lot of positions from water things like that but the way we're going to look at it it's just a different method of treatment for services for patients but we are considering how possible is that as a tournament so I'm a bit with that and just a quick comment you mentioned looking at up side risk too because I think you're probably hearing that hospitals are looking down side risk I think that that's a safe bet for all hospitals Medicaid smaller risk order we had 70,000 so down side risk for 18 the risk order is increasing for Medicaid in 19 which is why it's actually impossible just under a hundred grand for us but if you look back historically how all of the VONS hospitals have done in Medicare shared savings programs we've never really had an assisted level shared savings a very significant a Medicaid we have done we've done reasonably well with our big spend in being in Medicare being frank very transparent here I think it's unlikely that any significant shared savings I know the initial data of all the hospitals that are in Medicare this year is that they're they're actually doing a little bit better under that program than they would in bigger service and you can probably see the shadow in bigger service data but I think that's got to come off the watch over time and I think we'll be lucky if we all are even in Medicare but I think most hospital leaders are thinking that there's going to be down side risk over and after so booking upside point but I'm reluctant to do so I think it's just booking nothing not booking upside if everybody boasts a risk in essence it's somewhat of a disincentive to do the ACO and it does impact the rate when you put the puzzle together if you want to have a bottom line and operate your profit and you're booking risk I think there's a way you can see as well I think if in all three programs for 18 actually do well better than expected I don't think we'll have any problem gaining the hermitry to the lives we need moving forward because I think most of me jumping in The discussions I've had with some of the other CFOs everybody is going to be booking these reserves incrementally as the year goes on and it's to be based on the results and so how that should have been recognized in a budget where nobody actually knows how this thing is going to play out I don't really know what I do know is that we're understated clearly at this point and I'm willing to live with the budget I submitted in that regard and try to make this thing work but the fact of the matter is that it is done incrementally and it should be looked at very often during the course of the year to see if there is going to be an upside or not and our accounting firms in order to produce clean financials it's all about the comfort and the trust of the reader and if we're not recognizing any risk and we're running towards risk then no way we're going to come into agreement with our accounting firm and produce clean financials Thank you for the presentation I'm particularly impressed by the bold evidence with respect to harm reduction and opioid epidemic and also the excellent work on the formulating redesign the one thing I would just say out loud here is I'm hoping that it can be scaled up and outward some of what you're doing and I've pointed Jeff Thiemann out there at VOS and hope that some of the learnings that you've done there can be spread to the other hospital community can there be another assumption? I would be happy to get you in touch with the resource that I started with for education purpose Yeah, that'd be great, that'd be really helpful I'm intrigued by that and especially having sat through many hospital budgets now with pharmaceutical drug pricing to be the biggest expense driver of many of these budgets we need to figure out ways, innovative ways even at the margin to start cutting those costs so it sounds like we've done that and I think we can all learn from that So the NPR obviously is higher than what we asked for and I struggle with it because on the one hand it is higher than what we asked for but on the other hand you're a ward hospital and some of that NPR is coming in from out of state and it's out of state payers it's out of state commercial medicaid paying that NPR so it could be looked at as economic development for Vermont right, so help me reconcile the big ask here with thinking about 30% of your revenue coming in from New Hampshire and how we can think about that differently And again, the big issue is how do we we don't we don't market but we're not driving business to us and so when I look at the variances that we're seeing for what I'll just use in patient our inpatient variants April long variants have been driven by general surgery inpatient procedures so we budget like two a month historically we've had tons of states the scheme of Vermont is nothing for us 300% increase of some of the most expensive acute patients we're going to have and so, but we you need to have your appendix out you need to have your appendix out when people are price shopping they're not that's all off the table they have general surgeries available you can get it the same day for urgent and emergent that's where they're going so we don't really have a lot of control over that I don't see us closing the ER in August because we had our volume for the year and we had a 30% um fatal variance in ER volume and not related to any clinic deficiency just looking at the types of patients that were coming in so we don't really have a lot of control the other thing is what's going on at Alice Tech Day Valley Regional Hospital you know, in our other neighbors we've gained or lost because of that, they're doing a really great job and something, they're probably losing if we're doing a better job and something we might be gaining we have no control over those things and so that's the driver and the payer mix comes with the patient and so we really we struggled, we went through the payer mix and the volume repeatedly and nosy you know, my analyst is sitting over here he's probably burning the hole in the side of my head because I may have to redo it so many times but I don't have an easy answer for you, I can quantify what those dollars look like coming by payer from New Hampshire I mean I can do those things for you but it's kind of flotsam it's, you know I don't have a lot of pull or influence over that so obviously workforce recruitment if they concern and I'm wondering, Joe to some degree you're sitting on the one-care board you're very happy with us I very much appreciate that you're all in on all three payers I'm wondering, we hear a lot about administrative burden and I've often thought that the all-payer model and fixed payment could potentially be an improvement tool for primary care providers we're now going to be paid for care management with these additional payment fewer prior operations to medicate I mean are you seeing being all in on the all-payer model as a mechanism to improve your recruitment efforts in terms of primary care jobs so that's an interesting question doctors that moved to Vermont are we've had a breach in the choir already I think they all could have stated wherever we trained or where we worked previously and instead we had moved up here long before the APM was in play I think we overstayed the value of the prior operator because most practices have already been supported to deal with that incredibly onerous and irritating part of the practice where the story that I tell about primary care recruitment is yes, we're part of an APM we get fixed prospective payments but even a couple years ago we have moved entirely away from primary care from any RVU metrics or incentive or reimbursement our primary care docs are a straight salary that the opportunity to earn a little bit more I call it a citizenship bonus we're serving on committees if you're doing other work in the hospital if you're doing some of the one care work they're for a little bit extra but otherwise it's a flat salary and whether you see would likely to see 13 patients in a day but we have really moved away from classic relative to benchmarks and we're looking at more wellness and outcomes I would love to incentivize around outcomes as opposed to productivity but we're not there yet either that scares people because I can't help it bringing my concerns around the quality of the data by which we measure the outcomes you know I use that for BMI I appreciate that as an example so I think that's part of the part of the story but we could see this trend coming have moved away from the RV model as in clinic operations and entirely for compensation that hasn't helped we've actually had some recent interest in some primary care providers who were interested in moving away from that model as well take a lot of the money but our pay is a little bit more by going straight to other amount of activity I can't say what a product to a driven model would provide I understand your time I don't know We can also In terms of you're all in and the all-hair model I'm wondering yourself in short I've been asking this hospital are your employees also attributed to maybe one care having those conversations with your TPA so they're not attributed I knew this question was coming We are on the life path to getting like DHH benefits all of the hospital we actually kind of dug our feet a little bit over the last couple years because it would be a significant expense for us to move to the DHH benefit platform at this time a significant year for New York people so thankfully the DHH leadership understands that but I do worry about moving those into one care attribution knowing that I have to uproot the whole thing and again I'll take 36 months of data if you want to come so that's kind of where we are and my last question that I've been asking about hospitals to this relates to the beehive and the low we don't have a majority of patients in Vermont are still not on the beehive because of the patient-consent obstacles and so one of the vehicles through which we have come to understand that we can increase consent is through electronic consent through the EHRs at hospitals and so it's apparently a very small fix to the ABT and I'm wondering that would be considerate adding that to your budget or not adding to your budget and basically thinking and working through with violence and trying to increase electronic incentivations through the EHR system it's about 40 hours of IT time so the answer is definitely yes we need a few small victories with Bible we also have not only we can work on parallel line too with our patient portal through our GMR as well to help with that so I think the short answer is yes we should have a longer answer is I really think we've got to be looking at some of the national health information exchanges because they're doing hard work to build conduits to the large GMR providers we're going to be on epic in probably three years as part of the DHH's system and they've already built pipelines with Commonwealth for example and they have been with the resources to do that it becomes 30 minutes of IT time to connect up to the Commonwealth versus 40 hours of IT time with Bible but if this is what we have to do to make sure to get there then we have to invest in it thank you very much so my first question is folks is on your Vermont and New Hampshire patient mix and has that been consistent historically so in my five years it could probably be five years we are seeing some movement in specific departments I did as part of the submission we looked at that so the rehab before we did the CON we had an average daily census of 6.2 to 6.5 we had shared rooms and limited access so we did the CON we had shared rooms and we said we're in at 8.5 and guess where we're at 8.5 what we found is those two extra patients today a majority of those are coming over the border and so we have picked up in that particular department primary care probably not so much and it's a whole different range and then there are some departments of New Hampshire business so we have cardiac rehab pulmonary rehab so it's a whole wide range but at the end of the day it's creeped up a couple of points since I've been there if we were like the wild west like New Hampshire I'd be running that thing silly and if I didn't talk to you about your service revenue I'd be trying to steal everybody I could out of New Hampshire so that's what it is it has creeped up a little bit it's not stellar amazing but if it does happen we are seeing it in specific departments or the acute rehab service line is unique it's only us who doesn't have acute rehab facilities in Vermont and we're the only car for accredited cars that commission on acute rehab facilities we measure quality and compliance really for acute rehab facilities across the country we're the only one in Vermont and most is when Hampshire is down in New Hampshire so that is a whole more self-employed Hampshire business for those patients who are actually asking about quality of outcomes in our in-degree adherence so I don't want to sound like a broken record but obviously if you are bringing patients in from out of state it's not factoring into the total cost of care and calculations for us and if you can document the delta this court has been receptive in fact he was receptive a year ago for Southwestern because they could prove to us the increase that came to them from the closing of the clinic in New York by Glenn's Laws Hospital and from the closure of the hospital that was mass and so I wouldn't try to say that Green Mountain Care Board is an impediment to bringing those people from New Hampshire because we certainly don't want to view it that way I'm assuming that Medicare reimbursement you're getting the same whether they're Vermont and New Hampshire what's the variance between Medicaid rates between Vermont and New Hampshire leaving being managed Medicaid aside so I find that Vermont and New Hampshire are pretty close in my experience the payment methodologies aren't always the same but they still seem to be getting approximately the same I have not looked at that since probably the end of last fiscal year and people will take those good glance at it but it was just commensurate the issue when we get burned is that we're not able to provide all services to all the extra Medicaid people because we're here in the state but whatever we offer is medically eligible for payment with the Medicaid programs up here so when we have sub-acute ICF level patients from New Hampshire we're getting little or nothing for those patients so there's a couple of exceptions that we have to really pay attention to in the possible budget process but if you could just take a look at that sometime when you have a few extra minutes and just let us know what you're experiencing can you break down for us what percentage of your chartmaster is being reimbursed by commercial insurance on average and again is that better or worse on each side of the river if I had my patient from April I can just put a slide up for you but I don't recall what those numbers were and were and I don't have it broken out between New Hampshire and Vermont what I can tell you is that from a commercial perspective obviously our positions of B schedule has pretty much everything in patients generally is a percentage of charge on both sides of the river and for some of our largely more significant contracted relationships we have B schedules for lab, radiology and PT but not for the other application services I actually have that information just not split between New Hampshire and Vermont but I could probably use it to do that that would be helpful if you were to get your 2.9% increase in rate how would obviously we're talking about a Vermont regulatory body decision how does it impact your rates on the Hampshire side well every service is charged the same in regards to the state of origin of the patient, the payer and that's pretty much a federal regulation so that's what your pricing would be but your reimbursement would be different our commercial rates on both sides of the river are pretty close there's not a lot of difference between Anthem and Vermont probably venturing into territory I should be venturing but that's not the case so as a percentage of your chairmaster again what would that percentage be for commercial reimbursement I guess I don't understand the charge master of that question so say thank you to that and we'll use simple numbers procedure that's $100 what percentage of that $100 is going to be reimbursed by your commercial payers well it's going to well I can't give you that percentage but it's in your schedule you can actually see it in your schedule so I guess I can share if you get $70 you can realize out of that increase and then it would be similar on both sides of the river with a percentage point or two does that help it does I guess my point is that if you get a 2.9% rate increase you're going to get 70% of that from a commercial payer yeah from commercial payers we're going to get zero from Medicaid exactly on workforce has Dartmouth considered trying to do anything with scholarships or anything that would entice students to stay within the system there are L&A or licensed nursing system training programs that DH is sponsoring we have reached out to community colleges to do the same talk about the topic of scholarship opportunities for some students or high school students as well and so we already support that also I think we need to more of that I think we need to identify existing students and go to them and offer them basically free tuition for their training programs for radiology techs there are talent pipeline working groups statewide in each state that are part of DH and DEA also have tried to build those relationships even with that I pessimistically I don't think that would be how it works I just don't and I think we're going to have to even if we maximize our graduating seniors and community college students and college students there still are not enough folks I think that are going to stay and folks have to go out for a while and then come back and we'll guide the growing picture as they say it out actually and we came back but that was after spending some time away I think DH is thinking creatively about this workforce housing as a week changing workforce week maybe your full-time job is 3 days, 1 week, 4 days the next week and by the way even though you live in Manchester or you live in Southern Vermont we'll provide housing for you while you come out and work those 3 days and we'll also provide that to Southern Vermont so wherever the population exists we don't really have that option in Jitman County that county is growing and UBM has their own workforce needs as well but we aren't trying to coordinate our workforce efforts but we just we don't have the forces we don't have the people and I think we've got to go where the population is growing after we've exibized population trouble resources it seems to be a distant echo because so many of the youth believe that they have to lead the state to seize opportunities and yet we know that's not true with healthcare and just curious if you're doing anything as far as reaching out I think having career days in middle school or working with any guidance counselors to try to get people tuned to tremendous opportunities here in the state we are we do a lot of shadowing opportunities we have a strong role in school nurses for all of our school nurses but we actually was talking about this about getting into the guidance counselors and just really hosting open houses and and getting into the schools I have done putting vehicles back to our high school and talks about the opportunities in healthcare and I think there are various opportunities in healthcare but convincing students that that is their opportunity is also a challenge and I know that speaking with our auxiliary members they sponsor scholarships for graduating high school seniors who are committed to a career typically the path has been in nursing and they haven't had any graduating senior going into healthcare for the last couple of years despite a lot of strong community ever provided to the board and her team so that part is discouraging it's not just the opportunity part it's the opportunity in healthcare this is why it's a great job question if you look at 1.2 million plus travelers generally what we hear is that that's about 200% of what would have been the cost so right there alone we have well over half a million dollars of savings that could occur we could just improve that workforce for them I did have a student shadow me last year for half a day he told me my job sucks sorry are you wearing your green eye shade with that I'm going to turn it over to Julia Shaw from the healthcare advocate I just have a few follow up questions clarifying questions today so you mentioned in your presentation that pulling resources from across the world is going to reduce your prices I wonder if you can clarify and extend on that I think there are two sets of resources that are coming from out of state on the political side we are able to bring clinicians, physicians down to help provide specialty services that our community needs and I think of GI services as a technology television support but resources I think they wouldn't allow and all those things do generate some revenue certainly but I think the resources we're talking really about there's an increase both in New Hampshire business, New Hampshire patients that are coming across especially on the rehab side which we've mentioned a couple of times financial benefit that will allow constant getting gas gains, constant physical therapy resources like PT would be a big target for us because it's one of our real strengths and what we provide for the community and the private private for-profit PT groups around us you know kind of the prices that are pulling business actually in New Hampshire and away from Vermont is all the big centers in New Hampshire and Atlanta for physical therapy so I think that's really the resources coming across the resources pressure we should have been with patients and then you added the lack of harm reduction services currently available in your community and you also mentioned that it was going to be a focus for 2019 so I'm wondering if you can talk about any concrete plan or steps that you have earlier and how you're planning to hold your buy-in for some of the services? I'll start with stakeholder buy-in when the director of your emergency room feels like you're just substituting one for another and doesn't believe in long-term FAT non-access based programs that's a discussion that needs to happen in the family yesterday and we're starting that journey together and as a doc I felt the same way for quite a while but the data this is news to the deaf and we know that there are rising rates of hep C rising rates of HIV and I really latched on to the saying we can't get to recovery if you're dead so we need to reduce harm we need to prevent overdose deaths because all this work we're doing around all of the access and we're not describing opioids anymore but there's a whole generation that also contributes to our work-less issues that are facts that need to get into recovery often some of the data around getting into recovery is going to need eight attempts at recovery to get one year of stable recovery so it's hard for providers to wrap themselves on that so Sharon and her dad is the first step in getting stakeholder buy-in stakeholder buy-in also is a community needle exchange so that could be a hot topic let alone an observable injection site some some communities are strongly considering I think it would do to bring servers to me we're aware of ways from that but if we could get to a needle exchange program I think that would be a great comfort actually it would be the second step our first step was designating a site for free dark hand distribution which we were able to do actually one of my hospitalists said we are going to be doing this and we coordinated with our largest entity provider which is just on campus to have 100 plus patients there even our cancer solution site as well but again if we sit with the mantra we can't get into recovery then that I think clarifies the harm reduction picture for the people thank you for your question to this point I'll open it up to the public for anyone who has a public comment about the final step in the budget Dale good quick question how the workforce is actually affecting pricing other than that I think that was really well I wanted to comment on their attitude toward data if there seems exceptional to use it as a tool for them the other one would be children I didn't see a whole lot about how the children are doing that they serve how do you feedback on that sure we have two interesting pediatrics practices in our health health system the laser pediatrics practice is a different population of kids that are good stuff pediatrics we live in such an economics we're different between the town some incredibly high need pediatrics patients there's still need I think sometimes understated in Woodstock but a little bit different we've actually increased our pediatrics in Woodstock because it does seem to be nudgeing upward a little bit for our higher need patients and their families we started a common program one is family coaching service that we started with high-risk patients and now we're rolling it out to all patients in the pediatrics practice in Windsor so we actually have grant support to have family wellness life coaching for patients and their families to try to avoid cases these catastrophic events or adverse childhood events that tend to have long-term implications for patients health and well-being again we struggle with some of the blueprint data around our practice profile in pediatrics I think we're hiring that up over time and whenever we're not convinced that the data is accurate we just do real-time chartings to make sure that we're doing it in Woodstock we are considering actually having some pediatric office hours and half of the school of our pediatricians spend some time every week or every other week in Woodstock to see Dave's hair falling out quicker with something like that because that's not that a lot of the line but I think it would be an important adjunct so I think our pediatric practices are doing well we have state and staffing we're able to replace some pediatricians with them for 30 or 40 years and we've recruited some for a lot of state to fill his big shoes so I think we're doing well where we sometimes struggle with two distinct populations that we need and looking at our Medicaid data our highest spend, highest brutalizers in Medicaid are pediatric patients in the woods and it's all psychosocial dynamic and socioeconomic stresses that they have and some real intense psychiatric needs that thankfully we are able to recruit to leave but I will say that we have just hired a new psychiatrist that is also important for the pediatric psychiatry so that's going to be a great help as well So is there any other public comment? Seeing none thank you team Montescutney not to recent Monday we really appreciated the depth of the conversation but with those two guys you don't need to say much right now