 So good morning everyone. My name is Kevin Mullen chair of the Green Mountain care board and I just want to ask everybody to please refrain from using the chat function. It is not the proper method for a public comment. Public comments will be heard after the hearing for each individual hospital. Today is the final day of hearings and we're hearing from. Northeastern Vermont and Northwestern so. With that. I guess Sean if you could introduce each of the people who are going to testify and then we'll ask Joanne just where you all in. Sure. Sounds good. You ready Kevin. Yes. Okay. Well, I know we have a rather large team today here online and I think it's just emblematic of the style of leadership we have here at NBRH, but I'd like to introduce the leadership team. We have Sean Burroughs my CIO Betty and what can my head of HR Bob her see our CFO who should also be acknowledged as I believe the longest serving CFO of any hospital in the state of Vermont. Laura Newell VP of medical practices. Michael Ruse or CMO. Laura Ruggles VP of community health improvement and marketing. Julie Schneckenberger our chief nursing officer. Colleen Sinan VP of quality management and of course myself as CEO of the hospital. Great. Thank you Sean. And if the board members could please introduce themselves. Hi. Oh, sorry. Hi. My name is Jessica Holmes and I when I'm not working at the board I'm also teaching economics at Middlebury College and I've been on the board six years. Hi, I'm Robin lunch. I've been on the board for four years and prior to this role I worked in state government in various healthy roles. Good morning. Good morning. I'm Tom Pellum and I've been on the board three years now in no come come November. I was the former state tax commissioner and former state finance commissioner under Howard Dean. Hi, I'm Maureen Lucifer down the board a little over three years and prior to the board was in corporate finance as CFO. And also I'm on corporate public and private board. Thanks. Thanks. Great. So Julian, whenever you're ready, you could swear in everyone from northeastern. Okay, if you would all please raise your right hand. I swear the testimony you're about to give the truth the whole truth and nothing but the truth so help you God. We do. I do. Thank you. And if we could just ask anybody who is not presenting to mute themselves so we don't have any feedback. That would be great. And so Sean whenever you're ready you can begin. Okay, Bob, I don't know if you want to kick off the presentation now. And bring us to the introductions and overview screen. While Bob's doing that, I'll just open with saying that today what you're going to see is a budget that demonstrates our ability to return to profitability. And we're looking to achieve a 2% operating margin as we come through 2021. We have assumed that there will be no additional pandemic related disruptions as we navigate this next year. And that's the big unknown. We are requesting a 3.9% charge increase, but we feel it's justified given the budget we have put forward. We also recognize that we're going to be continuing to deal with the impact of the pandemic as we navigate this next year. And there are a number of expenses embedded in this budget that have been driven by the pandemic. But we are going to also continue to focus on avoidable ED visits and you will hear some additional updates regarding our efforts in that space. Our vision as a hospital is to be a leader in improving the health of the community. I also want to stress, you know, like all hospitals, we've been deeply impacted by the pandemic, but I am so proud of the entire team here at NVRH, not just leadership, not just our physicians, but everyone throughout the entire organization who have really worked hard to navigate the last six months and have put us in a position that we feel we're well positioned to be successful coming into the 2021 budget. I also want to say that the challenges that we had before the pandemic are still with us. So recruiting and retaining the talented workforce we need to care for our population remains our number one challenge. And secondly, we're continued to be challenged navigating health care reform efforts while we care for an aging, more medically complex population here in the Northeast Kingdom. With that I'm going to pass it over to Laura Ruggles who's going to give us a walkthrough of many of our COVID related efforts and work with the community over the last six months. Hi, good morning everybody. We're on slide five. So I usually do an update on our work in the community during these hearings. And since that work is continuing and more important than ever during this pandemic, we're using part of our intro to talk about it. So it's slide five. Thank you. So those of you who know us know that our mission and our top priority is to improve the health of the people in the communities we serve. And we feel it's our responsibility to be a leader and strong partner with others to meet that mission. And we are so fortunate to live and work here with so many strong community partners who really share that same commitment to community health. So we're all in this together. We've all heard that a lot lately. And our many years of collaboration and building systems of care and our proven track record of working together. That real strong sense of stewardship here that we really are all in this together was never more needed than now. And the strong relationships that we have with our community partners have only grown stronger during this pandemic. So slide six. So our community partners reached out to us during this pandemic because they know that we'll be there for him and we were. So we've just got a few examples here. You saw some on the other slide to some community testimonials, whether it's sharing or a COVID testing template. So they can do testing or removed Veggie Van Gogh, which is our partnership with the Vermont Food Bank outdoors. So we could continue to feed over 300 families a month. Working with the Northeast Kingdom Council on Aging to provide emergency food for seniors or really something as basic as providing cleaning solution for our rural community part transportation partners when they literally couldn't get cleaning solution from anywhere else. So we were here for them. So slide seven. So during the pandemic we took our role as leaders and help very seriously. So even putting aside all the misinformation that was coming from the White House. It was really just this fast moving pandemic it was hard for everyone to keep up with the rapidly changing data and information about COVID-19. So we were tried really hard to get ahead of the pack in getting reliable information out to the public. We went on social media front porch forum print media and on the radio with accurate information and simple information about simple information and messages about how to stay healthy and safe. So there's on the screen are 2 of the pieces that we created. These were print ads, but also posters and we shared them with our local chambers of commerce and they distributed to their business members. And because we could be fast and flexible. We had these ready months before the state agencies were able to produce similar products for general use. Okay, slide eight please. So this is just a few examples of our ongoing wear a mask social media campaign. Those are employees, employees that were doing their part as responsible citizens to keep everyone safe. Slide nine. So I've mentioned how we were here for our community and our community partners. They were really here for us to enlarge and small ways and we are so grateful for that overwhelming support from our community members. We got lots and lots and lots of food. We got donations of personal protection supplies and really simple thank yous like the ones that you see here. So the pandemic isn't over, but in VRH and our community is strong. And we will endure and bounce back from COVID-19 better than ever. And thank you for your time this morning. Trying to find my own mute button. Bob is having a problem finding his own mute button. Bob, are you able to find the mute button? I have a menu bar right on the lower part of the screen. He's having trouble. I'm going to run up to Bob's office and just see if I can help him on mute. Chief technology officer. You know, you got to do what you got to do in a small hospital. Is that something Abigail can do? Unfortunately, I'm not able to unmute people. You have to do it from your own screen, but Sean is right underneath. There's a task bar and all the way to the left is turn camera on and off and then there's the mute button. Abigail, is it different if you're sharing your screen? No, you still have the task bar. Okay. It is a bit different if you have the app downloaded. So my menu bar is on the upper right hand of my screen. And I don't know when that changed. So yesterday when I muted myself, I was expecting it to be on the bottom. And I didn't see it up top, but apparently that's changed in the last few days. Thank you. I just texted Bob and Sean. Can you hear me now? Yeah. All right. Welcome. Good morning. Good morning. Can you see the screen? Am I still sharing the presentation now? No, we just see you, Bob. Okay. Give me a second here. Let's see if I can do two things. Can you see the screen now? Not yet. Not yet. Who was sharing it earlier? Me. Okay. Can you see it now? No. No. Really? Now we can. Yeah, it's up. Okay. There we go. This is much more fun than doing this in person. Hey, Bob, leave yourself unmuted for the rest of the duration. Okay. So I mean to be on slide 10. We're on way above. Okay. Here we are finally on slide 10. Thank you for your patience. No problem. So I'm going to start. This is the income statement. I'm going to get into details on different aspects and components of the income statement. But I want to start by letting everybody know that the projection for 2020 that you see here is way off. We have completely redone the projections. These projections were done in May with May results, I should say. And our results for June and July were incredibly good. For example, when we did the projections, I projected that the month of June would be about 75% of pre COVID volumes and revenue in the month of July would be about 80%. Both months were a hundred and something percent over our original projections and over our original budgets. So putting simply the bottom line you see here the negative 1 million 184 500,000 is now a positive $325,000. So I will touch on a few of those details, but I do really want to focus on the 2021 budget, but I just needed to update that. Additionally, we didn't get these reprojections done in time to include them in this presentation. Moving on to slide 11. Just again touching on the 2020 projections, we're now looking at 82.9 million of net patient revenue for this fiscal year. Looking at fiscal 2021 budget to 20 to 20, I'm sorry, 20 budget to 21 budget, looking at about 3.7% growth in that patient revenue. The guideline is 3.5%, but I need to point out that there is one drug that we're using for infusion patients that has a cost and revenue of $676,000. I'll touch on that a bit more, but if you take the revenue associated with that one drug out, our budget to budget growth is 2.9%. We do have a little volume growth into the budget express care program we've added the provider to and we've also added the provider in our primary care practice. The 3.9% charge increase the process we went through was we projected our volume for 2021. We looked at cutting expenses where we could we look to maximize our other operating revenue and we look to see what we would need to close the gap. And to cover the COVID related expenses that we expect to continue into 2021. So the number we needed to close the gap and get us to a 2% operating margin was the 3.9% charge increase that we're requesting. I'll elaborate on those and a bit more starting with the charge increase request. To close the gap that I discussed earlier to get us to the 2% margin, we needed a rate increase of about 2.8%. However, we have about $415,000 of ongoing COVID related expenses into next year. Those expenses are for the increased costs for PPE of personal protection equipment. We have a testing facility off site that we're using to do COVID testing. We expect to do that all year. And we'll also get to a flu clinic out of that site I would add. And we have centuries we call them or people with the main entrances that screen every patient and visitor that comes into the hospital. Ask them screening questions and takes a temperature, et cetera, to make sure that we're not bringing anybody who might be infected with virus into the hospital. Just to note down here, every 1% increase in our charges gets us $377,700 of net patient revenue. Moving on to slide 13. This is a trend of our rate increases, what we've requested, and what we've been approved for over the past several fiscal years. This year again, we're looking for a 3.9% rate increase. Last year we asked for 3.5% and you approved a 3% increase for us. Moving on to slide 14, just to highlight some of our net patient revenue. I don't think we're moving the slides. Are other people getting the slides moved? There we go. Yeah, they're moving for me. Is everybody got it now? Slide 15. What I'm seeing is NPR slash FPP revenue assumptions. Yep. Yep. Okay. That's what it should be on. Thank you. We missed the other ones, but that's okay. We have them. Okay. One of the major assumptions, key assumption is that volume will return to pre COVID levels. Mostly there is still a small percentage of patients who don't want to come into the hospital. But that seems to be dwindling right now. We will continue to have telehealth visits for some patients. There is certain population that that still works for. We don't assume any pent up demand catch up. We're back to normal operations in fiscal 21. You're not expanding operating hours. We're not expanding diagnostic imaging and testing hours. So we're back to normal. Again, we were sued that we'll get the 3.9% charge increase. We're not doing any change to Medicare critical access payment rules. We do anticipate the sequestration. We'll come back the 2% Medicare reduction. We'll come back January 1st. So we won't have the sequestration October to December, but we expected to come back in January. And just as a side note, that sequestration on an annual basis to us is about a $475,000 hit. We do not expect any Medicaid fee for service reimbursement rate changes. I believe that has been confirmed by Deva at this point. We will participate in the one care Medicaid risk program. We've built about 600,000 reserve into the budget to participate in that. We are still not going to participate in any of the other risk models at this point. The 600,000 risk level we're willing to assume. But getting into the multi-million dollar risks associated with Medicare and the others is just not something that we feel is a critical access hospital that we can absorb. We do anticipate a slight decrease in our uncompensated care as a percent of gross revenue. We've been projecting about three and three quarter percent of gross revenue for uncompensated care. Again, that's a bad debt and free care of patient assistance. We're budgeting three and a half percent for fiscal 2021. And again, one of our key budget assumptions is the $676,000 drug for one patient. Incredibly expensive. Fortunately, insurance covers the cost of that medication no more than cost. We do get at least our cost back. I would also point out that this is not a drug that's eligible for 340B. It's administered in an outpatient for a series of complex reasons. We are not, as a critical access hospital, not able to get that under the 340B program. Moving to the next slide, 15, it should be. Again, because the projections for 2020 are so far off, a lot of this is not relevant anymore, but I do want to touch on a couple of the key highlights of the trend from fiscal 20 budget to fiscal 21 budget. We're looking at the change again, budget to budget, about $1,473,000 for rate increase. About $676,000 acuity, or that's that one drug. About $1,225,000 for volume related. And I want to point out that of that volume, $750,000 is for COVID lab testing. We do a large volume of those lab tests and the revenue associated with that is about $750,000. And we anticipate another 372,000 or so and other volume increases again, some of it coming from our express care and additional primary care providers. Moving to slide 16, other operating revenue. The slides changing, by the way. Yes. Okay, thank you. Just want to touch on a couple of key points here under our other operating revenue. We're expecting to use about $4.3 million of stimulus support, that's a combination of federal and state stimulus support for COVID relief. Again, that covers lost revenues during the pandemic period and some of our increased expenses. The other key, other operating expense, and you've probably heard this from a number of hospitals, is our 340B program. That's for the retail of the other operating revenue side, that's about $2.5 million a year. I would point out that the 340B program does help us reduce our outpatient drug costs. And that's right now is saving us another one and a half million dollars. So in total, the 340B program is worth about $4 million to NVRA annually. Moving to slide 17. I'm not going to actually touch on this one too much. I will note that our projected expenses for 2020 did not change much. Changes were all on the revenue side. Our expenses are still on target. I'm going to move to slide 18 and just talk about some of the trends from fiscal 20 budget to fiscal 21 budgets. Again, looking at our starting revenue, starting expenses of $90,308,000. The drug costs against $676,000 as a driver. COVID related expenses, $1,137,000. Salary increases and inflationary increases in total, about $1.7 million. Our inflation assumptions overall are 2.75 to 3% range. Some are going up higher, obviously, our PPE. Again, personal protection equipment expenses are going up higher than that. Drugs were projecting about a 3.25% increase for the drugs that we have here. Our health insurance is going to go up by more than that, 2.75 to 3%. But everything else, again, we're looking overall at about 2.75 to 3% as our inflation rate for the year. Our travel expenses, an increase of $435,000 budget to budget, or our total travel expense budget for the year is $1.6 million. We're making all several efforts to reduce travelers. One of our efforts is to hire travelers. We've had a few travelers come work here. They like it here, we like them, and we're hiring them. In fact, I think we just yesterday hired a traveler in our ED to become a permanent employee in the ED. And we're looking at other wage and compensation packages that will entice employees to come here and fill some of the vacancies that we're now using travelers for. And one of the other programs that we're looking at has helped us in the past and hoping to help us in the future is to hire some of the VTC grads when they're done their school year. MRI and lease service is a new expense of $250,000. That was part of our certificate of need approval. And that's right in line with that. Some changes to the hospital service. The cost savings, $625,000. That is made up of a couple of things. One is 10 reduction of 10 FTEs on a budget to budget basis. We've also maximized the 340B savings. I said that's up to about a million and a half now. We're working on a supply chain to reduce some of the expenses for joint replacements in particular. We do a lot of joint replacements here. The prosthetics are expensive and we're working to reduce those costs. I'm talking about joint replacements. One of the savings that's not identified here but is happening is most of our total joint replacements are done on an outpatient basis. The patients go home either the same day or the next day. So, you know, having that long-length estate that used to be associated with the total joint replacements, which is overall a cost savings as well. In depreciation expense, we have scaled back our capital spending program. And the savings for depreciation on a budget to budget basis is about $50,000. And we'll talk about our capital spending a bit more in a few minutes. Moving to slide 19. This is a trend of our operating margin. I just want to highlight here that fiscal 2020 budget operating margin down in the red area, the negative area, is now a positive about .4% at about $325,000. So a couple other comments. If you look for fiscal 17 to fiscal 21, our average operating margin is now 1.6%. That's been updated again because of the new projection. So that again overall is about 1.6%. Before the pandemic hit, we were in pretty good financial health. We were able to position ourselves if needed to actually even lose up to $2 million. At this point, I just want to stop and acknowledge the board's role in that. You know, a few times in the past several years, our community has asked us to expand essential services. And in doing so, that meant we had to go beyond a 3.5% revenue cap guideline that was in place. So we presented our argument to you folks. You listened to us. You trusted we'd do the right thing. And we delivered in our community and our financial health benefited from that. You saw some of the earlier slides, the community's response. Our reputation has grown tremendously in the past several years. And part of that is the expansion of those services that you've allowed us to do. 2% operating margin. Again, that's what we targeted this year. And that's what we feel is really humanly needed. We're getting music from someone. So perhaps people could use their mics if they're not talking. All of our representatives are assisting other callers at this time. Looks like someone called in on the phone. Please stand alone and your call will be handled in the order it was received. I don't know if there's a way to navigate it for you to mute someone or disconnect that line. So I can mute the entire audience but you will mute everyone so you all have to unmute yourselves. And I know Jess would have to pull out. You have to. Can you figure out how to unmute yourself again? I think so. We'll have to wait for Jess anyways. All of our representatives are assisting other callers at this time. Can you hear me? Yep, we got you, Bob. Perfect. Thank you, Abigail. Jessica, can you hear us? Yes. Can you hear me? Yes. Back in. Okay, great. Thanks. We're all set. Continue when we do another minute or so. I think we're all set. Okay, great. So it's on the operating margin of slide 20 just at the bottom. I'm not sure if everybody heard, but 2% operating margin each year is what we really feel is needed to support a red project other capital projects as well as staffing and being able to keep giving our staff increases to recruit and retain and invest in new technology. Moving to slide 20. 21. I am still sharing this slide, right? Yes. Yeah, hasn't jumped though yet, Bob. It's still on slide 20. Should be able to just hit your down arrow on your keyboard. Yep, I know. Not working yet. No, I've been doing it for. I don't know why it froze. There we go. Oh, there we go. You jumped it now. You're on 22, but. Okay. Yeah, I have to do, I have to do the cursor. So I'm on slide 21 now. I think actually I'm going to move to slide 22. There's nothing here we want to highlight at this point anyway. So some of the comments on the balance sheet that I want to make, you know, we're rebuilding the balance sheet. We're not taking as big a hit as we thought, but we're still not going to achieve the budget operating margin for fiscal 20 that we had anticipated. We do need to build the balance sheets and invest in future projects. And especially those projects that have been delayed again, we kind of scaled back our capital program and we need to build the cash back up to get that program back online. Our capital debt structure ratios are good. Again, we're focused on new ed expansion project in the future, maintaining that debt capacity is going to be key to us being able to issue some new debt to finance that project. The one thing I'm here at highlight two is the DSC DSCR the debt service coverage ratio at one point, it appeared that we're going to be in violation of our bond covenant, which requires a certain level of debt service coverage. We need to report that with the new projections that is not going to be the case and we will be in compliance with all the bond covenants. We did take advantage of the IRS's option to delay FICA payments so we're delayed about 1.9 million of FICA payments as part of our cash preservation plan in the COVID hit. And those don't have to be repaid completely until December of 2022 cash flow. Is everybody seeing that now slide 23. Yes. Yep. Great. Thank you. The other thing I want to highlight here is that that's likely to be about one and a half million dollars higher. So the two year projected cash growth with the reprojection is going to be somewhere in the $3.7 million range projected increase over those two years. COVID related. I guess what I'll highlight here is that the money that we took in COVID about 7.3 million in total. Excuse me. We're not going to need all of that based on our reprojections. And it's possible that we're going to have to repay some of those grant funds to either HHS. Or other organizations that gave us those advances. Excuse me. One thing I will highlight and we've had that money in the bank now for quite some time and we've been earning about $6,000 a month in interest on those funds which you know it's. We're a small hospital every penny counts. Next slide the comments on the cash flow again this is steps we took to preserve cash. Our cash preservation policy that would put in almost immediately after the pandemic hit a lot of us to preserve about $7 million in total. We prepared for the worst and I'm happy to report that that didn't happen. Adjustments. The common here is that we may transfer a community based practice to a hospital based practice that is looking more and more likely that it will occur. We have an ophthalmologist in the community who we're looking to be employed by us sometime after the first of the year. We're doing that in collaboration with Littleton Regional Hospital so although he would be our employee, we will share that ophthalmologist with Littleton Regional Hospital. And we're also looking to recruit another ophthalmologist that we would share with North country hospital. We're looking basically to have two ophthalmologists covering three hospitals and collaboration was in free range. There were no adjustments or any accounting changes to report. Some of you may recall that our local ophthalmologist was unable to practice for many months over the past year and left a huge gap of in care for our communities. That collaboratively with our partners is really important right now. And we'll be coming to the to the Greenmont care board assuming this happened such it looks like it will to ask for a transfer on for like revenue associated with that practice. Service line adjustments we don't have any I'm sorry I'm on 27 now. We don't anticipate any service line adjustments as it says here what we're offering is good. So we're also collaborating with North country hospital to have an express care in addition to our express care at our court medical location. We're collaborating with North. North counties health care to put an express care in downtown St. John'sbury. That is underway and I believe the target date for that is late December or early January. The police on the facility has been signed by Northern counties. We're working with them on building out the space and that gets at some of the work we're doing to continue to reduce, you know, the unnecessary ed visits. So I'm going to stop and pause for a while and let a few other members of the team have a few words. I think we did ask Dr. Yeah. Can everybody hear me okay. We can. All right. So I was tasked with exploring some of the risks that we see coming and I think a lot of these will be familiar to you. The staffing meeting staffing needs in the near future is obviously on a lot of people's mind. We have a hazard assessment and of our employees and, you know, the whole idea of going back to school and having pods quarantining and what that was going to do to our staffing is heavily on the minds of our employees. So how we're going to how families are going to balance teaching at home work schedules, various school schedules. So we're going to work through that and I think the whole state is and then the use of travelers we talked about. We've been pretty successful in trying to reduce the use of travelers as much as possible, recognizing that that is a real heavy expense for us. So we try to avoid low contendance and travels travelers as much as possible. I think we're going to talk about another surge and the effect that that could have on us if we have to shut down services. That was obviously devastating to us like it was for everybody else. We got back up and running as quickly as the state allowed us to and that has been part of our success actually. We're hoping that we continue to do as well as we have as far as avoiding a surge and I really credit for monitors and people complying with our PPE and hygiene requests. And I think we're very good at doing that and I think that's part of our success actually. We're worried about recruiting and retaining key staff. We had 19 nursing positions vacant before the pandemic and we have been fairly successful in filling those positions. I think working with the schools and recruiting nurses coming out as new grads has worked. But we still need to keep our salaries competitive or we will lose nurses to a more competitive environment. We are actively looking at the market and trying to keep our salary and fringe as competitive as possible. We do not want to lose our good nurses strictly on the basis of a few dollars an hour difference just down the road. The one care Medicaid program is a risk. At one point we were suffering some pretty hefty losses in that program that has since turned itself around a bit and we're projecting to do a little better this coming year. So while it is a risk we feel we practice under the guidelines and we're well positioned to do well under accountable care. So we're hoping while it is a risk we also look at it as a potential opportunity. Bob mentioned capital you know if we we have a nine room emergency room. I hope each of you get a chance to visit and see what it looks like is extremely crowded and add to that in a pandemic experience. We have curtains trying to divide respiratory and non respiratory patients. These are undifferentiated patients coming to the emergency room. It is a risky environment and we need a modern emergency room to sufficiently care for our patients and we need to keep working toward that. So that is something that we need to make sure we can we have sufficient capital to do that. Without that I really fear that you know we could have problems down the road. I want to but Mike I just want to add to that briefly because we knew we were challenged in our emergency department prior to the pandemic hitting and the pandemic really highlighted just what the challenges look like in that space. Not only was it dealing with people coming in with respiratory issues and how to protect them from other patients who might be experiencing trauma or another event. But also we have seen a real uptick in the number of people presenting with mental health in mental health crisis. And I think that is also a factor of the pandemic. So dealing with those two challenges in a space that is just not well designed for it has been very hard. You know it's very much our front door and we need to be able to get patients. That's where most of our inpatients come from is through the emergency room. And I do want to correct myself. I would like you to visit our emergency room but not as a patient so just as a out of interest. Okay. So and then we need to be able to deal with the long term economic impact in our community. Laurel. Ruggles pointed out you know what we do for our community here. NVRH is a major player in our community with Northeast Kingdom Prosper. And what we do in this community and without a strong hospital. A lot of these efforts are just going to falter so we really want to be able to play a major role in that. that uh economic impact. Again I'm sorry but uh Mike let me just add one more thing around that I just like to give the uh board an example of what we're facing. So we have a seasonal warming shelter here that uh in a typical year would serve on any night between six and ten uh people who were homeless. When the pandemic hit the number of homeless people that needed to be served in this community skyrocketed to over 100. Many of them families and and so that's an example of where many of these people may have been co-ordered with with friends or finding patching their housing solution together but then found themselves uh not able to take advantage of those relationships because of the pandemic and suddenly the needs jumped up significantly. We saw similar uh impacts with access to food so those are all the challenges that our community looks to our support and leadership in helping solve. Yeah our veggie van go food distribution has been extremely crowded cars lined up around the block here to get it to get the free food distribution that we do once a month. And then the last thing is our supply chain and again you've probably heard this over and over but um our inability to procure sufficient quantities of PPE now reagents to run tests the whole supply chain is up in the air um you know being able to do in-house testing for COVID is becoming essential to be able to adequately move our patients through um our hospital to do procedures on them to deliver their babies um you know the fact that we were we're behind the curve on that where we have to send all of our labs out and uh so we're um these are things that need to improve so we need to be in a good position to be able to provide all of this uh all of these services. That's it thanks. Thanks Mike. Great. Opportunities. Laura Nule you're up. Good morning everyone. I get the fun job of talking about all of our opportunities. As you read through the high level bullet points here you can see that in addition to all the risks that Dr. Bruce was speaking of we actually do have a lot to be excited about um this the pandemic along with our historically solid foundation has really provided us with many opportunities um as some of my team members alluded to and spoke about um NBRH's leadership and guidance during this uncertain time has really cemented our remarkable reputation within the community and this in turn with years of steadfast innovation innovative approach has really offered us the ability to strengthen our current partnerships as well as work with new partners on a number of exciting uh initiatives. The hospital was also able to use a time when things were moving so quickly and changing so rapidly to really take a step back and pause and reflect on some operational inefficiencies and do a reset um we found new ways to leverage data um and uh platforms like the OneCare Vermont um data uh analytics um as well as looking at changing workflows to better meet our community's needs um you know all in all we've all the challenges that we've faced have really afforded us the opportunity to look at things with a new and fresh perspective and we really do have a lot to look forward to in our upcoming fiscal year um things like partnering with our local education centers like VTC and NVU on training future healthcare workers um and getting them right into work after graduation um so that's it thank you yeah let me just add uh or expound on that I think one observation I've made over the last six months is that um we've always excelled at developing strong partnerships and relationships within our community and the larger healthcare uh environment here in the northeast kingdom north country and I think one thing that I've observed is that uh we've been able to really leverage those relationships and continue to strengthen them so that uh we can you know meet the health care needs of our community an example is uh ophthalmology working with littleton regional hospital as well as north country hospital explore how we uh meet those needs here Bob I think it's back to you with uh the capital budget plans yep can you hear me we can okay great so a couple minutes here on the capital budget plans as I've said probably a few times now we had to scale back our capital spending um on the pandemic hit one project we did have to go forward with was replacing all of our information system servers um they're all linked to our electronic health record we're all on electronic health records so we cannot risk losing those services and access to our EHR the good news is we were able to secure a great financing for that project interest free financing specifically for over 42 months so we had to do it but we found a good way to to finance it and you've heard about our ed project now we're going to start the planning process again that was the planning process was put on hold after the pandemic hit um and we're going to start that process back up during fiscal 21 and at some point most likely in fiscal 22 uh you will be seeing a certificate of need application from us for that project so that concludes our presentation yeah let me just uh closing comments yeah I just want to uh say that um again it has been incredibly challenging to go through this process uh the future feels opaque and I also want to thank uh the members of the green mountain care board for your flexibility supporting all of us through this and uh really um helping us get through the budgeting process in a way that still feels meaningful uh to all of us thank you thank you Sean so we're going to start with board member questions and we're going to start with board member Holmes Jessica great thank you can you hear me yes okay well thank you for your thanks and I'd like to return the favor and also thank you um and your leadership team and all your dedicated staff for all the efforts you underwent during this pandemic uh it's you know times like this in the last six months where I'm really grateful to live in Vermont where we have hospital leaders and community members and health care workers that really do um put mission first and are dedicated to serving their communities so thank you for that um also thank you for the budget submission I really appreciated having read them all multiple times now I really appreciated the attempt to create an easy to follow breakdown of expenses and revenues and the bridge table in the narrative was really helpful to me so Bob if that's your fancy work there it was very much appreciated thank you thank you and yeah that was really helpful um so let me just I want to start with some of the volume assumptions and I'm trying to understand every hospital's volume assumptions particularly for 2021 realizing full well that creating a budget in this time of uncertainty is you know it is what it is you're doing the best that you can we're all doing the best we can to to to predict the future we don't have crystal balls um but the original submission had a 7.1 million dollar decline in volume in 2020 and an assumed 6.5 million dollar return so my my original assumption was oh that's about you were kind of assuming about a 90 percent return um to pre-covid levels is that right are you on the same page with me pretty much yeah no pretty much was the assumption at the time yeah so now hearing your uh so 90 percent was sort of at the time of submitting the budget understandably you've had new information June and July being over 100 percent maybe some of that's a little pent up demand but at least it's over 100 percent which is great i'm really happy to see your bottom line returning and and things are looking up financially so now i'm wondering um are you underestimating you know is it going to be 90 percent next year or are you more likely to see that full 7.1 million dollar return or even maybe more and should that npr assumption be updated given the June and July results that's certainly something we're looking at Jessica you know i'm really not ready to go there yet but um we're still monitoring and we'll continue to monitor and if we find that we're you know as we get into the year a few months we find that our volume assumptions are off significantly we'll come back and let you folks know okay incident let me as a follow-up to that if there is more utilization than anticipated therefore more revenue of course also more expense but is there less needed to close the gap and would you also want to adjust the charge request again that would be part of what we monitor and reproject and yeah if we're seeing more volume it's you know enough that we could reduce the rates and we'd come back to you folks mid-year or after the first quarter probably and let you know okay i think jessica one thing that you know what i have described is there that in my mind over the last several months i've said there are three key markers that will give us a better sense of the progression of the pandemic one was the summer and what happened over the summer and we didn't see a massive surge here the second one we're in the middle of right now which is really kids returning to school kids coming back from college so far i'm gonna knock on wood uh that seems to be going well there's one third my mind final one which is what happens as we come into november december flu season people coming back indoors and and does that generate a resurgence of covid and a reluctance for people to then engage with healthcare etc and i think we really need to get through that third and final event to get a true sense of what's going to happen with volume okay yeah completely understandable and i literally believe none of us have a crystal ball and uh you know so everybody is you know we've got this target and we're all trying to shoot for it but like a lot not a lot of information a lot of ambiguity so i'm just trying to understand everybody's assumptions you've got a good grasp on it so let me ask you one more question about the rate request in the narrative you break down the rate request and it's a two percent normal closing of the gap and then a 1.9 percent covid related adjustment and you actually break down the covid expenses there in the narrative 114 000 for screeners 376 000 for the testing tent and ppe of 200 000 so it's roughly about 700 000 but then in the presentation you have only a 1.1 percent adjustment for covid expenses down to 400 000 so your incremental covid expenses drop from the narrative of 700 down to 415 so i guess i'm just curious why wouldn't the covid component drop from you know 1.1 to 1.9 to 1.1 but you still keep the two percent normal the same so you know i mean i'm just trying to understand what happened between the narrative and the price you know again better data you know as we solidified some of our planning around the security entrances and the testing tents one of the things we did differently was i believe the original projection was to have a screener at the employee entrance and what we've done instead is we purchased some thermal scanners so employees come in they badge in and they have the temperature taken with a kiosk so that eliminated the need for a position i mean that's one change i mean it doesn't account for the entire difference but that's an example of things that changed from our original projections and plans to today so i guess what i'm guess i'm trying to understand is why did the 3.9 rate requests stay the same if the expenses associated with covid dropped why wouldn't the rate request dropped at the same level 3.1 now instead of 3.9 if other other other factors that changed as well i mean as i said earlier you know we needed 3.9 to get us to the 2% operating margin after everything was we looked at okay um you also mentioned in here the 597 in the 2021 budget for stimulus support but i know you weren't applying for at least that it sounded like in the submission you aren't applying for provider stabilization funds from the state so i'm wondering what is the source of that for 597 in the 2021 budget for sure yeah we've already got the money we've got about 7.3 money million dollars has been received okay we're going to take some of that into income in 2020 and some in 2021 so the money is here i'm sorry it's a carryover it's not new funding that you're exactly yeah no the money is the money is already here got it okay i thought it was new money and i was trying to understand the source for that no um and uh zero dollars budgeted for non operating revenue can you just talk about that sure most of our non operating revenue almost all of it actually has to do with fluctuations in the stock market or financial markets the realized and unrealized gains on our investments and um you know i just don't take a stab at that my crystal ball for that has never been good if it was good we'd all be rich right i would certainly not be doing this i am not this isn't fun i mean i love this but uh you know i could think of other things to do if i you know hit the stock market right every time okay well i mean i just noticed a lot of other hospitals are projecting two percent three percent four percent return on their investments and so your your decision is to project zero percent or zero growth in yeah again i i don't know where it's going i guess maybe a bit of crystal balls and i do but i i just don't know what's going to happen okay um and i guess my final last question is you mentioned not you bob um i can't remember if it was uh one of the other speakers mentioned an improvement in one care vermont performance for this year and i'm just wondering what lessons uh potentially could have been learned for that improvement in in performance and why going forward you're more optimistic about the ability to meet the targets and perform well in that uh a co model sure maybe that's i don't know that's you and i'd be happy to take that you know um i think part of it is uh increasing comfort level and understanding of the model it's it's it's a massive change and it um and it has taken us time to really adapt to it number one number two uh you know our first first year of participation was not good and it appears that the that the the target spend was was probably miscalculated somewhere in in the system right and and so the entire system has has lost a lot of money in the Medicaid risk track um despite that we've done we've lost money but we're doing okay uh it looks like for that year but this year of course the big advantage is that um as the pandemic hit and uh and our uh visits dropped off you know we still as part of that model we're receiving those consistent checks month to month and so that provided a level of stability that that frankly helped us navigate the uh the financial crisis that we found ourselves in starting in uh mid-march um and i think if we can continue to build a strategy work collaboratively with one care try to narrow the risk order for the small hospitals because that's the biggest challenge right it's it's it's what does it look like in those wild swings um can we sorry i'm getting can't stand that um but can we build on build on that experience and provide a strategy that provides some stability for hospitals while uh trying to mitigate the risk as much as possible and and i'm optimistic i i think we continue to learn a lot through the program and and and that's a good thing and so and you're aware that the Medicare risk quarters have been reduced for next year i do but the the numbers are still uh significant okay all right that is it for me thank you kevin and thank you all thank you jessica next for the board member launch robin hi everyone thank you and i just wanted to echo jessus thanks for the work of you and your staff uh during the pandemic um we're we know everyone's been straight out and we appreciate all of your um efforts during this unprecedented time um so i had a couple of questions um one of the the positions that you talked about uh potentially coming back online was an audiologist um and i assume that's because of a vacancy but i apologize that i don't remember from last year what you told us about the audiologist so could you just give us a little more background uh yeah i think uh oh good more you get that oh yeah sure we had an audiologist that moved out of the area um a little over a year ago um so we've been without an audiologist um actually we've been partnering with little ten regional hospital and use utilizing some of their services um until we could find a permanent replacement um and we've been able to do that uh which is great and she actually starts next week so we're very excited about that great thank you um you i wanted to talk to you a little bit about your staffing you mentioned that reduction in 10 FTEs and in your narrative talked a little bit about some folks having reduced hours um did you have to do full-blown furloughs during the pandemic um could you talk a little bit more about that whether if so or those folks back um and then if you have a wage increase budgeted for fiscal year 2021 what is that for just for comparison purposes with other hospitals betty and do you want to uh give that update uh sure uh we did have people furlough um and we uh did it on a voluntary basis um so what happened was um people volunteered to furlough um in the heat of covid when um when we were not providing services um the um so then the employee had to request the furlough from the manager just to make sure that we didn't need them uh so we had um a lot of people doing that um and then some people were on like a partial furlough so they were working some and then they were also home some but um everybody is back um from the furloughs and um they started um they started coming back gradually but everybody is back now um we did do um an early retirement package um and we offered that um to 39 people and it was for um people who were age 65 and over and had been here at least 15 years and we had to when you do an early retirement package you have to offer it to everyone in that category and so we did that and we had uh 22 people take the early retirement package thank you and my last question was about the budgeted fiscal year 21 wage increase oh right bob do you want to share what we budgeted so we've assumed a three percent uh average increase um that will include some market adjustments as needed to keep competitive and ever-changing and challenging market believable great thank you um uh thank you for providing uh information about the travelers and how that's been going and your efforts to reduce travelers um i was wondering if you could expand a little bit more on what areas you tend to need travelers um we've heard for example from other hospitals or is a big area um as well as if you know the number of fte's um uh i think those were my only other questions related to travelers sir julie do you want to touch on that uh sure hi um so we have about eight travelers in um in place right now uh we've have had difficulties for the icu med surge and predominantly the emergency department we have been able to retain our staff in the or um which is is great so that those are the areas that we are struggling with and we've remarkably had trouble recruiting travelers um it's not usually as hard as it has been the last few months to get travelers here well i imagine covid does not help with that either no and some of the southern states that were uh offering huge amounts of money for people to come and work first new york and then down in the south texas and in florida in places like that huge amounts of money for people to come and work there so i think that was a little more enticing for the brave ones that wanted to jump into that so but those are the nursing positions that we have travelers for great um do you have other areas where you tend to need a lot of contract labor we have heard some around different kinds of text we've had to lab tech uh travelers at one point uh oh bob bob pros yeah yeah so bob's right lab tech um that's probably the other big one um obviously it's nursing's real pain point in general though you know we're tight labor wise across the board you know whether it's diagnostic imaging whether it's lab tech whether it's respiratory therapy all those you know allied health roles are are still are tough to recruit for here thank you um and then my last question relates to telehealth um you mentioned um that you're expecting some continued telehealth i wondered if you could give us a sense of at one point um how much telehealth were you doing how is it declined what do you see as some of the successes or challenges around telehealth sure we pulled together some numbers and laura is going to walk you through that sure i'm happy to talk about that thanks for the question um i'd say that at the height of our at the height of the pandemic um back in april there's probably about um an 80 utilization of telehealth um right now we're down to about five percent and i think that will stay pretty consistent um patients are actually really wanting to come in and see their providers um but there are definitely certain visit types and such that really lend themselves well to telehealth and and those services are continuing in that um certainly the challenges are our area and our ruralness um so broadband um i think caledonia county is about 20 percent underserved right now um and then also the um demographics of our health service area as well but patients and providers alike have really i mean we we implemented telehose or telehealth through a water hose right um through a fire hose rather uh so um people picked up on it really quickly and really embraced it since it was kind of the only option there for a little while and i and i know uh oftentimes what we think telehealth you think you know connecting over video with a patient but um a large number of those visits continue to be telephonic and and and i think we should recognize that as well you know for uh many of our patients that's still the most comfortable way to connect if they're not coming and showing up in person that's interesting yeah and i was curious uh the five percent is the lowest we've heard so far in terms of what people are expecting for a steady state would you attribute that to either the types of services that you provide obviously there's probably a lot more telehealth than uh primary care for example and you have a strong fqhc network um but uh we what would you attribute that to the five percent compared to other folks are anywhere i think the second lowest we heard was 10 and most people seem to be around 30 percent i would really say patient preference um they're really preferring to come come into the office versus um utilize the telehealth service um we're certainly still offering it where it's appropriate um for example a psychiatry is still 100 percent telehealth all of our behavioral health visits are still um utilizing telehealth and then you know some of the follow-up type appointments too we're utilizing telehealth but the option is still out there for patients but many of them are opting to come into the office and see their providers uh i would also be remiss in in mentioning i know bob is probably desperately trying to reconnect right now but um i believe the enhanced reimbursement for rural health centers in telehealth uh will be expiring later this fall and so we've got to keep our eye on that and uh that national stage and see what happens in terms of the evolution of reimbursement for telehealth services that yeah thank you so i'm sorry i um i'm in laura's office now no worries you know if you had the overhead and transparencies i'd be great you're doing great bob don't worry about it um great well that that's uh interesting i appreciate your observations because i think in the rural areas it's hard to tease out with the telehealth how much is broadband the issue which would you know i think drive more people to come in versus the travel time which you think would drive more people to want to do telehealth i mean it'll be interesting to see what happens over the winter when travel is more challenging as well but that was my last question thank you very much thank you robin thanks robin next we're going to move to board member pelham tom thank you um i also want to add my applause to uh the fact that you you're you're certainly well grounded as a stable force in your community and that serves the people that you serve well and i think it will serve you as an institution uh in the long run well that people just think that you're there and you're rock solid and and it's an embedded part of the community so that's a hard thing to build and so congratulations on doing that um my first question has to do with the grant funds and so you can see on the income statement the 7.19 million dollars in use of grant funds in 2020 and the 597 thousand in 2021 those two combined add up to 7.78 million dollars but then on your um your revenue replacement fund sheet um you only show an amount of 7.39 million dollars being uh not having to be repaid and so there's a delta there about 400 000 and i'm just wondering what your thinking is on is on that sure so um actually my thinking is completely different now um because of our volumes coming back we're not going to need all of the covid funds that we've received um i'm actually looking if things unless things change having to actually repay some of the money that we've received so um the the flow of those covid funds has changed completely so what i'm thinking right now is that in total we'll use about 4.3 million dollars of the money we've received thus far i mean some hospitals are saying that that they don't want to commit at all because they're afraid of audits uh you know of these funds relative to the regulations and so they're kind of keeping some tucked away to um in in case there is an audit finding right so um they're definitely going to be well i shouldn't say definitely as it stands right now because we've received more than 750 000 of federal grant funds which these i considered we will have to go through a single audit for them yeah okay you know so we've got the money we've got the money um it's just i'm not sure we're going to be able to justify all of it when this is all but you're earning interest on it yeah six thousand a month that's not bad good going um on the provider tax i noticed that your um amount that was budgeted uh for in 2021 was exactly six percent of your um 2020 projection for net patient revenue and ffp but now that you're you've got some uh you favorable wind at your back as as you begin to land at the end of the fiscal year that uh 2020 number is going to go up a bit and i'm just wondering what the process is to fine tune that number relative to um you know the end amount that you're actually paying tax so the end amount we're going to eventually pay in tax will be our actual fiscal 2020 net patient revenue so um that's a moving target but based on our reprojections the budgeted provided tax is actually a little bit low about 150 thousand dollars yeah so you so you don't know uh what the exact amount is going to be in your 2021 budget until the fiscal year 2020 is correct typically typically there's a reconciliation once the fiscal year is done the provided tax gets adjusted to the actual results for the prior year so in this case a 2021 provided tax will be based on our actual 2020 net patient right right um looking at the just the pair mix issue and uh i appreciate uh you know that uh you know diva has come out and said there's not going to be any Medicaid rate increases in 2021 but i'm i'm just looking at your growth in Medicaid um is uh 29.2 percent um over uh you know the 2021 uh pair mix number is 29.2 percent over uh 2020 budget and 15.5 percent over uh 2020 projected so um those so and so if those are all volume based they they seem pretty rich so they're not all volume based um a couple things to contribute to that uh one is uh under our a co program there's been an increase in the attributed lives so that's right treatment has gone up um and the other is we are building into the budget um a slight increase in Medicaid due to the economic downturn created by the pandemic you know things aren't as good as they used to be employment's not as good as it used to be so we did anticipate that there may be an increase in those coming onto the Medicaid program that's right i forgot that you were the lead dogs on this your revised way of calculating attribution um so um just thinking a little bit about last time we met i forget whether it was up there here uh you talked about the relationship with littleton hospital and that uh you felt some of that market share was coming back to you uh i'm wondering just how to this covert experience uh you and littleton uh collaborated didn't collaborate uh you know what what what that experience was like sure they reached out to us recently actually shan do you want to talk about uh sure up in there yeah you know i i think uh early on we're still very much operating in a bubble uh you know struggling to cope with uh the challenges we had internally but just in the last month and a half uh we've uh developed uh a collaborative working relationship the leadership teams have gotten together now a couple of times and uh we're we're exploring ways to to improve collaboration and partnership one of which you've already heard about which is the ophthalmologist and how do we work together to keep that ophthalmologist in our respective communities um but there are some other opportunities that we're also exploring around uh ent or uh even uh ortho and emergency ortho services so i i interested like i mentioned to you earlier i think one thing that we've seen is that uh we've always had a strength in in developing strong partnering relationships and if anything covet has brought us all closer together than not and my final question is um around this around infusion therapy i mean it's a big number and i'm just wondering you know what is the volume risk around that i mean it's uh i don't know the amount that you're paying whether that's one patient or two patients but but if there's a uh an addition or a subtract subtraction of a patient and getting getting that service it's significant so i'm wondering you know what the volume risk is is you know around that sure it is one patient it's one patient um $26,000 of drug cost every two weeks so if if that patient uh is not get that service anymore our expenses would go down and our revenue would go down by the same amount it's just basically covering our cost but so but do you have any kind of like sense of of what that um disease is in the community that is is it a high risk that another person could show up or very low risk i would just be careful about uh any HIPAA yeah i was gonna say yeah i can't thank you thank you Kevin i can't give you a lot of details but it is not a community communicable disease that i was just wondering about the demographics but um so that's that's my last question yeah n equals one it's very hard to uh speak uh directly to that i will say though that that's an example of the challenges what we have with the system you know that's one patient with a particular condition that needs a particular drug that could happen you know it's it's a roll of dice you could have a completely different person with a completely different um need and a very expensive drug that's gonna impact your your your npr numbers thank you very much thank you tom next is board member usa for maureen uh thanks and i also want to echo the thanks for everything you've been doing during the pandemic um and uh also echo just this comment on your presentation it was very straightforward i really appreciated all the bridges that you put in here the cost savings you're one of the only hospitals that actually has lined out that the cost savings on the chart and i keep asking about it every year and i've been asking every hospital and and you did um put that in and also we did a few more details on your cash flow so that's been um very helpful um i don't know if it's possible to bring the presentation back up because i do have a bunch of questions um on the financial statements it might be i know that i know bob was sharing before and i know i don't think i can let me try to i think i might have it up here okay hold on a second laura is going to try and do it okay did you have another question while she brings it up um a lot of my questions are going to go through you know are going through kind of some of the financial statements but i'll start with when you go when we would be on slide 10 which is the income statement and i'm going back to kind of 2019 as you know the base year since 2020 obviously there was a lot of fluctuation on what happened but when you look at the salary fringe line in 2019 it was 50 million your 2020 budget was 56 million your 20 projection is 60 million and your 21 budget is 63 million so there's been a huge increase across that line from um 2019 to the 21 budget and and there was a big jump that occurred in the 20 projection so really just trying to get a handle on it it looks like some of it might have come out of other operating expense which there was a reduction so trying to see one were there any reclassifications in what you were looking at between 19 and and where you're going in 21 yes can you hear me yes yes so uh what happened is um we've reclassed the travelers travel expense used to be other operating expense uh and that was it's considered part of the salary budget um so that's a big chunk of what's going on there so it's like 1.6 million in 2021 for travel expenses and in 2019 that was included as other operating expenses okay there's still a pretty big swing there you know from from 50 to 63 year over year and i know you brought up some of the salary increases but you cut fte's you know you had cost savings in that line so it was just having a hard time maybe you couldn't follow up i will yeah yeah i will marine yep okay yeah it's okay i mean i you also went down six million in your other operating expense so it could be um there's nothing else yeah from 50 to 56 but there's nothing else we'll get that for you okay um and then i also also wanted to talk about the COVID related expense and on slide um and slide 17 you had the incremental COVID related expenses for 15 that went from the 20 budget to the 21 projection but on the following slide when you went from the 20 budget to the 21 budget the COVID related expense was 1.1 million so you know there obviously there may be expenses that were expenses in the 2020 forecast you know i think the cleaner way to look at it is the background but i think the cleaner way to look at it is probably the 20 budget and the echoing so you're breaking up you're breaking up a bit but i think i get the gist of your question so if you look at like slide 17 you'd have to add the 722,000 and the 415,000 under 20 to 21 projection so those two together are the 1.1 million so if you're just going from 20 budget to 21 budget it's just that one number the 1.1 million for COVID related expenses so then to the commercial rating i think you might apply i'm talking yeah and i you're breaking up as you're you're asking the question at least on my computer here yeah so the 1.1 million looks to be the change from 20 budget to 21 and if we then look at your commercial rate increase um that would almost be the entire commercial related to the potential piece yeah again you're breaking up i think i get just the question again so the 1.1 million of COVID related expenses some of that is for laboratory testing and we get the revenue for that so we're not looking for any rate increase to cover what we're getting reimbursed by the insurance companies for the portion of the expenses related to lab testing okay that makes sense um the next would be on the balance sheet um when you talk about the ACO risk reserve settlement payable and in 20 projection you had 1.1 million and in 20 budget you have 1.7 million and then you also talked about early in your right up a 600,000 reserve for the ACO and really just trying to understand what do you have on the balance sheet for the ACO from 2019 2020 and then 21 um so so the the total uh that you see there the 1.7 million is for three years so there's a fiscal uh the plan year 2019 plan year 2020 and 2021 uh at some point likely that will have a at least plan year 19 piece of that which is about five hundred forty three thousand dollars um but you know i'm not sure when that payment's going to be made so the way it stands right now all three years is still showing up as a liability on the balance sheet okay and as far as you know in 2019 you think you're going to owe about five forty three and what would you have accrued for 2019 uh that's is when we ended up accruing yeah okay and then for 2020 you're kind of estimating are you are you accruing 100 percent of your liability it's like 95 percent of our projected liability and 600 thousand is the fiscal year 2021 piece of the risk and that is at 100 percent right okay we can see that and i mean obviously we hope at some point you're not incurring 100 risk each year and that is you know you would just have to what we are seeing with some of the hospitals now is just a tweaking of that budget year over year as they kind of look to reconcile that it won't be maybe 100 in 2020 um because we're hoping maybe there's some favorability there because of the usage right and then now you're putting on a full for 2021 so we're hoping and we're assuming that that might happen but you know again i'm just a little conservative by nature and until we have some better data that's what we're going by right okay um and then when you talked about 340 b um i believe you had four million dollars um in in one number you talked about in 340 b and then a million five i mean what is the what do you think your contribution so your revenue less expenses is for 340 b so the that really is on the um other operating revenue side that 2.5 million or so and that is net of expenses uh formally so the four million so there's two pieces to 340 b one is the savings we get for our outpatient drug purchases except for many patients um so you know that's just we don't have a lot of expenses related to that it's just uh our pharmacy directed as a great job of making sure we're getting all the 340 b savings as we can but there's no other costs associated with getting those savings the other operating revenue the 2.5 million again and round numbers is net of the drug costs that we incurred to for that program and out of the fees that we pay to the pharmacies for dispensing the drugs so that the 475 that's a change from 20 budget 20 projection to 21 budget i think in the other operating chart and then there was a negative 400 you know just i guess at the end of the day for getting the bridge charts for this part you know what's revenue less expenses and yeah so uh again the bridge part is is not accurate because of the reprojections but again i guess the the answer is that all of the expenses associated with 340 b program are netted out and the growth is on a net basis okay um okay that's all the questions i have thank you Kevin you're on mute thank you marine um i just want to start out uh with a big thank you to the whole team at uh at your hospital and basically um you know it's very evident when we've been there we've seen true community involvement we've seen a real sense of collaboration and i think that uh it was a major step this year to um hear that you're even reaching out across the border in the past it seemed to be more competitive in nature with little 10 and i think uh by having conversations with little 10 in north country in vrh is really taking the lead and trying to figure out how best to provide access to members of the community and really expanding what what is the community to others hsas as well so thank you for that and we're very glad to hear that um you appear to be solving that access problem when it comes to ophthalmology um were you able to apply for any FEMA grants and at this point we've not decided to apply for any FEMA grants Kevin for the same reason i mean we think we've already received more than cash and we're going to be able to support um so if we got any FEMA grants my concerns we just have to pay them back okay well one of the things i was thinking bob is i'm not sure if it was you or shan or who but somebody spoke about the uh real necessity to have good testing and one of the things that we've seen in vermont as many hospitals have not been able to have good testing and when when the testing is there the the time lag has been problematic and i didn't know if you had looked into um purchasing any equipment that would give a faster turnaround in that you would be given access to uh supplies yeah we um we've been paying close attention to this and it's a real challenge we actually um just as covid started the ramp up actually the conversation started we had a very generous donor in our larger community came to us and asked what our needs might be and one of the big needs on our list is a high-end uh lab analyzer it's called uh i think we ended up with a sephia and the uh donor said yeah we're going to help support you get that and they did um we put the order in in early march and because there was such a back order on those devices i don't think we got it until july and actually just got it up running but that's only half the battle um it's the challenge now is getting these they're called pods which are the which are the essentially the medium in which the test is performed so we have this beautiful new piece of lab equipment in our lab but we don't have and cannot get the medium in order to do the immediate testing that we really need and my understanding is regardless of the type of equipment you buy that is a challenge for the entire health care system uh word is that we may start getting that medium uh maybe as early as december uh but your guess is as good as mine it really comes down to the supply chain issues that we have um we're really hopeful for that because having that on-site testing would be transformative to us it will make a huge difference in our ability to care for our patients with the the machine that you bought what is the turnaround on the test shan boy half an hour 45 minutes right mike yeah 45 minutes to an hour yeah that makes it so much better for your for your your care you have to get the results quicker so um you know we we continue to hear from others as well that uh the the medias epi and kits are really tough to acquire and uh we just hope that uh as more people um in the production area see the the huge opportunities that are available that more production will occur and that will be a great help for you and many others in vermont so definitely so um with that i really don't have any other questions the board members have really done a good job of grilling you and uh your presentation was uh very good so i'm going to turn it over to the healthcare advocate and i'm not sure i didn't see mike on the line but i did see eric and julia who will be doing the questioning today i'll be doing the questioning great thanks eric um so one indicator of um kind of the efficacy of the free care policy that we've been looking at is a amount of free care relative to bad debt and nprh has over the last two years performed really well on that metric um in 2020 budget um you guys were the second highest um provider of free care relative to bad debt in the state on 2021 uh fourth in both years you guys were the highest um in terms of critical access hospitals um in talking with other hospitals what we've seen is a lot of times when that ratio is really high that organizations have a bunch of organizational processes that are enabling people to get free care so for instance screening people when they come in and then actually having staff go to the bed and making sure say for instance that a child who's born gets on quickly on to medicaid um and i was wondering if you could talk about some of these organizational facts that aren't necessarily evident in the written fap that you feel are um critical in getting the appropriate financial supports to your consumers sure yeah we don't go to the bedside um unless a patient asks you know if a patient says i don't have insurance i'd like to talk to a counselor um we try not to get into the clinical areas but we do everything we can once the patient gets a bill you know it's very clear on there please call if you feel you need help paying your bill or you can't pay your bill and we make every effort so we try and reach out to patients and we try we do reach out to patients try and get them on medicaid first and if they're not eligible to get on medicaid we'll work with them diligently to get them to qualify for our free care program we have a very talented person who's supported by others but the person that is most involved with that does a great job um helping people apply wherever she can and uh can it show this i think uh in the numbers i also would like to stress uh it's not just what we do here at the hospital that impacts that um we have great uh relationships with our human services uh and social services partners within the community we have our own department here and community connections uh northeast came in community action uh the AAA uh you know the council on aging um and uh those partners umbrella right here helping uh you know women who are struggling and all of those partners really work together well to ensure that um the members of our community are receiving getting the access they need to health insurance or other services as necessary and that really helps overall yeah that's a great point it is a community effort yeah it does really come through in the numbers and it's much appreciated um and i just wanted to ask one last question about the actual reduction in the overall number of uh free care dollars for 2021 b i mean said do the increase in medicaid or what's driving that i think part of that eric yeah i think that's part of the what's driving that um so our medicaid numbers have gone up a bit and i think it's uh one of the reasons why the uncompensated care has gone down a bit well that's all we have thank i want to echo everyone's voices on this thank you so much for everything you're doing and i know i can only speak from experience the messages uh coming out of my local community hospital have really added to my mental sanity in this period when there's a lot of noise and it's wonderful to trust your local providers so thank you thank you eric thank you thanks eric so now we're going to move to public comment is there anyone from the public who wishes to comment on the nvrh budget so hearing none um once again i want to thank uh everyone at nvrh um for um the dialogue this morning and uh again um echo the thanks that everyone has offered on the excellent work on um addressing um really ramping up for what we expected to be a much larger um hit from covid but really also i think that it's a testament to what you're doing that you are over a hundred percent again because your community has confidence that when they go to your institution they're going to be safe and so keep up the great work we are going to go into recess to 1025 and at that time we will take up northwest medical center so thank you everyone have a great rest of your morning thank you everyone thank you very much have a great day thanks bye