 ready might take it away. Thank you Chairman Bunn. I want to make sure I know how to make this thing work here. Do you get an explain? Okay. And then the pointer is? The black clock. Got it. Okay. Very good. Thank you. Thank you. Well, good afternoon. Good afternoon. I understand that we are the last of the hospitals coming before you over the last couple of weeks, so. Last but not least. Yeah. Thank you very much. We have a little bit of a story to tell you. Obviously, you've had a chance to see the slides beforehand, but we'll embellish those a little bit. But first, I want to begin by thanking the Green Mountain Care Board for inviting us here and giving us the time to tell the story, and hopefully we can answer adequately any questions that you might have. I also want to take the opportunity to express my appreciation to the staff of the hospital who do a wonderful job day in and day out providing care to the Springfield community and the patients that come to us. And to the folks on the hospital staff that helped Tom and I put this budget together for 2020. As you can see, it's a pretty conservative budget, we believe. But it's a very realistic budget, we hope. And we'll talk a little bit about that as we go through it. A little bit of background about Springfield Hospital. It is a critical access hospital. It is one of two in the state that are associated with a federally qualified health clinic. As you know, the clinic actually is operated by the organization called Springfield Medical Care Systems, SMCS, and actually the hospital is a home-owned subsidiary of that parent SMCS that operates the FQHC. So that's the way we're structured. Our hospital has an average daily census of about 12 acute patients. Sometimes it'll spike up to 17 or 18. It did that the other day. As you can imagine, that is a real challenge for us to have enough nursing staff to be able to handle those patients when they do spike up. But we do and we do a great job. We have a number of folks that are willing to be what we call on pervium. We will come in and take those shifts and they're very qualified people and then not work when the census goes down. So we average about 12. We also had a distinct 10-bed psychiatric unit. It's not on the campus in Springfield. It's down in Bellowsville at the old Rockingham Hospital that was converted to a 10-bed psychiatric behavioral medicine program. It averages about seven patients a day. It can go up to 10. That's our total capacity of the 10-bed distinct unit. There are days of the year that we are at 10. And we were there just recently. But most of the time we average around seven to eight patients a day. Springfield Hospital, we'll talk a little bit more about this, and Springfield Medical Care, the parent of the hospital, has filed chapter 11 with the bankruptcy courts chapter 11 reorganization petition that occurred on June 26. We'll talk a little bit more about that in a little while. But even with the cost that you're going to, the cost cuts that you're going to see in this budget and the other changes that we've done with operations, because of the uncertainty of those activity levels and the challenges that puts on the staff, we don't believe that the organization, as it is structured today, is sustainable. And so we're, and again, you're going to hear a little bit more about this in a little while, the steps that we're trying to take to see how we can reorganize the system of organization to function a little differently. From a financial point of view, we have about 10 days cash on hand. So we're living pretty much on the edge. And Tom, we'll talk about that a little bit further. And as I said, we're looking at trying to find a partner in our healthcare way we deliver healthcare in the area and the way that we could then restructure the organization. That's still being worked on as we speak. We have had several discussions with the Dartmouth healthcare organization and other potential partners. And we are currently in a state of where we are with those other organizations, the other organizations being Mountain and Scutney Hospital and Valley Regional Hospital. Along with Dartmouth, we're looking at how we structure those three hospitals along and have Dartmouth as a tertiary that would help support those three rural hospitals, provide care in their respective communities in a collaborative way. We actually, the Dartmouth organization is funding some financial projections that are being done by that firm called BKD. And we hope within the next two to three months to have those financial projections of how those three hospitals might be able to restructure, provide care to their communities in a more cost-effective and efficient way. The chapter 11 process that I talked about a second ago, it's a very fluid process. If you've ever been associated with any organization that's been through that, everyone tells us it will take anywhere from 6 to 12 months. The purpose for having done this strategy is, I think when we were here back in May, we talked about the fact that we can make the organization operate financially going forward. But it's the debt that had been accumulated has to be dealt with. And that's where the chapter 11 strategy process helps us deal with that. But it's moving slowly. The organization is a very complex organization because it is not only a hospital but an FQAC. There's a lot of local organizations entered chapter 11. There's a lot for the bankruptcy courts and the parties involved in that to understand how all of our organization works. And so it will be a slow moving process. We'll try to move along as quickly as we can from our perspective. So the budget that you've seen before you, and we'll talk a little bit about in a few minutes here, is one that's very much in transition. It does try to move us in towards a restructured organization for the future, but it can anticipate all the changes that might occur as a result of those discussions that I've referred to. It also does not and could not at the time that we put this together anticipate the cost of a chapter 11 position. So none of those costs are included in this budget. So the budget is one that if we operated just as we did in the past, this, you know, we would have some ability to be able to say the probability of these numbers being close to accurate and actually incurred. The difficulty with us having to be able to do that now is because of the chapter 11 restructuring process. It makes it very difficult to make those projections. We did not ask for another rate increase. Several people have asked me, why not? Basically because we didn't do that because we are so heavily used by the governmental payers, Medicare and Medicaid, 65 to 70% of our payers are paid by either Medicare or Medicaid. And those payments are fixed payments. So a rate increase only drives up the contractuals for that reason. And the other reason is the board appropriately so granted our request for an increase in the middle of the year. Many of the rate increases that we put in the insurance companies didn't necessarily honor or said they would honor it when they do their normal rate increases, which is first of October. So the 5% increase, we're not going to see some of that until October comes anyway. So that's why we did not ask for another rate increase. So we'll get into the meat of the budget right now. Tom Marshall, who's the RMCFO is going to handle several, the next several slides for me and explain some of the numbers that you see on there. So this is a picture of our operating results in 2017, 2018, our 2019 projected and going into the budget for 2020. As you can see revenue is a fairly flat throughout the year from projected to the budget, where we are in progress is in the operating expense line, we've reduced from $57 million, $5 million down to $51.4 million in the budget year. The projected of $56.7 million, I believe you all asked questions about how we were going to go from $56 million to $51 million in one year's time. But we've already started that process back in 2019 and we'll have some other slides that show that progress that we've already made to the expense reductions. Adjusted emissions, as you can see, have affected revenues. We're in the 98, 97, 98, 100 down to 8,400 in 2020. Average daily census has gone from 14.8 to 12 this year and in the budget, that's what we're using for average patient days. The birthing center has been closed during 2019, so that's affected some of those numbers in the census data. The site census has averaged, like Mike said, around seven a day. We're budgeting 5.7 within the budget year. If I can just add one point, when you look at the volume numbers, which is the adjusted emission line, it looks like we kind of fall off the cliff between 19 and 18, when in fact, if you look at it on a quarterly basis, the decline in activity has really started happening around July of 18 because of our fiscal year. And so the fiscal year that ended in September of 18 only had one quarter of some declines that started occurring around July and then started that decline had continued on and legally that has bottomed out and that activity level will continue to run. That'll be the new norm for us. That's what we anticipated in this budget, rather than those volumes coming back. We don't know the reasons for the decline. Could be population health efforts. That's probably what it is. It could be some of the publicity that the hospital has been through over the last six months or eight months in terms of what the public's images of the hospital. But we've seen that volume start to come back now. Not at great numbers, but it's not continuing to decline. So we're talking about the revenue declines and of course the closure of labor and delivery. We had 152 deliveries in 2018. We were down to 66 in 2019 when in May we closed the labor and delivery department. And gross revenues for labor and delivery in 2018 were $437,000. Net was $200,000. In 2019 we had a gross of $234,000 and net of $107,000. So that affected our top line mostly. Inpatient census again is down from 16.2 and 18 down to really 11.9 to 12 in the budget. We also averaged about 12 in our projected 2019 figures. The psych census has gone from 7.4 into the budget of 5.7. We've been running in this year of around seven in the psych center. How patient volumes, as Mike said, have come down quite a bit from 449,000 tests and visits in 2018 to 408 in the budget. And as of July, year to date, we had 420,000 visits this year projected to come in at 478,000 for the year. But again, it's slowing down quite rapidly. A lot of our EDE visits are down and therefore a lot of procedures are down on the outpatient basis. We had operating gross revenues in 2018 were $3.6 million and we had expenses. I'm sorry. That's the site facility was at $3.6 million and gross revenues in the budget will be down to 3.1 million. So there are no departments left on an operating basis that are losing money on the operating level currently. And with the changes in the restructuring, we still need a partner to successfully emerge from the Chapter 11 process as we talked about our expense cuts. Let me talk a little bit about those. Since this forum has been involved in January, and for me as the interim CEO and Wayne Schultz and now Tom, the two interim COPs have been here, we have really focused our efforts over that period of time of trying to reduce our expenditures to match up better with our revenues and the cash that we're bringing into the organization. So what we're trying to do on this slide is take a look at where we were in 2018 because those are the actual audited numbers instead of any projections that we were doing. And what are we saying those expenses for the entire organization are going to be in 2020? And then we gave you a list of some of the major factors. There's about $10 million reduction, which is awfully significant, but it's the only way that we can try to stabilize the organization from a financial perspective. We've done these reductions very deliberately, very consciously, with a lot of discussion, trying to minimize the impact on the care that we provided, trying to find ways that our items of expense that are more of an administrative point of view. But obviously, we have had to touch some areas that are patient related. The first one as Tom had indicated is back in May, we stopped delivering baby. That saved the organization from an expense point of view, about $860,000 from what we spent in 2018 to zero in 2020. All of the changes that we did in the acute medical surgical side of things, staffing changes, restructuring the way we staffed, our expenses we were predicting for the acute medical surgical side is incorporating some of the reductions in violence. We'll be about $350,000. We've really done an annual basis less than it was in 2018. There's employee benefits of about $1.4 million that we're rejecting less expense in 2020 than we had in 2018. Mainly focused around our insurance program, our health insurance program. We're doing what a lot of other organizations have done previously, and that is we're raising deductibles, asking the employees to pay a little bit more for their premiums, along with some changes in the pension program that we're booking that making as well as obviously the FICA with fewer salary dollars. We have less FICA expense. The emergency department, I think we talked about that when we're here back in May, we've changed emergency room providers, and we've changed the way in which we paid for that service. We accomplished, I think, the fact that we now have 24 hour a day, seven day a week, 365 days a year, MD coverage in our emergency department. Prior to that, we had some shifts that were covered by physician's assistance. Not that the care is any different, but it's proven that a physician can do a couple of things. One, you can see more patients per hour physician assistance can do, so our throughput is faster. As well as as Tom referred to earlier, what we're seeing and experiencing is that there are fewer ancillary tests ordered by those doctors that work for the new firm. For example, the imaging test that they ordered, more of those are coming back positive, so there's less of a test being ordered to rule things out. The emergency room doctors who are all trained emergency room doctors with this firm just treat patients in a different way. We've seen our throughput times go down, turnaround times go down, and so it's been heavily beneficial for the patients as well as taking $3.3 million of expense out. It did reduce revenues because the firm bills for that professional component, so our revenues went down as well, but it did still took $3.3 million of gross expenses out. The hospitalist program, we changed the staffing there to a different kind of a staffing model and that we believe will save us almost a million dollars a year. No difference in the way we cover the hours, just the difference in the way we the number of providers that we have on at any given time, it's just more effective and efficient. We're proposing to change our anesthesia service. We are moving from a hospital employed provider staff to a outside firm that will recruit nurse anesthetists and place those nurse anesthetists at our location on a permanent basis. Those folks will be there. That we believe will save us almost one over a million dollars of staffing and locum cost. And then the final item, the key item there is we're trying to do our staffing without the heavy use of locums, the use of travelers. Locums in the ED alone, in addition to the $3.3 million savings, locums in the year 2018 cost the organization almost a half a million dollars. And we don't see the need to have to do that. For locums anymore because this outside firm recruits the doctors and the physician assistants that are staffed in the ED. And so that the need to have to use locums is almost no. So all of those items make up the majority of the $10 million in expense savings. Tom is now going to show you what some of that has done over the last couple of quarters. This is a 2019 fiscal year that we're coming rapidly to close on. For the first six months of the year, we had the gross revenues of $60 million. Then the next quarter, $24 million. And then for a year to date, June of $84 million were projected July through September of $25 million and finishing up with a projection of $110 million, $500,000 for the year. Now the real importance of this slide is to look at our operating expenses. We've gone from an annualized rate of $62 million in the first six months. We started making our cost reductions in March and April of that year. That quarter was coming as an annualized $53 million. And then so we're projecting the last quarter of the year July through September of the year. An annualized run rate of $49 million as opposed to our budget, which is $51 million next year. Now part of the reductions are all those items Mike had gone over, but we purposely are monitoring our expenses very closely. When we filed for bankruptcy on June 26th and prior to that, we were doing weekly cash flow projections, because as you saw, our cash was very tight. We were down to like two or three days at one point. So we're really managing our expenses based on our cash inflow. And under the bankruptcy rules, we have to maintain the payment schedule that we submit. We submit a 13-week schedule every 13 weeks. It's updated and we have to live by those expense categories. So that helps us control our expenses. We've had to redo how we order items. And that's been a learning process with the department heads. At one point, a lot of the department heads could do their own ordering and order supplies and services. And now we've centralized all of that. We're building up our materials management department and putting the tighter controls, because we've got to know each week what we actually need to spend. Now in bankruptcy, of course, we get relief from all our creditors that were in place prior to the filing, but post filing, we have to pay all our bills under the court orders. So we can incur anything more than we can actually pay. So we have to have real tight controls on that. And it's been a learning process for our department heads and staff of where we're accomplishing the goals as set forward. And that's reflected in the budget for next year. That's why we are able to feel very confident that we could achieve those expense goals within the budget for next year. This is kind of, again, a summary of what I just spoke about by quarter and how we're coming down with the expenses under this new control system. You've heard Tom and I now talk a lot about just the actual revenues and expenses of the organization. But we wanted to take a look at and use some information that we have received from One Care of Vermont back for the period of January to March in terms of what the total cost of care was in comparison to other hospitals to see if there was opportunities to look at it. And you can see on this graph that we tried to do is just reflect where Springfield Hospital ranked in terms of other hospitals in the state relative to some of those major categories of lines of care. And the area that popped out was obviously our emergency room. Both being two or more standard deviations above the meeting. And so we've done a few things in this next slide. We wanted to share with you a little bit about what we've done that we believe is going to have a major impact on that total cost of care measurement. This slide just lists off the bullet points that do that. The one I really want to take you down to is the second from the bottom. The biggest change we believe that will have an impact on the total cost of care was what I referred to earlier, the change in the providers in AED. The new model that we have an MD 24 by 7, they're less likely to admit to have longer observation periods. They have a greater capacity to determine the level of care on a very quick basis. And they appear to have a different, we'll call it a more appropriate use of imaging. And what I referred to earlier was that the fact that on average a physician is not just our location, it's across the country. On average, you can see one and a half patients an hour where the average for a physician assistant is more like a half patient an hour. They just move through the care for the patient much quicker. So that was probably the major impact that we think is going to have on that total cost of care. If you go back up to the top of that slide, the second biggest one is back in July of 19, just a month ago, we brought on to the staff and a care coordinator in the AED for follow up with mental health and substance abuse issues in placement. So some of the things that that person does are the next several bullet points. They're planning outreach by care user to develop more efficient and effective plan of care. They're providing onsite assessment for the intensive outpatient program that we have, which is basically a group therapy program in collaboration with the designated agency that's there in Springfield. The planning implementation of rapid access to the medication assistant therapy program. So all of those things that that care coordinator in the AED now can do that we didn't have before, we believe will have a major impact on the total cost of care. And then the last bullet that we've just recently instituted was increase in the capacity of same-day visits in our primary care practices at hours in Springfield, in London Dairy, Lundlow, Charlestown and Bellows are now seven days a week. Six days a week is London Dairy, five days a week is in Springfield. So we believe that added capacity for those walk-in type primary care services will have a major impact on that total cost of care also. One of the last things that we wanted to then address is the issue of the payment reform and the One Care for Life organization. We end the FGOAC as participated fully with all the payers in the years 2018 and 2019, we're in that right now. However, we believe that the challenges that we faced in 19 in getting some of the information on a timely basis puts us in a position that we believe at least for the Medicare payer that the board felt it was not fiduciary and responsible on their part to take on the potential added risk of participating in the One Care program for Medicare and that being the hospital being paid the traditional way was more predictable for us. The downside risk was less for the organization and so for the year 2020 and it'll be re-looked at in a year from now but in the year 2020 the organization will want to participate in Medicaid and Blue Cross for the ACO in 2020. So in case you have any questions concerning that. Then just to summarize if I can basically I think we've talked about this before when we were here in May in late 2018 and early 2019 we were an organization that was pretty close to classic on a financial point of view. It was very very minute by minute. Today we're an organization that's in a state of transition. We believe we've been able to get our arms around the cost of the organization without materially decreasing the quality of care that we provide. We had the CMS organization through the Department of Health visit us on July I think it was 8th and 9th shortly after we filed our petition in the bankruptcy courts. They spent two very intense days at our organization. What I've told people is they pretty much picked us up, shook us around and looked at everything that we did that actually gounded and went into the OR and at the end of that visit they said they were very impressed with the dedication that the staff had towards the patients. The energy level that they had, the enthusiasm that they had and that they did not see in any area where we were deficient in making sure that our care to our patients and the safety for our patients was being jeopardized. So we are an organization in transition, financial transition. We have begun the restructure of our cost of providing care and continue to do that every day. We're always looking for ways that we can do things better and cost us less. We thank the state for helping us with our cash crunch in the early part of 2019. We thank the board here for listening to us back in May and bringing us a price increase. And so we continue to work on that. We have tried to address the past debt by doing a very well thought out by the board decision to file a chapter of a reorganization petition. That's challenging for the organizations. It's challenging for the staff. It's challenging for the community to understand. But we are open. We are anxious to take care of patients who come to us. And we're trying to collaborate with hospitals like Brattle who are sending some of their staff up, their obstetric staff, so that if it's convenient for a woman who is pregnant to see their provider prenatal type services, they can do that right there in Springfield on our campus and have access to all of the ultrasounds and so forth that they might need. So we're trying to do those kinds of things while we do this debt restructuring. And then finally, we're spending a lot of time with folks from the Dartmouth organization, from Montescutney, from Valley Region, trying to see how we can restructure the way we provide care for those communities in a more cost-effective way of doing that. So that's kind of where we're at. This is only going to work if our community supports us during this period of time. Our staff has been phenomenal. They have supported us all along. There have been some staff that have left because of the uncertainty of the organization's future. And I don't criticize them for that. I understand that. But the staff that are there are very dedicated to Springfield Hospital, to the Springfield Medical Care clinics, and to the community and the patients who come see us. So with that, I just want to, I guess, our recommendation would be that the board with C-50 be able to approve our 2020 budget as we've submitted it. We're ready to answer any questions that you might have. Thank you. Thank you, Mike and Tom. I'm going to start with Jess. You don't want to forget me this time? That's right. Okay. Well, thank you for the presentation. I guess my first question is, given your financial situation that you came into, you have to say no choice but to do a deep dive into your expenses in it. Judging by what you've done, saving $10 million in one year, it's huge deep cuts and lots of thought that went into it. Finding opportunities for cost-eating. We've just had budgetary and a bunch of hospitals, many of whom are not in the same situation, but are facing many of the margins and looking for opportunities for cost-eating. I'm wondering if there are any lessons that you would share places where other hospitals might look. Things that surprised you when you walked into Springfield Hospital and saw this is the way they were doing it. Wow. Here's a little hanging fruit. What lessons could you give in part? I'll try to address that because I've got more tenure than Tom. I was there from the very technical term, the giddy up. It's difficult to answer your questions. It's a great question, but it's difficult to answer it because every organization is different. Tom referred to earlier, and I'm going to try not to be critical of the previous management of that administrator and so forth, but the organization was, as Tom referred to a little while ago, kind of loose in the way in which they ordered supplies and so forth. Everybody could order a supply, and if they found out that it might take two days, they were ordering it on Amazon. So we had to tighten that up. We had to try to get to a centralized purchasing arrangement. So those are the kinds of things we did. One of the big pieces in the puzzle of the cost was looking at that service of Chaubert. That was a very difficult one, not one that every community can do. But for us, it was a must. We didn't have a choice because we just couldn't find other areas that we could reduce cost and continue to run that program. It's only because we made that decision that we could change some of the staffing for our hospitals and change some of the staffing in our anesthesia services, because now we do not have to have someone waiting in the wings all the time for any woman who would come in for the ED and have to have a surgery C-section. So those kinds of things, I think it's just, boy, to try to generalize it, it's just not that other hospitals aren't doing it, and that's why I'm trying not to be critical, because it's hard to... I know I put you on the spot. Yeah, it's hard to answer that because you don't know what other hospitals are doing, but for us, it was just tightening up a lot of practices and policies that we had, things that we had to get our arms around and not stock our shelves so much, try to get people to see that it may take... Yeah, no hoarding, it may take an extra four or five hours to get, so you don't need to stock up 12 of them. It's just some of the basic stuff that we had to do, and then some of it was, as you knew before, we had to ask people to give up some of their pay for some period of time. You know, and some people have criticized us for having done that, but it gave us the opportunity for a short period of time to be able to have our expenses lower than what our revenue that we're bringing in, so we can buy ourselves the time to do some of these other things. So I know I'm not answering your question, but I'll... Let's talk a little bit about this, and the other, I guess my second question related to that, you've also had to think about appropriateness of care, right? Balancing access to what was needed by your community with can you cost effectively deliver, and you have enough volume to be able to produce the quality outcomes that you would want, and so I can imagine some of the, you know, you did some service line evaluation, right, to some degree, and the fact that you're encouraged to hear from Mount of Stutney that the four hospitals, Dartmouth, Hitchcock, Valley Regional, Springfield, Mount of Stutney, are getting together to think about some sort of regional planning in terms of service lines, and I'm wondering if there's anything you can speak to with respect to that, what criteria will you use to try and figure out who does what to ensure that access to care is not compromised, but it's delivered in a cost-effective, high-quality way? Yeah, I don't think there's not going, there's be a little bit of science in it. I've been involved in these kinds of situations before we're hospitals, I've tried to get together, there's a lot of just gut feeling, and when I say that what I mean is there'll be hospitals that will do a particular line of business better, and when you take a look at some of the measurements or some of the capabilities of doing it, for example, if I get specific, we've got two very highly qualified urologists, for a hospital or science that have two urologists, you know, it's marvelous, and so, you know, but when I sit down with the other three CEOs in Dartmouth, I'll be pushing that if we're going to start looking at centers of excellence between those three hospitals, that urology could be on the table for Springfield to maintain or find a way to do that, because what we don't want to do is do something that will scare those two urologists away, and that uncertainty, because they're being recruited, like every other physician especially is being recruited on a daily basis, on an hourly basis, and so we've got to be careful about, you know, how we move forward. So there'll be a little bit of that kind of discussion that, you know, where those patients come from, which organization would be best to have it at, but the whole idea would be let's not try to triplicate what we're doing, because that's not very cost effective, and it begins to challenge the quality, because you can't assure yourself that if you need two specialists to do that particular service, you're going to be able to get six of them to come to this area, you can get two, but you may not be able to get six. I think we're all looking forward to the results of all those conversations. Can you turn to the total cost of care slide? I think it was 10. Yeah, that one? Yeah, that one, that'd be great. So first of all, I want to say I appreciate the efforts that you're making to lower total cost of care, to think about these initiatives, you know, you've got several initiatives to address the total cost of care in your community, particularly in light of the financial situation that you've been under, that you're still finding time to think about ways to address this. A couple things. The slide, I think, I don't know if you could redo it for us, because unless I'm misunderstanding this, the orange is reflects being one to two standard deviations either above or below. There's a big difference. You have almost two standard deviations above and almost two standard deviations below. There's a big difference in there, but they're all colored the same way on here. So I'm wondering if you could resubmit this with another way of looking at it. So we can tell where are you above the average and where are you below the average. And you can have darker colors if you're way above the average and a slightly lighter shade if you're slightly above the average. But you see what I'm saying? Yes, definitely. We use this, the initial time we used this, this was more directional, and that's why we did it this way. The direction we wanted to really hone in on what we thought to be the greatest opportunity for success and not get scattered in too many different places. And I just bring that up because in the data that we submitted in our guidance, the total cost of care for the Springfield HSA, actually not risk adjusted, but Springfield is the second highest on that chart in our budget guidance. In the blueprint profiles, it's also second highest in the state, and that is risk adjusted. And it was the third highest in resource use. So when you look through some of the blueprint profile individual data, advanced imaging goes really high, as you mentioned, and I'm really glad that you've got a methodology to try and address some of that. But screening rates, chronic disease management were low, inpatient use was high, admissions for conditions that could have been prevented by early intervention, primary care were high. So to me, it almost suggested that there wasn't enough primary care in the community for some of the conditions that we're seeing not being addressed, not being managed, not being screened for. So I'm also really happy to see that you're increasing capacity for primary care in the community. But I'm still, that data is a little out of date in the census 2017, and that's what the blueprint profiles have now. So it would be helpful for us to see this is one care data, much more recent, but color-coded in a more specific way. That'd be helpful. A question about your bed. So we always hear in all of our hospital budget process, the number of borders for psych patients and ERs, the lack of capacity for psych beds. You have 10 psych beds. And my question to you is, it's been at our documentary has been about seven. I would have thought it would be closer to 10, given what we have in the state of need for psych beds. But I'm even more surprised that in the budget for 2020, it's dropping to 5.7. So can you just tell me, just to me, there's a disconnect between the obvious need in the state for psych beds and the dropping in projected capacity or utilization there. I think the only connection that we can really draw is we are limited to being voluntary admissions to that psych unit. And so we can't. And those are all stepped out, right? That I don't know, Kim. I don't want to say yes, I believe it is, but. Well, we're definitely not inpatient at cube psych beds. Right. No. But there, but some of the, some of the, I thought some of the pipeline issue was there were that step down or people having trouble placing people when they're ready to leave hospitals, there aren't enough places in place, particularly for geriatric. I guess I'm just trying to understand. The other thing is, the second reason is, is that, that we're trying to approach this on a very conservative basis. We're trying to underestimate and overperform. And so, you know, we've watched our census go down a little bit. And again, don't know why, why that doesn't jive better with what appears to be a demand in the state, other than the fact that we are solely voluntary admission status with the state. But we try to be conservative and project that census. We need that census. And there's not a lot of additional staff we need to have to have nine or 10 patients versus seven or eight. So it's a big plus to us if we have another one or two patients a day. And that was one of the operations that was actually breaking even or actually contributing to a margin, right? It was. Yeah. And my final question I've been asking all the hospitals to get a census relative pricing. So service that's reimbursed by Medicare, $100. That's frankly, what would the same service be reimbursed on average by your commercial payers? I'm sorry, I fully understand the question. So a service that's being provided a Medicare patient comes in, it's reimbursed at $100. That very same service, a commercial payer comes in. What would that reimbursement be on average, given that's a commercial payment? Same service, different payer. You can get back to me if you need to. Yeah. I think what you're asking is we were looking at this before we came over here today and what the difference for Medicare charge versus what we're getting paid on average. And I believe that was someone in the neighborhood of 42%. So we get 42 cents for every dollar that we charge a Medicare patient, we get 42 cents in reimbursement. So I think what you're saying is it would almost have to be $1.42 to the commercial payer in order to cover the shortfall that we're not getting from Medicare. If our charges were equals our cost. But that's not going to be the case either. So we'll have to get back to you. That'd be fine. Let's see if we can answer that. Thank you. Okay, Marie. Thank you for the presentation. A few questions are somewhat rude to the bankruptcy. But I know as you've gone through this process, you need to pay everybody now going forward. However, have you had any issues with suppliers or continuity of supply for people maybe weren't getting paid for some of the stuff that was in the past that now you expect to partner with in the future? Are you having any other concerns with any vendors or suppliers? Many. It's initially almost day one. It's been a constant negotiation with a lot of our key vendors to assure them that even though what we owe them in the past is now put into the bankruptcy protection that we have to pay them going forward and will pay them going forward. So it's been, I've been on a lot of conversations with CEOs of the companies that represent the vendors and we could pull, we could force vendors to supply to us through the courts, but that's a very expensive and time-consuming process. It's better if we can negotiate. Even if, a lot of times we wind up negotiating, we prepay for services and now we're starting to get to the point where we can maybe get a net 10 days to pay and eventually we hope we can get back to a reasonable net 15 or net 30 payment plan with our key vendors. Okay, so some of it's prepay and are you seeing any vendors or because you have to change suppliers costs going up? No, no, we haven't had to change suppliers yet. One is linen. Oh well, linen, the linen provider went bankrupt on their own and we went from a laundry service to immediately we're now going into a linen rental program and it's going to cost us twice as much to do that program but we were at a position in the area that there was no alternative. Clean, laundry went out of business with servicing a lot of hospitals. And going back to your financial results, your trending page you have, a couple questions on that. One, in 19 where your operating income is the negative 6.5, you know in your most recent financials you have a little over eight million dollars in other operating revenue, although of course it's not revenue, it's a loss, getting to 15 million, you know how it's a loss. Do anything move in 19 from what would have been an expense category to those areas and in 20 what's your projection because you have zero there for other operating. So it's not on this slide. It's your non-operating revenue. Are they transfers? Yeah, so can you talk a little bit? Those are costs that are part of SMCS and that the hospital we have cross expenditures. For example our health benefit program is all paid by the hospital and on a cash basis and the cost of that is transferred over on the books to SMCS. We have staff that's on SMCS books that's transferred over to the hospitals. We have a lot of cross pollination going on and that line over the years it was detrimental to the hospital the positive to SMCS when we had those kind of services. I guess there's a follow-up so in 19 it's a negative 8.6 million right and in 20 we have it as zero and just want to... Yeah we're moving towards where SMCS has to stand on its own as well as the hospital will be standing on its that's going to be forced to us through the bankruptcy process so we're planning on that going forward. So that was another question. So as far as the FQHC you're not subsidizing the FQHC in the 2020 budget? Correct. You started off talking a little bit about there was some conservatism in the forecast that always worries me a little bit especially with the history with Springfield but when you look at the 11 million if you look at the projected July through September of your net patient revenue it's 11 million in the last quarter and your projected 19 is 49 million and your projected 20 is 49 million but most of that trend had occurred in the first six months of the year so just want to talk about how comfortable you are that that's going to increase each quarter to get you to a run rate of 48 million for 2020 because obviously you cut some services things have changed and that's part of the reason why you're coming down so I see you know you had 9 million in the in your third quarter you're projecting 11 for the fourth but you know the first two quarters were running more like 14 million each. We've had a number of adjusting entries that we've had to record in contractual adjustments that are catch up entries even from back in 2018 that the current books we brought in some of our quorum experts on reimbursement and issues and you know the PIP program with one care etc we've had to make a lot of adjustments to our contractuals the net revenue numbers historically right now are now being trued up we expect in 2020 we'll have that all in enough shape that we we feel confident in our net revenue numbers going forward but we've had a lot of catch up entries about some of that contractual change actually was a favorable change we had a two million dollar and where did that book through in the month of May so that would have been 11 for that quarter and then it's 11 now I'm just saying get to 49 million you have to get back that trend going up right each quarter and but that stabilize what we feel is our going forward contractual that we've baked into the budget going forward and it's not a true run rate to just to take that one quarter okay it's just you know in the past the expense load you kind of have that as a base that's harder to change and if you ended up only coming in at 44 million that would be a challenge and I know you'll be watching it every day if you need to and then you talked a little bit about why you didn't do a commercial rate increase and I would just question you know whether or not you know if if in fact when you're saying it didn't really go through potentially when you did the secondary one this year because then if it did if some of the did go through in May you wouldn't be seeing a new increase until you know a year plus later so not saying the board would approve it but obviously you're in a lot of financial difficulty and if there were a commercial rate that was trying to put forward you know what were your thoughts on that yeah again it was it was more the fact that the the amount of dollars that ends up falling to the net revenue line from a rate increase for us it's just not you know it's not significant enough to be continuing to raise our prices I'm concerned that we're going to get to a point for the folks who are price shopping that the prices are just going to get you know to a point where they're going to choose to go elsewhere because our prices are so high they don't understand the concept that we've got it was more of a price market sensitivity issue right and you're about 45 is what your revenue comes in commercial so you're you're not on the lowest but you're on the lower side but you know because of some of the other hospitals don't know about that but I understand what you're saying the commercial gets fairly high that's all I have things just a couple of questions sticking with the payor mix here for a second so I'm looking at your history um from 2016 to 2018 uh that the Medicaid was uh between 13.6 percent or 14.4 percent of your NPR commercial 53.3 percent 56.2 percent and Medicare 29.8 percent 33 percent and now the most recent is for 2019 projected and uh Medicaid is up to 18 percent commercial is just noted is around 45 percent and Medicare is um at 35 percent so I'm kind of looking at that and then thinking about this morning's conversation about the capacity that exists within 20 miles of Mount Scottney and Springfield and and the hospitals in New Hampshire and I'm just wondering as you hope that things are bottoming out here and making a turn uh and meeting with people that might be potential partners what are the two or three positives reactions that you get from those folks that uh inspire you to that that there is the light at the end of this tunnel not sure if I know that there's a light at the end of the tunnel or not um I think you know the kernel that I'm getting is the willingness for for us to talk pretty frankly around the table um and to talk about the fact that uh we've got to look at trying not to duplicate and triplicate what each of us are doing that's not going to be the success in the future but we also recognize that uh we today each have our own boards that are in our own balance sheets that we have to worry about um and and so I think there's only one single kernel if I understand your question I think there's only one single kernel that keeps me optimistic is that that uh Dr. Paris uh Dina Howard um Steve LeBlanc and myself are willing to have these kinds of conversations and pretty frankly in an open conversation we're not trying to hide the why I can't I can't even think about talking about that because that's kind of like a sacred count we've got to have that in this community we're not approaching any of that that fashion we're approaching any you know how do we best do this amongst the three hospitals with Dartmouth supporters with those conversations start going sideways on me I'm going to lose that optimism and uh my other question was just looking at the uh trying to get totally acclimated to the math here associated with healthcare provider tax and so I'm looking at from 2018 to 2020 the total operating expenses um at 83 percent of what they were in 2018 but the provider tax is at four and a half percent at at a hundred and four and a half percent so provider tax still going up and your operating expenses going down and um is is is is that what should be happening as I understand it the provider tax is a percentage of net revenue not so much your expenses so cool it is but uh I don't think they base it on the budget I think they they're basing it on historical numbers so it's going to take a little while for that to catch up for that calculation as I understand it Robin um most of my questions have been asked so I had just have a couple of clarifying questions um in your narrative um you indicated you weren't expecting any additional pay health reform payments and I'm assuming that's because the population health payments from the ACO go to the FQHC so those will be brought up separately is that that's correct that's that that gets reported on the SMCS records thank you um and you had said that you understandably had not included the cost of the bankruptcy proceeding in your budget can you just give us a sense of magnitude in terms of what that might look like we've we've been told to plan on somewhere in the magnitude of about a 1.2 to 1.5 million dollar yeah that's legal fees and professional services and the trustee cost the court cost that's if we can get out within six to twelve months it goes on longer than 12 months and that number is going to keep it larger and larger so Mike and Tom are you the two committed to staying through the restructure um Mr. Chairman I can say I am um Tom has had some personal things that that have come up in the last week or two that you will probably have to make a change at that CFO level we do have uh that's going to be hard on you because this will be number three um sorry Tom yeah I don't know if I'm chasing him away but um I hope I'm not uh yes but on the other hand um these are very very talented CFOs and it doesn't take them long it's probably more difficult on the accounting staff the training that they have to take time out to do the training when the person is coming on then and so much difficult on there but um they're very talented executives you know we're very fortunate um it's going to sound like a commercial but and so maybe it is uh you know I've been around for a long time we have a lot of very talented executives that want to work for form and so I'm very confident that I don't we already have somebody lined up very experienced knowledgeable knows what the situation is um and we're working on a transition timetable right now but I'm I'm committed you've got willing and as they got willing and the creek don't rise I'll be here perfect you talked about um expansion of the primary care practices and yet last year you lost money in the primary care practices is the expansion result of better knowledge of when people would actually access the care or how did you come to the conclusion to expand and something that was losing money are you referring to the walking clinics yep um primarily from the standpoint that that's what we believe the customer really wanted um and um we're going to try to see if that's what they wanted by making sure that they show up that they if it turns out after several months that we're not as busy as we thought we were going to be then we'll have to pull those that that you know staffing back but at this point um it's a contracted service it's not a hired service so we can get out of that relative equipment so help me understand because I know that technically we're focused on the hospital side here the hospitals was fully owned by the FQHC the bank allowed for separate filings of the two entities so what does it mean for the hospital if the FQHC continues to lose money um it will have almost an impossible task of coming out of Chapter 11 if it continues to lose money it's going to have to show an exoplanet that exoplanet is going to have to show that it can stand on its own financial could it possible result result of the bankruptcy court beat though a split up of the entity um it could be Mr. Chairman I think it's going to be more of this um the issue that's going to play into that more is going to be this regional planning that we're working on because because you know no one can own that FQHC I think I've given my general counsel coronary so I thought a lot of the question does the uh estimate that you gave us earlier in include the um creditors I'm sorry you gave us an estimate of the cost of the bankruptcy proceeding oh no that's not that's not the settlement of the creditors that's just the attorneys and professional fees for the court itself the court itself and so forth okay that's we we haven't gotten to the point and we're a little ways away from figuring out the settlement for the creditors and what that the amount of debt of the organization might have to continue to care as a result of that and I'm assuming much to my chagrin the attorneys get paid first oh yes that's what I thought but the court really is got high controls on that the court decides what the attorneys will be paid okay I guess that's all the questions I had at this time Robin from your questions around the primary care I would assume that if if part of what's going on as you expand ours people stay locally instead of perhaps going to primary care someplace else not only does that help to FQHC but it could also help some of your ancillary services and referrals back to the hospital is that a fair assumption that's what part of our logic yes okay thanks I just wanted to make sure my logic was matching thanks okay at this point we're going to turn it over to the healthcare advocate thank you thank you thanks for your presentation looking at your bad debt and free care members I recognize that you are small and so you know a percent of bad debt as compared to your medication revenue that looks high or seemingly high to us might be related to a few small a few cases I guess that's really my question here your numbers for 2018 you're showing 11 percent your bad debt is 100 percent of your net patient revenue your best that's significantly higher than the other hospitals you have the idea what's going on I think it's probably a combination of a couple of things one is and I don't know this for facts so I can argue against or correct it but since I've been there I've been told that the economy of our service area is one of the poorest in the state and so I think we have a number of people who either came qualified for any kind of the free care programs and then just choose not to pay the other thing that that we've been working on is trying to tighten up our whole collection our hospital collection efforts before it goes off to a collection agency because once it goes off to a collection agency it's basically written off as bad debt and if there's any recovery it's offset so if we can improve our services we can reduce the amount of money that we have to send it to that debt then the other comment sort of just generally when we look at your 2018 numbers your public payer versus private payer you don't low you actually look like you're in better shape than many in the hospitals and that's confusing to me that for 2018 some other people said some of these numbers said that we were showing 45 percent of your net patient revenues from the public payer and 54 percent from the commercial payers and you know I see you sort of shaking your head that again we're comparing you to the other hospitals it just sort of leads me to the question well actually it did lead to the question a moment ago you said you didn't ask for a rate increase because of how little impact it has yet all the other hospitals will come in and ask for a rate increase even the smaller percentage of the net patient revenue coming from commercial payers but but I'm wondering if those other hospitals had they gotten a bid year this past year would also ask for another if they didn't get one 12 months ago I mean we would be also asking for a rate increase but since we just got one that doesn't make a difference for everyone that's good okay thank you this is my question okay so at this time I'm going to open it up to the public for any comments about the Springfield budget. Dale. I didn't see anything in documentation and I realize this may not be totally relevant maybe to the type of presentation this was but considering during chapter 11 wouldn't there be a concern about surveying the community from a qualitative quantitative perspective to see how they are responding to what is happening with the hospital because they're the ones that are going to support this hospital in order for it to be successful so I'm just kind of wondering did I miss something where's that something that tells me how the community is responding to this well I think that in Mike may want to say some more on this but he's had a number of town hall type meetings with the community trying to explain the situation what what you're bringing up was my concern from the beginning that the community itself needs to get more involved that they truly want to save their hospital and that's been a concern of mine from the get go but Mike I don't know if you want to add anything sure I can I can add that we have had several rounds and Josh Dufresne who's in the audience and is very very involved in the community and involved at the hospital and with the clinic has been joining me on these town hall meetings where we're trying to get the feedback from the community as to how they're feeling initially those were very well attended the last round there wasn't as many people attending so we're not reaching out to as many people as we were hoping the other thing that we did is every three years we have to do a community needs assessment and we're just completing ours now and as a part of that there are focus groups as a part of that process and we're using that opportunity so that we're not over flooding people with town hall meetings or surveys or anything like that we use that process of meeting with the people during the community health needs assessment to get some kind of reaction as to how they're feeling about their community hospital just in general in addition to the community needs that we're doing. Okay is there another public comment? Jeff? Yeah I'm Jeff Keeman with the hospital association just a few quick thank yous as we conclude first thanks to the powers that be that these hearings are over and really importantly thanks to Mike Halstead and Josh Dufresne and the team at Springfield for really amazing efforts to begin to stabilize a really struggling hospital that's critical to care in Vermont and then last thanks to the board for a couple things thank you for the opportunity to address you at the beginning of these hearings with with sort of the perspective of the hospital association we really appreciate that opportunity and thank you as well for your thoughtful questions this is not an easy process and the outcome is really important and you took it seriously and always do and we thank you for that and then finally thank you for the good judgment you're about to use in reaching the right conclusions thanks. We'll see in two weeks if you still say that. Yeah but thank you. You have one over here. Oh yeah. Mr. Chairman do you ask the hospital if they do radical prostitutimies? So Mike? Nope. The question from Mr. Davis is do you do radical prostitutimies? I don't have a clue but I'm looking at my chief medical officer back there. We have the capability I don't know if they're done at Springfield we have your office at Dartmouth as well so it depends on the case and I'm not exactly sure what exactly is he doing at Springfield. Is there any other public comment? Seeing none I wish to thank the team from Springfield I know it's been some trying times a lot of hours put in trying to save the hospital and I know this board appreciates all the work that everyone to try to keep services available for people in the Springfield community so thank you.