 We'll resume our meeting and next we'll be hearing from Northwestern Medical Center and I see Mr. Wright is here with his team. So, Mr. Wright, I'll have Mr. McCracken swear everybody in and then we'll have an opening statement from you and your colleagues. And then director Lindberg will start going through the slides to review. And I think Mr. Sutter will be leading some of the staff walkthrough of the factors and the questions. So, I'll turn it to Mr. McCracken. And thank you all for being here. Thank you, Chair Foster. Good morning, Mr. Wright. Who from the Northwestern Medical Center is going to be presenting and answering questions today? Mr. McCracken, I've got John Cassavent, who's chair of our board of directors, myself, Stephanie Bro, our chief financial officer, Devin Batchelder, who's the manager of budget and decision support. And then we also have Dr. John Menadeo, our chief medical quality officer, Dr. Don Kregel, our chief nurse executive, and Jonathan Billings, our chief operating officer. Those folks will be answering questions potentially anyway. Thanks very much. I will swear you all in at the same time. So if you could all raise your right hands. Do you solemnly swear that the evidence you shall give relative to the cause and under consideration shall be the whole truth and nothing but the truth. So help you God. I do. I do. Great. Thanks very much. And I will turn it back to you. Thank you, Mr. McCracken. Chair Foster, Sarah, let me just start by saying we really appreciate the wonderful support and collegial partnership that we've had with Sarah and her staff during the budget process. It's really been quite nice. Communication has been really strong. Chair Foster and members of the board, as well as the healthcare advocate, we greatly appreciate your the dedication of your service to the state of Vermont. I'm going to quickly hand over the opening part of our quick presentation to our board chair, Mr. John Cassavan. Thank you, Peter. Thank you to the board and thank you to chair person Foster for joining our board meeting a few months ago. I'm going to be pretty brief. I want to tell you a little bit about our board and a little bit about what we're doing and then I'll turn it back over to Peter. I've been on the board at Northwestern Medical Center twice, starting in 2002 for the better part of the last 20 years. My dad started practicing medicine in Franklin County in 1954. The hospital provides services to me and my family, to our community. On our board is the chief of our medical staff, a retired lawyer, a retired hospital CFO, district director for the Vermont Department of Health. We're pretty, we're pretty deep in our knowledge, I think, and very, very committed to Northwestern Medical Center. Our administration under the board's direction has developed a budget this year that I think is both sustainable for our board or for our hospital and responsible to our community and to the healthcare system in Vermont. We're very aware of our place in that community in Vermont, not just in Franklin County. In the year of transition, we were in a new era, kind of post pandemic and a time of endemic. And we have, luckily enough to have great leadership stability, most of them around the table today or maybe all of them around the table today. We are working hard, as I said, to be responsible to us and to the system and in that way this year we've reduced our number of travelers. From 53 to 32 and hope to in the next 6 months, reduce that again significantly. That obviously affects our cost greatly. We've invested in a system to help recruit and train nurses, kind of an earn to learn program. There are 2 of them that allow our staff to move through the ranks, the nursing ranks. Which we are very excited about or really, I have a sister retired. Educational administrator who started by taking care of my mom during the pandemic. And is going to go off and get her in at 62 years old. We are reestablishing connections that weren't interrupted during the pandemic with our partners. In the community and in the greater healthcare community in Vermont. And we think we're on the right path. As I said, we've developed a very responsible budget and we ask your support of that budget. Thank you. Thanks, John. I appreciate that. I also want to take an opportunity to point out that Wayne Hobbs, our chief administrative officer is also joined us today. Though, because of his newness won't be answering any questions and a strategic partner chip homes from ovation healthcare in which Northwestern Medical Center has had a 40 year relationship with has also joined us today. Just to show his support. As John said, it's been a year of transition. It's also been a year of challenge for us. We're currently at a negative 6.5 operating margin. That is a result of short shortcomings in gross revenue. Massive ships and pair mix that have had a significant impact on our net revenue. We've made some strategic investments in salaries and benefits to keep with the market. And that has actually helped drive down that traveler number that has helped recruit and retain, which believe it or not, even though we're making the investment and are over $2 million and over in salary is actually helping keep costs down. If that doesn't sound too upside down. Our benefits are off. You know, you can't really control when you're when your team members need to use their health care plan, but our benefits are a little bit over. Our supply costs are over, but that's strictly because of utilization. I want to point out that one of the things that we're the most proud of is we have about a 13.3% supply cost when compared to our revenue. And that is one of the highest in our peer groups in the ovation and premier network. So we're really, really proud of that. But the shift in reimbursement continues to be a concern, particularly a pretty significant upward shift and Medicare Advantage and the kind of contract terms that we have with the big Medicare Advantage provider, which if you want to talk about, we'd be happy to go into executive session later on. So that's just a quick outline of what this year has been like and what we're trying to do. As we try to climb out of that hole, we've done everything we can to be a good fiduciary by trying to climb out of that hole and get to operational stability while doing our very best to follow the budget guidance that the board has put out. So there's no doubt about it. We didn't hit where your recommendations were, but I think we did a very good job at coming very, very close. And what we're asking for could certainly be more, but we wanted to be, again, responsible to your requests and responsible to the community at the same time. And I think when we look at community need, we've only put forward what we need, and we've struck a fairly fair balance between the two requests. So I'm going to turn it over to Stephanie Brower, Chief Financial Officer, who's going to do a quick recap about where we stand today in terms of Northwestern Medical Center being a low-cost provider and some of the good stats around that. Thanks, Peter. And thanks to everybody on the call today. You know, I think John and Peter have really already touched on some of the things that I wanted to touch on, right? John started by saying, you know, we never take a budget submission lightly. We never take a rate increase request lightly. And so I really just wanted to take a moment and acknowledge the conversation that I heard at the beginning of these budget hearings, right? How do we look at affordability, but also hospital accountability, right? That's an issue that's very real and it's really complex. And so I don't pretend to have all of the answers. I don't think anybody does. And so that's why I think we have to continue to talk about it as a group. I do want to, I think what's something that struck me, right? The most about that conversation is how similar it really is to the conversations that we do have internally. Our leadership team and our board, you know, every time we prepare a budget, we kind of take a step back from that budget and we ask ourselves the same sort of questions that you ask of us, right? Did we hit the guidance? If we didn't, how come we didn't? And how close can we be to achieving that the compliance with your guidance? What is the rate increase request that we have asked for? And what is that due to pricing? What is it due to our community? Is it fair? Is it appropriate? Is it really a price increase to help us cover some expenses that we truly can't control, you know? Or is it a price increase for things where maybe we should be taking more risk and be on the hook? And so I really think this budget does put a significant amount of accountability and risk on NMC, but does help us cover some things that we truly can't control. We ask ourselves how much of an operating margin, right? What is that reinvestment margin that I like to call it? What is that? And is that enough? And is that sustainable? So really a lot of parallels. You guys are wrestling with the same things that we're wrestling with. And I really think that we're taking a step in the right direction. With Sarah's tool, I know the tool her and her team have developed. I really want to go ahead and echo some of the compliments that I know my peers have already made around that tool. It's not perfect, but we can't let perfect be the enemy of good. And it's really a step in the right direction. So I really appreciate it. I think the data will show that NMC is a low-cost provider. It's something that we pay close attention to and want to continue to be. It's really important to us. NMC has worked really hard to control our expense growth. And we think we have budgeted fairly and appropriately for inflation. NMC has a long history of being below average or below the median for rate increase requests. So I think the data shows that too. Peter already mentioned and John already mentioned, you know, some of the great progress we've made on reducing travelers. And this budget holds us accountable to continue to do that. This budget holds us accountable to continue to be a top performer around metrics like supply cost. And I really just wanted to give, you know, really some credit to Sarah and her team for all of the analysis, all of the time, all of the work. If anyone can appreciate how much time it takes to put these budgets together, it's me and all the other hospital CFOs out there. So huge kudos and thank you for everybody's time. I'm going to turn it back over to Peter just in the interest of time. He's going to speak a little bit more about kind of our future strategic direction. And then I think we'll hand it over to Sarah. Thanks, Stephanie. So just kind of where are we going now that we've kind of the past is the past. We can't change. We only can control what we do today and where we go tomorrow. We're in the process of launching a strategic refresh come October 1 will be the beginning of the third year of a three year strategic plans and we're going to be doing some planning over the next six months. So as we look to develop next year's budget, we have our strategic focus in line. Our strategic plan is exceptionally strong. One of the things that I was really impressed about when I interviewed and a major decision for me to come to this organization was an incredibly strong commitment from frontline staff all the way to the the board to be a leapfrog grade A hospital and to be a five star hospital. Those are above all else how we start every meeting with those two goals in mind and how we keep our razor sharp focus day in and day out. The board is committed to being an independent hospital but not a hospital on its own. We have incredibly strong partnerships with the University of Vermont. We obviously with them being 22 miles down the street. We share a lot of patients that go back and forth. As my friend Jonathan Billings likes to say we have the greatest NICU in the world. It's just 22 miles down the road. So as we deal with challenging babies. We work really hard to make those transitions and care at all levels whether older adults or young babies really really smooth and we're very proud of that UVM partnership and I work very closely with my peer Dr. Leffler and with Dr. Ethan to make sure that that partnership continues to strengthen. We also have an incredibly strong relationship with Dartmouth Hitchcock Health and a telemedicine program. So we have a tele ICU program. We're looking at expanding that telemed program into other areas like psychiatric care and a variety of different places. But our friends at Dartmouth are very, very helpful day in and day out with patient care. And then one of the partnerships that's just emerging in the last nine months is something I'm really excited about. And we're calling it the Vermont Collaborative Hospital Network. And it is a collaboration of independent hospitals in Vermont who want to do a variety of different things together. So an example of that is our great partnership with Copley Hospital. How we're sharing a cardiologist. Another great example is a group of those six hospitals who want to lower their cost on fuel oil. Really exciting projects there. Things that we can't get through our premier GPO like fuel oil. The cost of laundry is probably one of the single greatest cost increases that is driving our budget to be out of whack. And something we literally have zero control over. So we're partnering with Ovation Healthcare, a national organization that manages and works with hospitals across the country to figure out how we can come up with our own solution to not have to rely on outdoor outside vendors. And that's really exciting. And the collaborative network, like I said, is just getting off the ground now, but all kinds of purchasing and collaborative efforts that again, strong partnerships. We don't necessarily need to talk about ownership to talk about being part of a system. But what we really want to talk about is who do we work with day in and day out to provide great patient care and keep it at a low cost. We're working diligently to improve our access to specialty care. We have long wait times in some of our subspecialty areas, and we're working hard to get those wait times down. We're working now. I think, Stephanie, I'm going to look to Stephanie to check my numbers on this, but I think we are four days from referral to scheduling an appointment. Is that right? Yeah. So that number was way out of whack. It was several weeks, and we worked really hard to get that down, and that is a continuous project. We're very committed to becoming a high-reliable organization. Dr. Minnadeo and some other folks lead our efforts to continue to provide education on what that means. So every week we're providing education sessions. We require new employees to go through our high-reliable education, and it's really quite helpful in making changes every day and improvements in safety and care. We're also very committed to lean daily management, doing Gember rounds every day, having KPI boards and all of our key departments, and driving change and improvement on a day in and day out basis. But again, we still face all the budget risks that we've already discussed. Subacute days is something that we've gotten questioned about, and that's one of the risks that Stephanie is talking about. We're budgeting for a thousand-day reduction in subacute days. That's a big risk. That relies on our ability to get patients out of the hospital and into a more appropriate level of care. Our payer mix and net reimbursement also continues to be a risk that we're willing to take. The increase in Medicare Advantage, just one of the items under that. And uncontrollable cross increases, like I just talked about laundry, that we're all struggling with. So we have a razor-sharp focus for the future and a good plan to attack it, and we're looking at all the partnerships to help make that come to fruition. So I'll stop there, and we look forward to answering your questions. But thank you for the time. Thank you very much. Let me just give a quick overview of the things we're hoping to hit in your hearing today. So you've already addressed some of these in your opening statements, but just trying to understand some of these investments in some more detail, maybe get some pro tips for how you were able to reduce some of these administrative overhead costs. What you're finding to be successful in your traveler reduction efforts. I know that it certainly makes sense to me that you would need to invest to realize some of those payoffs. The increases for their non-physician salaries already touched on some of the strategies you're using to increase your efficiency and, you know, all your continued focus on quality. Just a little bit more detail about some of that variation in the cost inflation, which you talked about already some strategies that you're using to try to manage that. And then just trying to understand a little bit more about pricing and specifically the gross versus the realized net among the commercial population and how you're kind of grappling with some of these utilization changes. All our PPS hospitals. We just want to double check if that little bit of bump in the final rate is going to be material to your budget. Talk about how you're thinking through the unwinding. Also, you address some of your wait time and visit lag issues that you're addressing. And you just hit the amount of time it took to get between a call and a referral. I mean, just understanding some of your strategic decisions around infrastructure at your facility. So those are the ones that we hope to cover today. And I will move over to the tool and have Matt take it from here. Great. Can you all hear me? We can. Excellent. If we filter on PPS hospitals, which Sarah just did, we can see Northwestern came in just about the 8.6 benchmark at 10.3%. And below that for change in operating expense at 3.5. Just wanted to note that among the PPS hospitals, this was the smallest increase in OPEX we've received, excluding of course, Roland, who budgeted a decrease. You'll also see a 6% increase to the charge master and 4.5% increase to commercial. As noted, the NPR and operating expense is on the previous slide. If you are coming in above benchmark and operating expenses to have an official benchmark, but below that 8.6%. Moving to labor, you can see that there was a provider transfers. We had to count for Northwestern that kind of. Distorted these high level indicators, but if we, yeah, if we move to the labor tab, you can see the ECI benchmark. They're below that and you can see a reduction in FTS over time. A question on labor, which you kind of touched on the opening remarks and in your narrative, but you mentioned several items related. To labor like investment and position to improve patient care and outcomes. Reducing reliance on travelers, reduction in some executive level positions. And you also mentioned you're launching a strategic refresh. So I'm hoping not getting the cart ahead of the horse, but. Just wondering if you could speak a little bit more about your kind of how you're doing the workforce issues like holistically. Sure. Do you want us to talk about that now? Yeah, that'd be great. Absolutely. You know, a reduction in labor costs and reduction in travelers and retention and we've had a drop, a significant drop in open positions to the point where we're pretty close to pre pandemic levels. When it looks at open positions. I can sum it up in three words, culture, culture and culture. This is something that certainly predated my arrival in January. But, you know, the folks around here will tell you my mantra is us them money. So what that means is you take really good care of your people. You make sure that they feel safe. You make sure that they feel heard. You make sure that they feel like they have a voice and how we're providing care. And, you know, our leadership team, their job is to take care of the staff at the frontline because they take care of patients. You know, I don't take care of a single patient. Nobody comes to Northwestern Medical Center because Peter Wright is the CEO. They come because of Mr. Cassavance. Sister is working on the front lines and they know them and they listen and they take the time to walk someone down the hallway to a place they're going instead of pointing. So it's all about culture and that is since the organization has started to focus, we've seen those open positions start to melt away. We've seen those labor costs start to come down. And, you know, we have quickly earned a reputation of a place that people want to come to work because they feel valued and they feel heard. Great. Thank you. And I just add to a couple of things Peter said, you know, I think when you look at this graph in front of us and you look at our most recent data point, you know, we're creeping our way up. If we, you know, look at maybe PPS hospitals or just all the hospitals in general, it's just an area that I continue to worry about, right? Yeah, there we go. We switched to all and Northwestern's kind of down towards the bottom, I believe. Yeah, and that lower chunk. And so I think one of the things that Peter and I talk about that we talk about with the board that sort of keeps us up at night is, you know, how do we keep pace? If we're still not at the top, not saying we need to be at the top, but, you know, depending on budgets that get approved and decisions that get made, you know, will we be able to as our budget going to allow us to keep pace? So it's something that we just have to continually monitor and keep an eye on. But in the current year, we absolutely, you know, made investments in base wages and in base salaries that were above and beyond what we budgeted for. And we knew it, right? We took that on as, hey, we're going to make a strategic investment and a strategic decision outside of what our approved budget was. And we're going to invest and we are starting to see a return on that investment, which is very, very nice. That's what you hope to see when you make those decisions. Yeah, I think on that labor tab, our average cost is 116,000. And again, as Stephanie said, it took a tremendous amount of work to get there. And again, we're worried about what will happen if the market shifts again and labor goes up. Obviously, 65% of everything we spend money on is salary and benefits as being an organization of people taking care of people. So it's something that we watch very closely. And as Stephanie said, we very much keeps us awake at night and particularly through this process. And were there any board questions about labor? Seeing none. I'm sorry. I was just slow. I think in the areas in the area slide that Sarah had pulled up earlier, I think one of the areas was related to the care management. I wonder if we could just get a little more color commentary on what's going on there. Sure. We added FTEs in care management. And that's absolutely about managing average length of stay and avoidable days. I'll ask Stephanie to fill in with a little more detail. No, you're right. It was, you know, just like we decided to make investments in wages above and beyond what we budgeted, we did decide to make an investment in care management. It's one FTE. So for our organization, that's what we added above and beyond what we had budgeted and we did that intentionally. I think you've heard it's been a pretty common theme for most hospitals, right? That it's been more challenging to place patients and get them into that right care setting at the right time. And so we really found that if we could add an FTE to that care management team that, you know, it could quickly be a return on investment if we are able to, you know, move some patients to the appropriate care setting in a quicker way. And so we're just starting to see a little bit of a decrease in our average length of stay and, you know, it's early, so I don't want to make any promises, but at least it's moving in the right direction. And so it's going to be key to our strategy next year of, you know, really reducing subacute days and avoidable days. Yeah, we've had, we've had subacute patients that were here over 200 days. Actually, when you put two stays together, one patient was here over a year. And just, you know, incredibly complicated, working with a state working with every day that requires effort, every one of those over 400 days that that patient was here. When you factor out the outliers, we're doing a very good job when we benchmark against the geometric length of stay. So Dr. Minnedale and I look at that information and we're making great progress and feel that that investment is certainly paying off. Thank you. That was helpful. I'm wondering if this is related to an on your submission and I'm sorry I'm not seeing page numbers. Hold on. I think it's 1, 2, 3, 4, 5, 6, 7, 8 and page 11, which has an operating expense chart on the bottom that might be the easiest way to find it and across from the bond covenants ovation healthcare chart. In your narrative, you indicate that you using the benchmarking through ovation, you know, there are opportunities for continued efficiency and that you've made the choice to invest in positions that place you outside of the benchmark to improve care and experience and outcomes for patients. Is that sort of alluding to some of your care management staff or I just wanted to understand that a little bit better. Yeah, that's a couple of different areas. It's I believe that care management is part of it, but it's also things like environmental services. So, you know, if we were to fall, we first of all, I think it's important to point out we don't go for the 50th percentile like you might expect. All of our departments are benchmark at the 75th percentile. So that's their target. And we're 96% of that target. So I think that's really important to point out. But in areas like environmental services, we have to and actually intentionally make investments with added FTEs and make sure that we have a clean and a safe facility. We need to keep that infection rate down. So, you know, those are areas where we're a little bit, we're a lot closer to the 50th percentile in terms of the benchmark. But I think it's really important to point out that we're already holding ourselves to a much higher standard. I'm going to turn to Stephanie and have her fill in with some more info. Yeah, so care management, definitely one of them that the one FTE we talked about environmental services, one of them. And then for us, it's some of those, you know, you want to disproportionately invest in those areas where you're really trying to make gains. And so human resources and organizational development, right, building that culture that we talked about earlier on. That's an area having to recruit and retain so many employees over this past year and and going forward. So there's 1.5 FTEs there where we know we're not hitting the 75th, but we feel like we're doing what's right and what's appropriate information technology. That's an area we want to lean on our electronic record. We want to lean on information technology as much as possible when it comes to high reliability and our processes and processes and making things more efficient. And so that's an area where we know we're outside of that 75th percentile by again about at 1.5 FTEs and then quality and process improvement. So much of high reliability, lean daily management, KPI boards tracking, you know, our goal against being five star and leapfrog grade A, we're really investing in that quality team to help us use that evidence based information and be out on the floors working with those clinical teams and getting our workflows where they need to be. So those are just some examples. Those are most of the examples really of the areas that are not achieving that 75th percentile benchmark information that we have from Ovation. Thanks very much. Thanks to a quick follow up on that because I think it's really fascinating and I really appreciate all the efforts that sounds like multi pronged efforts to improve efficiencies and ensure that you are delivered by quality care with the goals of the five star rating and leapfrog A. So I'm really intrigued by all of this and I'm just wondering with respect to some of that Ovation health care benchmarking. Do you do benchmarking within each department in terms of something more like visits per day per clinical FTE in terms of throughput of patients? I know access is an important issue. It came out in the community needs health assessment as a critical area. So I'm wondering if you can speak a little bit to what you're seeing in terms of the benchmarking there in terms of throughput of patients. And what metrics you look at. I'm just guessing something like visits per day per clinical FTE. But I don't know what you're using or how you benchmark. So I'd love to hear more about that. Go ahead Stephanie. Yeah you hit the nail on the head. So for the outpatient practices that is what their benchmark would be right. It's office visits per clinical FTE for an area like our inpatient unit it's going to be patient days. Right. For an area like our laboratory it's going to be a number of billable lab tests. And so I think one of the great things about the premier benchmarking information that we have through Ovation is that it really is tailored in its department specific. So if we have you know 45 different departments we have 45 different benchmarks and we get them updated annually and they're broken down into similar sized hospitals to us. And so you don't feel like you're working with you know really old stagnant information that kind of doesn't even apply to you but but the short answer to your question is it depends what you are for a department because they're all a little bit different. In terms of those types of outcomes you're still targeting the 75th percentile. Yeah we are targeting yep 75th for everyone we're asking them to get 100 percent of the 75th percentile and some are over and some are under and we just talked about some of the areas that are under but it's a pretty aggressive benchmark but we believe that you know that that should be the right target and then when they're not meeting it we have conversations it's a tool it's just it's part of the bigger picture of well is this an area where we know we're trying to focus and we're trying to invest or is this an area that's kind of business as usual and really should be able to achieve that benchmark. We look at every FTE that's that's trying to be filled and we bring in that benchmark as a tool and we have a conversation before any position is posted just to make sure that each and every FTE that we put out there is reviewed carefully. Thank you. You're welcome. I hope you don't mind me jumping in here Matt but this might be an interesting time to just talk about what I think a lot of hospitals are grappling with in terms of figuring out right sizing the hospital versus what might make sense as a community practice and I was just wondering if you could talk us through how you approach those strategic decisions and what sort of input goes into it for you. Sure. Any services that we provide and whether they grow or whether they shrink is a strategic conversation. It ties directly to the community health needs assessment. It ties directly to what we see are the needs of the community what we're hearing from we do not own primary care as you kind of inferred and could see from the physician transfers so we work very closely with our strategic partners we have we have primary care folks in an FQHC that sprawled throughout the region as well as a private practice that not only has several clinics in Franklin County but has clinics across the state so we're not dealing with small operations we're dealing with larger sophisticated operations who really have an understanding of the market from the primary care perspective and we put a lot of weight and emphasis on their input. We also look at if we don't do it who else will and what will that cost. You saw a lot of information and you know we're not much for bragging but I think on this one area we're going to take a moment to brag. We are a very low cost provider where one of and in some areas the lowest cost provider in the state depending upon the metric that you want to look at. And so it's very real to us that as we balance our fiduciary responsibility with keeping the organization to float and making sure that we're here for the next 100 years. We also do that with but if we don't do it who will and how much will that cost the community. So I think you know it's a complex process. It's a delicate balance. The conversations are are always rich and robust but also very hard because it's just it's just not easy anymore. I hope that answered your question. Yeah. Thank you very much. Actually Sarah may I just jump in here for a quick second because one of my questions was about this point exactly. Is that all right. Yeah. Yeah. Okay. We are trying to figure out it is interesting we hear about as hospitals employ independent practices the costs actually for to the patient tend to increase because of higher reimbursement rates and facility fees and all of that. And yet you know it's interesting Northwestern has chosen strategically to transition the pediatric practice and the primary care practice and addiction medicine and dermatology out and and I'm and it's listed in your narrative as a cost savings. And so I'm intrigued by the strategic decision and how also the practices are able to be sustainable outside the umbrella of Northwestern. And yet they were not sustainable with the umbrella of Northwestern is we're sort of watching, you know, nationally these consolidation of vertical consolidation just trying to understand the strategic decision you faced and why it's a cost savings to you not to keep these practices under the umbrella and how they're sustaining themselves outside. I'm sure I'll take a first step of that and then I'll have Stephanie fill in where where I fall short. Let me just point out that the dermatology transfer. That was a desire from the provider to go into private practice. That wasn't a strategic decision on our part to to move that that was a provider saying hey I'd love to be private practice. Okay, no problem. I will tell you, as long as I've been doing this, there is there is nothing that will turn a clinic less productive and and frustrate the staff more than having them become part of a hospital network. We're good at running hospitals. And when we bring on clinics, we treat them not like clinics. And this is the field. This is across the United States. We treat them like small hospital departments and we burden them with hospital policy and hospital bureaucracy which we have to do by regulation and that just add costs to it. So I would tell you that while it's it's easier when you own a practice to drive a strategic initiative. It is certainly in my opinion, in my experience more cost effective when they're managed outside of the hospital system. It also drives better collaborative discussion and a more robust broad look at the way the system works you in our organization in our community. We have a federally qualified health center. By definition that's like critical access hospital status for primary care. They get cost based reimbursement for Medicare and Medicaid. And so, literally what would be our worst pairs in a clinic become their best pairs in a clinic. There's also RHC status, rural health clinic status that provides enhanced reimbursement in those areas. And quite frankly, it's about focus. So, you know, the notch who's our FQHC, they do one thing. They just do primary care. They don't do anything else. They have an electronic medical record that supports primary care. They have an administrative staff and infrastructure that supports primary care. And so when you do one thing and you become razor focused, I believe you have the opportunity to do it better. You don't always do it better, but you have the opportunity to do it better. And that's what we've found and certainly I believe that's the case here in Franklin County. Our private practice as we said, you know, they don't just have clinics across Franklin County. But they have clinics across the state. And again, they're focused on one thing, primary care, their electronic medical record, their sharing of best practices and keeping up on what's best for the community. They become razor focused. And so instead of everything coming under one system, you've got a lot of individual experts. And what we've seen and what I've seen in my time, you know, a little over 22 years is that particularly when it comes to primary care, this proves to be really, really beneficial for the patient, for the community and for cost. So we made those strategic decisions to make that transfer. It did save us money because we were investing, right? The profitability or the, the, you know, on those individual departments, we were subsidizing them when they were part of the system. Now we don't have to subsidize. So that's where the savings comes from. But now they're moving into an area where that not only not have to be subsidized, but because of the certain designations in the experience, they're actually getting better reimbursement and more operational efficiency. Stephanie, did I leave anything out? I think I would just say like, you know, these decisions are always really individual. And so again, with primary care, adult primary care, you know, we had the FQHC and so why compete, you know, let's get together with them and have this conversation. That one can be a little bit of an easier thing. Again, you are, you know, Peter already explained dermatology was really just something that was approached. We were approached about, I think pediatrics was really tough, right? I'm not going to lie. Like if, if there had not been a workable solution somewhere else for pediatrics, Northwestern would still have pediatrics because we can't just abandon the community in that way. Right. So I think some of these services, you look at them and you have to ask yourself if there might be another solution and then you go have those conversations. And if you find out there is, then that's the best news possible. If you find out that there isn't, then there isn't and you ask yourself what your responsibility is as a community hospital. And then I think in terms of, you know, the budget narrative and talking about our changes and expenses over the years. Part of this truly is a math reconciliation as to what has happened with our total expenses. Well, these expenses went away. These ones went away. These ones went away. And these expenses came on board. That's a little bit different than trying to say this is the amount of operating loss that went away. So I don't know if that helps, Jessica. Some of our numbers are really just trying to help reconcile the change in expenses versus, you know, what we gained from profitability or losses as a result of those decisions. And that's really helpful. The whole conversation has been helpful. So if I could just, if I could just add to that, Jessica, some historical context, we got into the pediatric business because the large group in our community had fallen apart. And we got into that business to stabilize pediatrics and access to pediatricians in our community. And in the same way, we got into the primary adult primary care medicine business because there was an access issue in Franklin County. And so those things are both seen, I think by the board is temporary and temporary was a few years longer maybe than we anticipated, but it was about creating and maintaining capacity for our service area. Super helpful. I really appreciate it. Thank you. Chair Foster, this is Tom and Director Limburg. If I could just take a second. No real questions, but I just wanted to compliment Peter and Stephanie and team. Peter, your description of the benefits of separation. Following a long period in our country of consolidation was one of the best of her. I hope I'm sure we have it recorded. I want to listen to it again. But it was really excellent. And your commitment to community needs assessment that you started off with in the alignment of your practices based on that was outstanding. And your commitment to a focus on safe and reliable health care and your HR journey being as important as your budget. You've talked more about your HR journey in the beginning than you did your budget. Those were all outstanding. And I'm just really pleased to be hearing all of it. So I think you're on a great path for what it's worth coming from one board member who's spent a lot of time thinking about high reliability and separation versus integration. Thank you, Mr. Walsh. I appreciate your compliments. I don't have any questions. This is a very strong submission and a strong presentation. So thanks for putting in the work. This is impressive. So thank you. Welcome, sir. Were there any additional board questions on this topic? I'm not sure what specific topic we are. We merged a lot together, but I guess I have one question that's related to utilization that I just wanted to ask, which, you know, talked a lot about the increased length of stay of patients you're trying to get to skilled nursing facilities and had a nice analysis of that and the submission. I was just wondering if you could comment on other drivers of length of stay other that you've that you've identified other than trying to get patients to skilled nursing facilities. It's all over the place long term care. Yeah, yeah, it's all over the place. Even if it's not long term care. Sometimes it's just to home. We've had scenarios where we've, you know, we pay for hotel rooms because somebody lives on a second floor and they're not quite ready. They don't meet acute status and so they're no longer appropriate to be in the hospital, but they can't get into their apartment, which is on the second floor. In all honesty, there are less and more heartbreaking scenarios. This is an actual, you know, we're at the mountain and we're not able to pick up mom, you know, until Sunday or the weekend. There's crazy stuff like that as well. So it really does go all over the majority is certainly access to long term care. Some of it is patients with Alzheimer's where we're seeing a dramatic increase in, you know, patients who suffer from these type of memory diseases and become quasi violent. You know, certainly mental health as you've heard from other hospitals, you know, access to appropriate beds, particularly if it's a pediatric patient or an adult where you have mental health on top of memory issues and and complex medical issues that again don't meet hospital level care but but need a lot of care coordination and follow up. So there's a variety of different reasons. Our care manager would love to spend hours with you and and lay that all out because I know she's keeps track of them very carefully. But those are the major issues. Sometimes it has to do with just a simple ride. How do we get somebody home because they don't meet the criteria for an ambulance ride home yet. You know, we are not comfortable putting them in a taxi and just saying go home and we do to the safety and quality aspect that Mr. Walsh was talking about. It can be frustrating when someone's ready for discharge, but we're just not comfortable putting them in a taxi or or some other mode of transportation. If we don't feel that they're going to be safe. If we don't feel that they can get in their home or anything that we feel would cause them to be readmitted as much as we work on length of stay. We're even more focused on readmissions and keeping that number down and making sure that the patient truly is ready to go home. Stephanie, do you want to add anything? I think I would just say our partnership with Dartmouth around tele ICU and tele stroke is also something that's helping us keep more patients here. And so those patients tend to be more complex. And so there's the kind of a QAD piece that goes along with it. But I think, you know, that I think that our clinical teams would tell you that we keep sick or patients here now than we used to. Thank you for that. It's how many, one of the other questions I had along the way was how many tele ICU beds are you staffing at this point or beds that you use the tele ICU services for? We have 10. Oh, sorry, go ahead. No, Stephanie, please. We have 10 beds that are wired for that tele ICU service. And I believe we're bringing two more online. So it's a combination of ICU patients and step down patients who use those beds. And we do have Don and Dr. Manadeo here as well. If you had more questions about that, but 10 is the answer. And the other question I had for you on labor related expenses was you discussed your plans to reduce traveler expenses. And I just wanted to know whether or not you were having any concerns that that would decrease access to care staff beds available, ED space available. Yeah, and I think go ahead, Peter. I think we're committed to keeping those beds open as long as we can afford to do so. You know, if you know, again, we're we're in a scenario now or a negative six and a half percent operating margin. It's really tough to continue to invest in those travelers, but we need to do it in order to keep the beds open. Our census remains high today. We have 34 patients on our inpatient unit and 10 more in our family birthing center. So a lot of those are in the emergency department as well. And so making sure that we are able to handle that load is is critically important. So it's one of those things where it's painful. And it's the one thing we'd love to be able to change. But, you know, as long as we're committed to serving the community with the the the number of services that we do today, we have to keep them on board. But we also have a plan. And so there's several permanent staff members in training and orientation. So we also know 1690 120 days out how that's going to chip down. Thank you. You're welcome. Well, I see your hand up was I mistaken. Okay. Thank you. Also, thank you on utilization in your exhibit 10. You also, you know, almost a $2 million reduction in overall commercial NPR just due to utilization. And this seemed almost entirely attributable to professional fees. I was just curious if you could describe what's occurring there. What's driving that. Yeah, so some of that data is being skewed by the transfers. Right. The movement out of pediatrics and adult primary care. So that's a big part of it. And then the other part of it is, you know, we mentioned in our introduction. And again, if we need to go into more detail with this with you guys, we're happy to but really seeing that big shift in the Medicare Advantage and we bucket those under the commercial bucket. So all of those Medicare Advantage plans are in that commercial bucket for our budget submission for our numbers and reimbursements challenging in that space. And so that's really starting to have a significant impact. So those are the 2 things that are kind of driving that number. I didn't have any more questions about utilization if there are other. Stopper board questions. Mine's just a request for a quick follow up on with regard to the wait times, which I'm not sure falls into utilization, but I'm going to put it into utilization in terms of access. And I appreciated the information about the referral lag being 4 days. In the in the narrative, it mentioned that you don't document referral times. And so it sounds like now you've updated your EMR to be able to do that to be able to calculate those referral lag. So on the one thing so appreciated. Secondly, I'm just wondering if you might be able to submit that along with the visit lags by specialty so that we can get a sense of where the bottlenecks are. And we're trying to get that from all hospitals so we can really understand where the access pain points across the state by specialty area. So just a quick request for a follow up on referral and visit lags by specialty area. Yeah, yeah, we definitely have to collect it somewhat manually. So we created different categories for ourselves to track the referral lag. The goal is is three days, we're averaging four days. And so some of them are at one, and I think the highest one is around 10. And so we're happy to provide the work we have done to capture that data and provide it to you. I want to say I really appreciate that because I think our referral lags is underhounded and I'm sitting on several myself personally that are in the weeks. And I'm not going to NMC, I will say, but I think if we don't capture that information on referral lag, we don't really truly know or understand how long people are waiting to be seen. So I appreciate the efforts manually, if it may be, hopefully you can get it into, you know, a better way through the system in the future, but really, really important. I know many people who are waiting weeks to have appointments just even scheduled. So thank you. Are there any other board questions on utilization? And I'll pause and ask. I apologize. Again, the healthcare advocate has any questions on topics covered. Thanks Matt, not so far. Our questions are more of the cost coverage category. Thank you. So jumping to pharmaceutical expenses and cost inflation. I was wondering if you could speak more of your experiences with pharmaceutical expense growth. And general cost inflation. I know during the narratives, you've mentioned laundry being a major kind of uncontrollable driver. And other than pharmaceuticals, I was wondering if there's other kind of categories like that that, you know, maybe are significant to the hospital. But, you know, like laundry, we don't immediately or at least I don't immediately think of. Yeah, we another benefit of our partnership with Ovation Healthcare is through our group purchasing organization. It's all tied together. And so they provide us with these really wonderful reports right around budget time every year that says, hey, here's what you can expect for inflation. And it's broken into really detailed categories. And it's even more detailed than what we can honestly fit into the budget system. But we try to not just do a blanket or just doing across the board. So we're able to see, oh, we should expect, you know, this type of orthopedic implant to go up by 15%. And these other ones are only going to go up by 2% or by nothing. And so we do try to, you know, get as specific as what's reasonable. All of that really both on the pharmaceutical side and on just the other supplies and other inflation side for NMC ended up averaging 5%. And so that's our approach every year is to take that really detailed information, put it into our budget system as detailed as we can, but then calculate the overall. And speak to that overall in our budget narrative. I think linen is one of those things where our inpatient census has been higher than what it had been historically. And so part of it is just a usage, like a poundage issue, right? You actually pay for linen by the pound. And then some of it is being driven by a cost issue. The lack of choice and providers available to have that linen service. And so to some extent you kind of feel like you're out there at the mercy of the market because there's not a lot of choice. And I'll turn it over to Peter for any other comments on that. Yeah, recently coming from Maine, I can tell you that the major systems in Maine, as well as New Hampshire, you know, linen cost per pound is driving them to think about creating their own facilities, their own networks becoming their own vendor similar to what we're exploring in the Vermont Collaborative Hospital Network with Ovation. So it's just one of those odd things. It generally doesn't fall within the reach of a GPO. And so the price volatility is far more sensitive. Thank you. Any board questions along inflation or pharmaceutical expense line? It might not be, you just mentioned it, Mr. Right, but the Vermont Collaborative Network, I hadn't heard of that myself and maybe I'd missed it, but when did that launch and who's participating in it? So right now it's just formal conversations, although we did efficiently develop a logo for it. I believe that Northwestern Medical Center, Copley and Springfield are firm participants. We're also having conversations with some other hospitals and I hesitate to mention their name because it's not my place. But you know, three other independent hospitals in the state of Vermont, so you can do the math on your own. It's just about saying, hey, we're an independent hospital. Hey, we want to participate in things like maybe I need half of this subspecialty of a physician and you need half. Can we recruit and share that member of the medical staff? It could be a physician. It could be an advanced practice. You know, I could certainly use to save, you know, 10 cents per gallon on my fuel oil. But the boundary is killing me too. You know, IT, how do we, you know, how do we continue to make investments in IT, keep our system safe and modern, but also find ways to, you know, share costs, whether through a collective data center or things like that. We're just getting the conversations off the ground, so the network hasn't formally legally come together, but it is a group that is actively talking and actually now we're working with Ovation to hire, to jointly hire a physician that would staff and drive these initiatives forward, hopefully by the fall. But we're doing things like, you know, for example, Copley Hospital is also doing their strategic planning, you know, kind of reorg their new strategic plan in the fall. We're going to participate in half a day of their strategic plan to figure out what we can do together. They're going to come over to our strategic planning process and spend a half a day with us and with our board. Our board chairs are talking about how we can collaborate more. You know, Mr. Wooden and I spend lots of time on the phone and, you know, I'm looking at a chemical that he discovered that helps clean surfaces a lot better than what we're using today and is a bit of a revolutionary product. We're sharing those ideas and collectively doing purchases together where it makes sense. So it's very early in the stages. I'd say it started maybe just shy of a year ago in terms of its development and people meeting and getting together and agreeing to work together. And so it's in those early kind of forming stages. Well, thanks. It's interesting to hear about. I might try and reach out and learn more about it at some point that's appropriate, but thanks for the overview of that. You're welcome. We'd welcome the opportunity to talk to you about it more. Great. Cool. Thank you. You ready for me to walk through my esoteric stuff, Matt? Thank you. Sure. Okay. So, again, in our learning phase about the cost report and what we can learn from it. So here, mostly just to hear your response to some of these measures, but for a small rural hospital, we see Northwest right at the median. So again, 50% of the hospitals with comparator group were smaller and 50% were half or larger. And for your case mix index, we see a relatively lower acuity, very similar to your peer in Southwestern at 1.39. I was just curious if I've heard other hospitals say that, you know, really getting full credit for your CMI usually depends on some expensive software and other tools. So I was just wondering if you feel like there's any distortions in that CMI compared to your peers and if you had to guess. I think that number might be a little bit soft with Stephanie said earlier with our new partnership with Dartmouth and tele ICU. So we're keeping higher acuity patients. So some of that maybe just the timing of that data. Stephanie, I don't know if you want to chime in on that. Yeah, I mean, it's every, you know, CFOs love this stuff. Right. Like, how do we make sure we get paid for everything that we do do right and get credit for everything that we do do. And so, you know, we've really looked at something called CDI clinical documentation integrity and have one of our staff members actually going through a CDI certificate program and education so that she will be reviewing in real time, you know, the impatience on the floor, looking for anything that might be missing around coding or documentation. Just to try to make sure that we get this right because I completely agree with Southwestern. It's a tricky thing. And you miss stuff and sometimes you don't know what you don't know right you don't know it was missed. And so that that's, I would just say ditto to Southwestern. Okay, fair, fair. And then when it comes, I think this is the indicator we're struggling the most with and maybe is going to be one of the that we need the most work to make sure measuring what we intend to but we do see your. So again, this is the ratio of what's classified as true admin in general on line five compared to the salaries listed through line 32 100 so it'd only be the labor that actually shows up on your cost report which I know often doesn't represent everything so I just wondering from where you fit like what might we might be missing from looking at it this way. Yeah, this was one where I've you know I really thought about it over the weekend and thought man I don't I don't have a great answer to it knowing that we're a bit showing a bit on the high side but you know I will say I'm really curious it's one of the things I'm going to dig into right after this budget process and try to understand if I'm doing something differently on the cost report than my peers are. No specific comments at the moment I won't call it wrong I won't call it any of those things but it's just something that we're really going to dig into. I appreciate that and you know we are playing with kind of more representative ways to get at like a apples apples admin ratio. So appreciate your wisdom on that. And what I understand that line five doesn't have a whole lot of guidance and so all sorts of things may or may not end up there. Thank you. Yeah. So this would be cash available for operations at the end of fiscal year 22. Given your submission I think your cash position probably looks a bit different today. And I also know that this would not account for any donor restricted funds so just want to give you an opportunity to comment on anything you think might be non representative about that particular measure compared to your peers. We've always been fortunate I won't say always but in the recent history have been fortunate to maintain our strong days cash on hand. It's just it's really helped us get through the last five years right. And we absolutely were using that money right now to fund you know an E.D. renovation project that's really needed and we're very excited about that you all approved a couple years ago. So you know we continue to look at that money as a way for us to really move the organization forward in the future at a lower cost to the system if not having to borrow. Yeah I think that's important that we we fully fund appreciation. And so our capital costs each year are cash and we're not taking on debt and that allows us to maintain a really strong structure of low cost. Yeah. And then you know like I said the profitability measures I don't think or where anyone would like to see them in fiscal year 22. So obviously that came in negative but around the 25th percentile so even kind of relatively the first operating results then some of your companions here. So it seems like things are starting to turn around in fiscal year 23 but still a long way to go. Is that feel representative. Yeah. Yeah it's my least favorite statistics are and the one that keeps me up at night is our current operational deficit and you know we're going to have to make some some very complicated decisions to get to get back in a safe and responsible level. Yeah. And so when we look at the average cost for a Medicare discharge. So from what I understand this 13000 if say your CMI was a little bit up would probably drop down into this box is kind of what I'm picking up. But I just thought what your reactions were to seeing that compared to some of these other hospitals. Yeah. It's the first time I've seen it CMI adjusted. So if I do just the traditional right cost per adjusted Medicare discharge I get like nine thousand five hundred dollars. So seeing this CMI adjusted number. It's kind of like oh is that is that correct. Is it that sensitive to the to the adjustment of the case mix index. And that's just something that it's also something I'm really going to dig into after these budget hearings because I think that's the only difference between the way I've always traditionally calculated it and the way it's being done here. So just something for us to dig into but happy to dig into it. I've already been in a once because I didn't see teams being in an outlook. Let's see somebody. Okay. I think we're good there. Okay. And then so cost coverage. When I look at Northwest for one I see not having cost coverage covered on the inpatient side from commercial and that kind of stagnating looks like there was a little bit of a bump maybe again this is sensitive to the data we have access to but kind of been stable through 21 and 22 feet kind of a general deterioration in the inpatient coverage for Medicare for you all and low but more consistent outpatient coverage and again seeing a similar downward slope for the Medicaid. And when I look at you compared to your peers, you do show up as being one of the lower cost ones. And it does look, I just look at the outpatient you are notably one of the lowest with the coverage being about 261% of that Medicare allowable cost. Yeah, Sarah, I think that's North country. I believe we were under the PPS hospital and MC. Of course you would be. Thank you. I was wondering why this didn't make sense. Okay, there we go. Thank you very much. Yeah, so there you are. Yeah, very in line with your peers but that cost coverage, quite low for inpatient for both governmental payers and also not keeping up with commercial as we saw. And I think for that correction sets a totally different story and we see yeah you're at just under 200% of the Medicare allowable cost, but not needing both costs for either governmental payers so just seeing that your relative payment is quite low you and CBMC being the lowest. And that seems to tie it to if I were to reverse engineer some of the things in your narrative, you saying that your charges are among the lowest in the state and so my main question here just has to do with it's always a tough decision about figuring out what you need to ask from the commercial payers and just curious how you approach that task and how you're dealing with it in this recovery period. Yeah, I think, you know, as you can see this kind of really highlights the cost shift effect. You know, what we ask for commercial, you know, we always try to go in with his as low a rate request as possible to try to be reasonable just to keep, you know, operations going. I think that, you know, we've, we've got to have some very real conversations about the cost of inpatient care and the shift back, you know, we saw a dramatic drop in utilization during the pandemic and those patients are sicker. And they're coming, you know, in a regular stream. And that's not just Vermont. I saw it in Maine. I saw it in New Hampshire. And with the connections I have across the country, we're seeing the same thing. So we've got to think about this. This goes back to rate reductions that from about eight years ago. There was a pretty significant rate reduction. And, you know, we've paid for that in the eight years since with operational losses. So we've, we've got to find a way to get that back to at least, you know, that dotted line. But, you know, do so in a reasonable way. I mean, you know, things are changing and, you know, and payment reform is real and something that we not only subscribe to, but we're an advocate for. So we're trying to figure that out. And I wouldn't say that we actually have an answer for it today. Right. You'd be too busy collecting a Nobel Prize if you knew that. And so as far as the RAND data goes, I think this is where I noticed it's most material, the lower than typical commercial reimbursement. So Northwest is below the 25th percentile on inpatient at that 14,000. So what we do is we figure out how much was paid for commercial and divide that by a standard unit of service. So compared to your peers, you're quite low on both inpatient and outpatient side. So below the 25th percentile and right at the 25th percentile. And I think, again, that jibes with what was in your submission. So those were the things that to cover in this tool. I don't know if there are questions from the board or the healthcare advocate that would be helpful to have this up for, but I would welcome those down. Sarah, can I just ask a quick question on this, which is, can you or Stephanie or Peter understand how to reconcile that CMI adjusted cost for Medicare discharge, which is high and the RAND cost per inpatient stay. They're at the opposite ends. Most of the trends in what I'm seeing is that their reimbursements are low, but I'm not quite understanding how the cost for discharges high with the reimbursements being low in other places. That is definitely a Stephanie question. And it's definitely one I don't have the answer to today, but but yes, we can, you know, right after this really dig into that. And because that's just when I go through all of our data on this tool, you know, that CMI adjusted cost per adjusted discharge number is just the one that I was like, oh, that just really doesn't look right. It doesn't make sense. So, so yes, we're just going to have to figure that out. So, I would just point out that this specifically is going to be limited to the commercial side of it. So it's entirely possible to have a high cost per discharge but not get reimbursed. Well, for my commercial payer. That helps. Well, I mean, I don't mean to have a judgment there, relatively lower than your peers. And you came off camera. What do you got? I don't know if this is the best place for it, but I think it makes sense. San Pais healthcare advocate. Good to see everyone. Just want to start off with a couple brief comments. I really want to commend Northwestern for the work that you've done coming in really close to the guidance. I think last year, if my memory serves, you were the only possible that came aligned with the guidance and also your strategic investments in labor and reducing operational expense at the same time. I think sometimes we hear that those two things can't go together. But I think it's a testament to the culture that you spoke about. Now, I wanted to mention with the implementation of act 119, the patient financial assistance bill, we hope that we can work together as we did years ago. And a kind of interactive process to that we hope to do with all hospitals, but we have that existing relationship. So we have to build on that. So our question is, I mean, no surprise related to free care and bad debt. We notice a trend towards more uncompensated care overall and also more bad debt in the last couple of years. I'm just wondering if you could speak to that and elaborate on why that's the case. Sure. I'll let Stephanie provide the detail, but I think we're pretty consistent with what we heard other hospitals testify. We'd love to see that shift. We'd love it if patients would fill out that paperwork in our current our encouragement. You'll notice in our budget submission that we provide access to financial counselors and have a very robust charity care program upwards of 400% of the federal poverty level. So there's a lot of opportunity. We would certainly love to see that shift. It's really about patient engagement and patient participation that we're just not seeing a response and patients taking that seriously, which is painful for us as well. Stephanie, you want to fill in some more detail? Yeah, I mean, I think you're right. We're seeing both buckets increased and we want to see the charity care increase above seeing the bad debt increase, right? And everybody, you know, I really don't think this has an impact to our bottom line. I really think if we can get more charity care, it's really just going to come from that bad debt line and have a zero, you know, effect on our P&L. So we would absolutely love to see that. But right now we're seeing increases in both and increases in both does have a bit of an impact to your overall bottom line and profitability. And so I think, you know, I don't have a great answer other than to say, you know, I really do think that some people personally haven't financially recovered from COVID, right? Whether there was a loss of employment or, you know, whatever the case may be, I really think that we are seeing, you know, folks have not really recovered personally from the last few years and that's really showing up. And so they probably deferred that health care for a long time and can't defer it anymore. Now they're receiving that health care and they really truly don't have the means and the resources. So we're just trying to strike the right balance as an organization between, you know, providing the resources to get them pointed in the right place to get them help. We've got, you know, our staff not only doing the financial counseling, but they're also those trained, you know, certified on the exchange, you know, whatever that title is. You guys know what I'm talking about. They're trained in helping folks get those Medicaid applications done and getting health insurance through the exchange. So what else can we do to provide support? Because I think what we're seeing really is just a bit of a lag in, you know, the day-to-day struggle of some of the folks in Vermont. Navigator. Navigator. Certified insurance navigator or something like that. You're right. Yeah, no worries. Does that cover you, Mr. Pysh? Anything else you wanted to ask? Looks like maybe we're having a little technical difficulty. Eric. Eric, John Mew. Technical difficulties. He just froze. But that is all our questions. I mean, I think just one comment is for Stephanie, I think, you know, where our office is interested in the kind of figuring out the underlying processes and the path towards free care. And so I kind of have a gut reaction to the dissipation. Like, right? I mean, I think it is partially, but like, if I have a $5,000 bill or $1,000 bill, like, the kind of underlying premise of that is I don't care. And so I think, you know, most people care and I'm, you know, you know, most people care about a quarter of their monthly salary, right? Like, I just don't find it plausible, but I am interested and I think this will partially aligns with lean thinking is how do we optimize the processes and the pathways that cause that. And I think that's been a consistent process that we've been interested in. And I think Rutland has done a really good job of, or their staff members done a good job of looking at that. So I think that is something we'd like to address. Your ratio is, honestly, it's one of the worst in the state. And I think we see that trending towards being worse and worse and worse after the, you reach the high point. I think in 2021. So I think that is a process that we could look at and should look at because it's trending in the wrong direction. But again, I want to echo Sam's statement is we really appreciate how close you've come to the guidance this year. And it is, I think worth pointing out that you guys were the sole Vermont hospital that came at guidance last year, if my memory serves. Thank you. I completely agree with you. And I think, you know, when we talk about, you know, can we get these patients to engage with us more? I couldn't agree with you more people are going to fill out a piece of paper if that piece of paper is worth thousands of dollars to them. And so I think where we do a bad job explaining it is what what we really mean is we think that we are advertising it well with like signage and what's on the website and with the counselor at the front of the house. But still somehow the message to the patients isn't getting delivered because I do agree with you. If they knew about it, they would do it. And so if there's someone you folks Rutland, you know that we can talk to and work with about, you know, how did you change the level of awareness to actually change the results? That's the piece where I just feel stuck and would love to collaborate with folks. Sorry, go ahead. Mr. Right. No, I was going to say, oh, we both said go ahead. I would agree with that. And I mean, I think it's a, you know, we don't know the answer obviously to how do you create a system that works and it's exceedingly complicated and I kind of think it's, you know, somewhat of a trial and error, and interested in, you know, I think the knowledge share and how that occurs in Vermont is something that you guys are working on. And I think it's been a longstanding wish of mine or hope. And I think, you know, to the extent that we can facilitate it around free care, we'd love to and I'll write down a note and reach out and see what we can do, Stephanie. Yeah, that's what I was going to say. You know, this is a great high reliability lean daily management project for us. It's obviously an area where we're not strong. And if we haven't been able to figure out through our own internal improvement process, then we are more than than wide open to learning from others. I think it's something that, you know, Vermont hospitals do really well as share best practices, but I agree with you. I'm not sure that while Rutland may be doing it better. I'm not sure we do it well as a system anywhere yet. And so, but anything we can do to improve the numbers, we're certainly up for. All right. Sorry about your technical difficulty there, Mr. Pysh. Any other questions you'd like to ask? Yeah, sorry about that. It was not my intention to ask a question and ghost my computer just shut down. I just wanted to, I don't know if this will be covered by the board, but I heard, I believe correctly that Northwestern you want to talk in executive session on Medicare Advantage plans and I had a couple of questions related to that. So I wasn't sure if there was a process for that, but just wanted to bring that up again. No, we didn't have it necessarily a desire to proactively talk about that, but I know that the board has had some questions. And so, if the board has questions in that realm, we would just ask to go into executive session. Nothing else for us then. Thank you. Before we maybe entertain that eventuality, just making sure we're all ticked and tied here, the final rule had three tenths of a percent increase for Medicare Ips between the perspective and final just wondering if that had any material effect here, but then. Yeah, so for us, that's worth just over just a little over $100,000. So not material, but I understand that that's real money. I would say what has me very worried on the other side of the coin is the Medicaid redeterminations. And I that question is probably coming next so I can wait if you don't want me to go there, Sarah. Perfect segue. Have at it. Okay, so we did not budget anything specifically for those Medicaid redeterminations again, not knowing like those patients are going to go somewhere. Are they going to go on some sort of a commercial plan and it will actually be better? Are they going to be true self pay? Are they, you know, not knowing? It just felt like we couldn't take an educated gas. And if I can't take an educated gas, I don't want to put it in the budget. So, so I think that there's a little bit of money there on the Medicare side, but I'm really worried about the potential of the Medicaid side. Understandable. Okay. I think that covers all the staff questions. We think we've heard from the advocate any other board questions or further business related to this hearing. I may have missed it in the submission and so my apologies, but could you speak a little bit about ACO participation in the coming year? Yeah, the ACO. So we've budgeted to be a participant in the ACO. In this budget, when we put it together a couple of months ago, there are some things that have changed to be honest since then. And so we're in a dialogue with the ACO right now and our board of directors about the fate of our participation. So in all good consciousness, I can't tell you one way or the other, but it is part of the budget. Any other board member questions or comments for Northwestern? Okay. I may have a question on the MA issues, but first I'll take any public comment via the raise your hand function. Okay. Seeing none. So, Mr. Wright, I'm not sure how familiar you and your team are with this process, but I need to ask some questions first before we can go into executive session. I would have to make a motion. And so I need to ask you what I'm going to ask you about is some of the details relating to the pay or shift MA and some of the impacts that that's having on your business. And some of the negotiations and work you're doing with the MAs around the Medicare Advantage plans around those issues. So the first question I have is whether or not you believe those questions, the answers to those questions would the premature general public knowledge of those issues would cause you substantial disadvantage with respect to your negotiations. Thank you, Chair Foster. We do believe that that would have a negative impact us and would request a more appropriate venue to discuss them. Okay. Oh, and before you make the next motion, there's another topic that I think potentially could be added to executive session, which is I think having more detailed information about the contract negotiations with the ACO program would be helpful information to have. So I will ask you, Mr. Wright, if having premature general public knowledge of those negotiations might negatively impact Northwestern's ability in that negotiation. I believe it would miss lunch. Thank you. Back to you. Sure. No, thank you. So I'll move that we find that premature general public knowledge of Northwestern's negotiations and work with Medicare Advantage plans and negotiations with the ACO would put Northwestern at a substantial disadvantage with respect to its negotiations with the ACO and Medicare Advantage plans. All those in favor, please say hi. Hi. Hi. Hi. The motion carries unanimously. Hi. The next motion I would make is that we move into executive session under one VSA 313A1 to consider Northwestern Medical Center's negotiations with Medicare Advantage plans and also with the ACO. Second. All those in favor. Hi. Hi. Hi. Hi. So the motion carries unanimously. We will resume the hospital budget hearing on Northwestern Medical Center. I think we have gone through all board member questions, public comment, HCA and. And we did closings. So I think we are all set. Is that correct? Am I missing anything? I'm not sure we quite gave an opportunity for a closing remark so we can probably do that and call the meeting. I'm sorry. Then we will do so. Mr. Wright, please go ahead. Yeah, I just want to thank everybody for your time, your encouragement and the great questions that you asked like other hospitals. It's a challenging environment. But, you know, we're very proud of the budget that we put forward. We feel it's responsible. We came close to the guidance as best we could while maintaining what we hope is our fiduciary responsibility to our organization and community and keeping our patients and our staff at the forefront of everything that we do. So thank you very much for your service. We appreciate this time to talk to you about our budget today and look forward to any follow up questions that you may have. Well, great. Well, thank you very much. Stephanie, Mr. Wright and Mr. Batchelder. Is it Brealt? Is that how you pronounce your last name? Brealt? Boxing and necessary letters. It's just bro. Bro. Great. Well, thank you, Miss Bro. So we will adjourn this time.