 You know I haven't been doing this but maybe it wouldn't hurt or a little ahead of schedule maybe if the other board members could just introduce themselves so that Allen would know everybody. Why don't we go on alphabetical order Jess. Sure. Hi Allen how are you. I'm Jessica Holmes and I've been on the board now six years. Hi I'm Robin Lunge I'm I work prior to this in health policy for various parts of state government and I've been on the board for four years. Good morning this is Tom Pelham and Chilly Berlin Vermont this morning a lot of do on the ground. I've been on the board for two and a half years prior to that I was the state's finance commissioner and tax commissioner and had some other jobs but this is certainly a challenge. Hi Maureen Youssefer I've been on the board for just a little over three years three and a half years and my background is corporate finance and CFO of several companies. That's to me also. Okay do we have the court reporter on. Yes I'm here Joanne Carson. Good morning Joanne. We only had one a couple of situations on Tuesday where people started to get jumbled but any time that you need to ask somebody to repeat or just jump in okay Joanne. I will do that thank you. Okay and I guess we'll officially kick things off. My name is Kevin Mullin chair of the Green Mountain care board. I want to start by saying that please refrain from using the chat function. The chat function is not a method to create a public comment. We will take public comment on each of the three budgets that we hear today after each presentation. So with that Joanne could you swear in our witnesses from Springfield. Sure I would ask you each to raise your right hands please. Do you swear the testimony you're about to give will be the truth the whole truth and nothing but the truth. I do I do thank you. And Mike I assume it's just you and Allen. That's that's correct great. So Mike whenever you're ready you can go ahead and take it away. Well now that my support just left my office I'm trying to figure out how to get to the other it is I guess screen share. Yep and I think it's the presentation. And I think I have to get into slide show. Well it's good that we're seeing Springfield Hospital Fiscal Year 21 budget presentation. That's a good sign. Yeah I think so. Down to the very bottom Mike about four icons to the right you can click on it. It's a click a quick button that goes right to the. Is that it. Am I am I now on. Oh boy I'm not sure why I got it. I got a big echo. Do you guys have big echo. It seemed to have gone away with your last statement. Sometimes we get echoes when people are both on a phone and using the computer at the same time or sometimes it's just that some people's mics are a little bit more sensitive. So we ask people to mute themselves if they're not speaking. Okay is that is that better. It is. Are you able to hear me OK. Yes. All right. Well yes it's just going to be Alan and myself making a presentation today. I think we have a number of folks from the hospital and supporters of the hospital that may try to sign on and listen. But it's just the two of us today. It's almost hard for me to believe that it's been a year since the last time we were together as a group like this presenting the fiscal year 20 budget. And that at that time if you recall that was Tom Marshall and myself. It's a it's a real shame that we can't be together in the same room. I know most of our businesses conducted these days by zoom. So we're getting better at it. And probably by the time we get better at it is when we'll get control of this pandemic and not have to do it anymore. So anyway what we want to try to do this morning is to for Alan and I to walk you through a number of slides that we have. And I don't know if you've seen them before this presentation this morning or not. But what we're going to try to do is to show you where we've come with this organization since 2018. And I hope you can appreciate that the situation here back in 2018 was pretty dire. And we've come a long way and there's been a lot of hard work by a number of folks here at the hospital and the medical staff the nurses. There's been a lot of dedicated effort that's gone into getting us to where we are today. And hopefully these slides will show you where we want to try to get to in transitioning this organization so that we can continue to provide care to the community. And I think that's the most important thing that goal that we can have. And so that's what our slides are going to try to show you. Let me go to the first slide if I can figure out. Too fast. There we go. Just to give you a little bit of a refresher on who we are. We're a hospital critical access designation with Medicare and we're affiliated with an organization called Springfield Medical Care Systems that basically operates a federally qualified health clinic. And that's how we operate the clinic basically has the primary care physicians that work with the hospital. The hospital does employ the specialty physicians but we do not have any primary care physicians employed by the hospital. So it's vitally critical that we operate together in a collaborative fashion between the federally qualified health clinic and the hospital. That's going to be the success for both organizations. The hospital itself where we'll focus on today has an average daily census of 12 patients a day. We have a distinct part psychiatric unit that is off campus. It's about 10 12 miles from the main campus of the hospital. And it has on average about seven patients a day. The ED which I don't have a point on a bullet point on just give you a little knowledge about the ED because that's a very vital part of our organization. The emergency room back in 2019 had about a little over 14,000 ER visits. That's about 39 on average a day for the period of January through February of 2020. We had about 2,500 about 42 patients a day. And I cut off at February because that's kind of the pre-COVID period of time that we like to refer to. Then the period from March through July. I hate to interrupt but we're still seeing the cover slide. I'm seeing the second slide so I don't know why that is. So you're not seeing. I am not seeing the second slide. Is anybody else seeing the second slide? No. Oh boy. And I am not the best technological person. One of the things I think you're sharing your desktop. You might want to share the presentation versus the desktop. We are seeing it now. But what you might want to do is X out of all the individual slides that we see on the one side of your screen. Yeah. Yeah. That's better. And now we are seeing you flip through. Yeah. Perfect. So I'm back on that. All right. Sorry about all of that technology. Not a problem. Glad you guys can help me with that. I really do would rather be in person. I'll tell you. So we were talking about the ED visits. Pre COVID. We were running around 42 visits a day in the ED compared to the 39 we had the year before. For the period of March through July. Which is all actual. Our ED visits have gone down to an average of about 29 patients a day. So you can see what we've been seeing is that's one of the key areas that we've seen the impact of the pandemic is in our ED visits. And we'll talk a little bit later about what we think some of the causes. But many of you probably can figure out what those causes are. The next bullet down then on the particular slide indicates that, you know, we are an organization that's in chapter 11. Reorganization. We're in that process. We entered that. On June 26th of. 2019. We do have a plan. That we've developed for exiting that reorganization process. We expected to be submitting that within 60 days. We're targeting for the mid ladder part of September. So it could be. Sooner than that 60 day period. We'll also talk a little bit further in detail about that. The hospital today has 56 days cash on hand. As of June 30th. And we're predicting to have close to 36 days. When we. File our exit plan. Are you guys seeing the third slide now? Yes. Okay. Great. We believe. The operations can be sustainable. Going into the future based on four major. Elements. One is we conducted. Pretty significant cost reductions. That were executed in the early part of calendar year. 2019. Around February and March of 2019. We've we're continuing that effort to. Have initiatives to achieve services and economic efficiency. So we're looking every day at how we can change our. Services to be more effective and efficient. And we've got a number of those things. We'll talk about in a few minutes. The third major component. Which is really the. Very, very difficult thing to do today. Is to try to predict. What the patient volumes are. And what we're doing right now is we're anticipating. That our patient volumes will be back to pre COVID levels. Around October 1st of this calendar year. Which is the start of our fiscal year. You'll see all the projections. Assume that. But that's key to our component to being. Sustainable. And then the last major piece. Is to predict what the patient volumes are. And what we're doing right now is we're anticipating. That the patient volumes will be back to pre COVID level. And then the last major piece. Is that we have to have a successful exit from chapter 11. Reorganization. That means that we have to have the cash. Available to. Negotiate with the major creditors. That we have at the with the hospital. To be able to. Have the bankruptcy judge. Rule in our favor that we are a sustainable organization. For the future. And that's what we're doing. Chapter 11 and get off to an in future. So those are very critical to us. The budget that you're going to be seeing. And a few minutes. Needs to be seen as a. As a continuation of a transition. To a future as an independent community. Critical access hospital. That's that's. The way that we're going to exit. The bankruptcy. Process. And the last thing is that. We've asked for a 4% rate increase. In our charges. Going forward. Into the fiscal year of 2021. So let's take a little bit of look at where we've been. From financial point of view. When qhr arrived on the scene which would have been around. January of 2019. We realize that. If we are going to be able to. Keep this organization. In this community providing health care. And recruiting. The talented professionals that we would need. That it was going to be a multi year turnaround. Effort. We weren't going to be able to do it. All in one one year. And so that's what you're. Looking at on these slides. That's why I go back to 2018 fiscal year as a. As our foundation. I don't want to walk you through every one of these. Individual. Columns but what you're looking at is a 2018 actual. The 2019 actual. Which we just got the audit. In a few weeks ago. What we had submitted. To this organization. The gremont care board as a budget for 2020. Where we stand as a June 30th. Is when we put the budget together that was. The latest actual information that we had. What we projected. For the ending this particular year. And then what we're submitting. As a budget. You can see just across the page. We've. Slowly been. Climbing trying to climb back to the. Total. Operating revenue. We's not going to quit. We're not going to reach it. In the year 2021. Yet. The next line down or row down. You can see is the. Operating expenses. We've gone from 61. Almost 62 million dollars. Of operating expense in 2018. We believe we were down to about 53 million. Or actually we believe we're going to end the year. 2020 at 51 million. So we've got almost a nine million dollar reduction. In a couple of slides in the future. Slides that we'll show you. Indicate how we're. We've. Taken those. Expenses out of the organization. The major reasons or. Causes to that. You can see that then our operating income. About 7 million dollar loss in 2018. Continued in the fiscal year. 2019 mainly because we didn't get our. Ability to put some of our initiatives to reduce cost. In quick enough. To have any effect on the 2019. Results so we had about another 8 million dollar loss. We have brought that down if you go over to the column. It says projected. We think we're going to end this year at about a 3.6 million. Loss. And we think in the budget that we can get to. About a break even. At $185,000 positive. And you see the. Adjusted admissions. At the bottom of the page and how the volumes have. Declined to some degree. And when we think it's level off. In 2021 and will be climbing back up again. So what has changed. About a million and a half reduction in. Revenues from the 2018 period. Our inpatient acute senses. Biomes have gone down. 16.2 and fiscal year 18 and 19. Down about 13.6 in a year 20. We're projecting that will be at about 13.2. In the budget year. In May of 2019 we close the labor and delivery. Service here. In the budget year. That removed a significant amount of revenue. As well as cost. It actually was. Costing us more money to operate that. Unit. Then we were bringing in in revenue. We were doing around a hundred deliveries a year. Sikes. Senses is down a little bit in 7.4. But we're projecting it to be about 7.3. And we'll talk a little bit more about the. Future slides. Surgical cases have dropped somewhat. But we're rebuilding the surgical. Program we. Have recruited a second physician. Surgeon. To start in the fall of. This year 2020. And then the other two major pieces to the. Revenues going down. But it does improve the operating margin. And that is we changed our. Billing arrangement with a new provider in the emergency department. In the past the hospital would bill. For both professional and technical component. The new arrangement that was put into place. In early. Calendar year 2019. Was that. The. Provider. Bills. For the professional component. And we only bill for the technical component. And then we only provide the. Emergency room provider. Provider. A dollar amount that was significantly less than what it was costing us. To. Pay for those providers. In the past. The same type of arrangement. We changed in the anesthesia services area. Brought in a new provider in fiscal year 2020. Does their billing. For the anesthesia professional component. So we only bill for the technical component now. That was over that period of time from 2018 to 2021. As you can see. Here's the. Almost nine million dollar major components to that. The childbirth center. Reduced expenses by eight hundred and sixty thousand dollars. We've done some changes in the laboratory restructured some things there. Been able to save about four hundred and forty thousand dollars. In our laboratory. Our emergency room benefits. I'm sorry. Our employee benefits. The entire. Benefit program the benefits structure. And through our consultant the Richmond group. We've been able to restructure that health insurance for our employees. Without a significant change to the employees. We've been able to reduce about one point nine million dollars. Over that period of time from twenty eighteen. To twenty twenty one. Our emergency. Department change that I just referred to earlier. About a million six reduction in expenses. Hospitals program. We're looking at changing the hospitals program in the year twenty twenty one. To using the same provider we use at the for the emergency department. So we're. Doing better collaboration we're going to save about a million dollars. With that hospital is program change. The reduction in anesthesia. Cost by six hundred thirty five thousand. We've really worked hard. At trying to reduce our travelers and local. Expenses. In twenty eighteen and prior. The hospital is relying a lot on. Locums and travelers. I think. We've been. Able to benefit from the fact that this organization. Came right up to the edge. Of falling off. And so our staff are very focused. That I've stayed with us are very focused on. This organization and doing what it this organization needs to get done. So we've been able. To get people to do a lot. That we weren't able to before and so our need for locals and travelers. Have been significantly reduced. We've done some restructuring in the management. Side of things. We've removed some some vice presidents we've. Changed some directors and asked people to do a lot more. Then what they were doing in the past and that's going to be that's a. I got a typo there I needed another zero it's about a million. Thirty five thousand dollars. In savings over that period of time. Physician fees we've been able to reduce a little bit. And pharmaceuticals we've been able to. Find some ways to reduce the drug cost. So that's the period of time. That we're looking at. As a transition. I'm going to ask Alan now to talk a little about the next slide which tries to. Give you some insight into the. What we believe to be the financial impact of. Of COVID on the organization. So Alan would you pick. The next few slides up. Sure Mike. Thank you. You might want to get an echo. Let me see how I do that. Okay I think that's better. Can everyone hear me. Yes we can. Okay great. Just can't hear myself. First of all thank you all for introducing yourself and. It's hard to believe Kevin a couple of weeks I've been here a year. So we've. We want to talk about the 2020 financial impacts. And some of the changes. You know that we've made some of the things that have affected. Operations. If you look at the this this slide. What we're trying to show here is. The first column is October 19th through February 20th and that's. That's what we'd call the pre COVID period. And then from March to June actual. That's our COVID which we're still actually in. July through September. That's the projected. Into fiscal year 20. And then we're going to look at. October through February which is pre COVID per day. Cost or revenue. And then coded period per day. And then we'll look at. What do we look like. For the forecast for the rest of the year. July through September per day. So when we look at gross price gross patient revenue. Going across in. The. The first pre COVID period we were running about 44. Million. And as you can see. Jumping over to the per day is about 290. But during the March and June. Period it dropped down to 213. Obviously. Everyone knows about the COVID-19 effect and it's really hit. Hospitals in our hospitals. Pretty hard with. With the effect with its head on revenue. When we look at deductions for revenue. Those are pretty much in line. With what we experienced. Not a lot of change in what we expect from. From contractuals. We'll look at net patient revenue. We're running along in the first. Several months pre COVID and we're at 19.8. And then. As you can see. The last part of the year. It jumps down to 10.6. In July, August, September. We're still right around the same net patient revenue. But if you look at the per day. During the March and June period. We dropped all the way down to 85,000 per day. So. Again, I sound like a broken record. But COVID has really affected us. Tremendously. When we look at outpatient revenue. I'm sorry. I jumped a little bit there. Other patient. Other operating revenue. We notice as we go through the period. That the March through June period is 5.9 million. Well, that represents the cares act. And COVID money that received. So normally run about 5,000 per day. And. That allowed us to have about 49,000 today. To keep us in line. And you can kind of see that. Illustrated when you look at the total. Operating revenue. During the period of October through February per day. It's 135. And during the COVID period, it's 134. So. Those monies actually. Helped us to stain the same level. Of operating income. And as you look during the period of July through September per day. For all total. Operating revenue. It's it's down. And. We don't know yet from Congress. If there's will be another stimulus act. We don't know if we'll get more COVID money, but we do know that there is a real impact. With volume. So that's that's kind of illustrated. I also want to point out in the expenses. As we go across, you can see in the pre COVID period. It's 146,000. And during the COVID period. We actually had about 154,000 expenses related to salaries. And. Employees that had. COVID related expenses. But during that period. We took initiatives. To have cutbacks furloughs. And other. Permanent layoffs to in order to. With staying that large downturn of revenue. And you'll see that in the 146,000 per day pre COVID. And then the 130. And then now that those employees are all back. And working. And the furloughs or you'll see it jumps back to about 145. So that was necessary to make it through that period. And as we look at it as basically that's the earnings before interest. Taxes depreciation and amortization for those. We don't know what that acronym means. We see that Mike, could you just move the slide up just a little bit for me? Because I'm had. It's blocking. Is your bar blocking it Alan? Yeah, my bars blocking my nose. You go to the side of the screen into the black and click there. Your bars just disappear. Okay. Okay. Well, I have paper so I can look the paper. What I want to point out is, is the pre COVID Ibida. Is. A negative 660,000 worth of cash we were generating. And. If you look during the period of. The COVID. We actually were generating. Sub positive. So it was very helpful for those stimulus monies to come in. To help us. And we're projecting. 1.8. Million 1.9 million. Impact on cash. So. And those are very unknown territories we were. We really don't know what's going to. How that's going to affect this, but we do know. What things are how they're running currently. It has a huge impact. So. Right now with no COVID monies in mind. That's kind of our, that's our projections. For the rest of the year. And Mike, if you want to move on to the next slide, we can talk about. Some of the current volumes. There we go. So when we look at our acute missions. And we're going to look at. And first of all, I want to go over the headings before. These things are just slightly different. So we're looking at. 2019 fiscal year 2019 actual. And then we're going to look at that pre COVID period. And then we're going to look at the March 2. September. Which I would call the. COVID through the end of the fiscal year. And then look at what we have projected. For the full. And then we're going to look at the fiscal year 2020. Compared to the budget for 2020. And then the 2021 budget that we're presenting. And. One of the things that. That I, that wanted to point out is. Is if you notice. That the 2000, the 2021. Although less than the budget. It's more than the projected. And the reason I want to point that out is in most cases. In 2020. Although it. The budget that was presented. We didn't meet it. Mostly because of COVID. We also are planning in 2021. To have a point. I think it's point five, Mike. Jumping anytime, Mike, that you want to help, but. Increase in some of the volumes of patient volume. So when we look at acute emissions going across, we look at 2020 projected. We're at a 27. So that's significantly down from the budget of 1140. But notice in 2021. We have a slight increase from what actual we had in 2020. Acute patient days. I want to talk just briefly about acute and patient days because. Due to COVID. Our link to stay was up. And our patient days. Would be up. And we had patients that. If they had COVID or if they hadn't been tested and got the results back. They were not able to be discharged. So our link to stay. Caused our acute patient days to be a little bit more. So if you see in 2020. That's a little bit of anomaly of the other. The line items you have more in the projected in 2020. And we'll actually budgeted. But then we bring it back in line to 2021 budget. To what it normally should be. When we jump down to the psychic missions. Our psychic missions are down. Mainly because the state of Vermont has decided to. Designate our. Wynnum center. Psych center as. COVID. Level one psych center. So during construction. We haven't had any. The psychic. Admissions or or or psych patient days for that matter. So about this. We do have an agreement with the state. To cover our costs during that period. But you'll see. Those. 2020. Psych days and missions down. From the actual 20 budget. And then back up in 2021. As Mike alluded to. Earlier on the ED visits. 2020 budget. Is 14,700. We did have a much, much. Less. Activity. In 2020. But then we expect. In 2021. To start to regain some of that volume in some of those cases. In 2020. With people coming back. To the hospital. Not afraid of COVID anymore. Surgical cases. Pretty much the same issue. We're starting to see a pickup. We're going to miss the mark for 2020. And but we've. Put a factor in for 2021 budget for make. To make those. Projections. Mike, if you want to go to the next slide, we'll talk about. Financial results and what they're trending. One more. There we go. So on this slide, we want to look at our fiscal year. 2019. Look at the October. Through February, which is, we talked about as the pre COVID. And then we want to look at the COVID to project it to the end of the year. That period. Projected for the fiscal year. 2020. And budget for 2020 compared to the budget of 2021. So as we go across and we look at gross pressure revenue. And there we have the price increase. From the actual prices for 2121 budget. The deductions. We don't expect to have. A much change to that. We're critical access or cost reverse. So it's a very complex. Calculation to come up with those deduction numbers. And those are the best estimates that we have at this point. Net patient revenue. As a slide earlier, you notice that. Projected in 2020, we have. Less than what we budgeted, but we're going to make that up in 2021. So, again, due to COVID, we didn't make the budget, but we, we have an uptick in 2021 to make that. If you go down and look. As I mentioned. A little earlier on operating. Revenue. We had the COVID money. That helped us. And that's what we did. During that period. You'll see. The projected period through March through September. We actually had. Operating income of a positive. And that is due largely to the CARES act. COVID money that we received. Want to jump down to EBITDA. And as Mike alluded to, and. I mentioned this briefly. You notice that EBITDA in fiscal year 2019. 6.1 million. As you go across and you look. During the period. Obviously the COVID period. It was a positive 1.4. But. All the way across and I'm jumping all the way to the 2021 budget. We went from taking the organization to have an a negative. 6 million dollar EBITDA to generating 2.2 million dollars. That's a huge turnaround. As Mike. Had alluded to. In his presentation. Earlier. With all of the initiatives that we've taken. That we put in place over the last year. That has allowed us to do that. And. I don't want to go down a rabbit hole, but a critical access hospital. It's very difficult for them to turn around that quickly because. Because of the way we're cost reimbursed, but. We've been managed to do that. And. 2021 looks very. Very promising. Mike. If you don't have anything to add. You can. You can take over on the trending assumptions. Okay. Thanks Alan and hopefully everybody can hear me. And then I'm just not talking to myself here. But the slide on the trending. Revenue assumptions. That just recapped some of the major. Assumptions that we have. You know, the revenue for the organization, this organization. Anyway, and for most organizations. Is really going to be. Dependent on a lot of factors that we don't have a lot of control over. We're assuming that our inpatient admissions are going to return to pre COVID levels. Plus a half a percent. Starting in the budget year of October 1. Who knows? I don't. And I've been in this business for over. Four decades. I just. I have no. Real way to be able to predict that. So that that's a tough assumption if it doesn't happen. You know, we've we've got some decisions that we have to make. Our acute length of stay. We're assuming is going to get back into the. Normal range of of below four. That's going to be a critical access hospital. Part of that is going to result from the fact that. We're going to have a new. Group of folks. Performing our hospital services. It's going to be coordinated with our emergency department. Much better than it's ever been. So that'll make it easier for the patients and transition. When the patient. Has to go from our emergency room into an inpatient bed. To have the same. In the same room with the same. Objectives. And the same philosophies. To be able to move those patients in so we think we can. Really impact that length of stay and get it in line. The psychiatric admissions. We're predicting that it's going to return to again. The pre COVID levels. With that with a half a percent increase. In terms of volumes. Again, no way to predict. What will happen with the patients. When we reopen that. Distinct unit. Hopefully that reopening will occur in early September. It'll be dedicated solely. For patients who need inpatient psychiatric care. We have a positive. Result for COVID-19 test. We don't know how many of those patients we're going to have. From September when we reopen. Until the end of December. That's the arrangement we have with the state. To to isolate those patients in that facility. Should they occur. The arrangement we have with the state. Pays us our cost. So if we have one patient. Or we have 10 patients. We're going to get our costs recovered at least for the period through the end of December. The emergency department we've already talked about. In terms of getting back to kind of a pre COVID level. We're seeing that. Historically for the last four months. The visits in the ED. Have increased about three visits per day. So we think we're going to be back into that level. Of about 37.6. For the year fiscal year 2021. Surgical cases are already talked a little bit about. It was impacted by COVID. Obviously because we had to shut down a lot of our elective surgery. During that period of time now we've. We're reopening it, but we're doing it very cautiously. Making sure that we're. Protecting the safety of our staff. As well as the safety of the patients when they come in. So we can't today quite do. The same level of. Surgeries that we'd like to. Or that we can. But we want to again. Safety is the number one issue. But we believe that. Effective October 2020. Things will start getting back to normal. And then we have a 4% rate increase. So much of the revenue that. That Alan just. Walked you through. Is all based on those kinds of assumptions. Now the next few slides. And that's where we're going to be wrapping things up. Is. In the areas that we do have a fair amount of control. As a organization and as a. Management team. So I want to. Probably pains taking the take you through. The changes and expenses that we've had. So that you understand what some of the major changes are. And why we think we can hit a target of $53 million. In operating expenses. When our operating expenses as recently as the fiscal year ending. September of 2019. Was at 58 million or how we think we're going to reduce. By 5 million dollars. Our operating expenses. So I'm going to I'm going to. Take you through the next few slides that will focus in on the. Major categories. That you see on this slide. Of salaries. Going down slightly from the 2019 levels. Employee benefits. Going down about a million to. A physician fees. Down a million seven. From the 2019 levels. Medical supplies and pharmaceuticals down slightly. And so forth. I'm going to the next few slides are going to. Do a comparison. Go back one slide. Second. Let me see if I can do that. Is that it? Yeah. Where would blue water fall into your category? How are you listing them on this? They would be under management and contract fees. Okay. Great. Thank you. Yep. So let's walk through and I'll try to do this. Quickly because you can read it as well as I can but. Salaries. We did a comparison between the projected where we think we're going to end this year. To what we told you a year ago. We thought our budget number would be. And we're about a million eight less in salaries and those are the major categories or causes for that. We instituted some changes in our clerical positions. We combine some folks we. Change responsibilities of some folks. And so we got about a $240,000 savings there. Now some of this. Is a result of of COVID and you're going to see where some of it comes back. In the year 2021. But but some of those. Savings occurred as a result of COVID if we had to furlough people. Or reduce their hours. We had some reduced staffing in laboratory. About $780,000. We really restructured our laboratory. We've got assistance from. The Dartmouth organization in a part time manager who has been outstanding and helped us. Handle how we can do our laboratory more effective and efficiently. Physical therapy pharmacy respiratory therapy. A number of changes in that area. That produce some savings. We had some temporary reductions for surgery staffing. That's during that period of COVID. That's a COVID impact. Obviously if we weren't doing the elective surgeries. We were asking people to take time off. Or reduce their hours. So you'll see some of that come back. In section B here. Savings in the nonpatient service areas housekeeping dietary those kinds of places. In psychiatry. We did a reclass there. That's that's a simple moving the cost of the psychiatrist from salaries. You'll see that come back in. I think it's under physician fees. So those are the major categories for the reduction of a million eight. Now we take a look at how is the budget 21. Compared to the projected 2020 from where we're experiencing now and you'll see a million three of the million eight. Come back. In some form or another. Wage adjustments. We're trying to provide some dollars for wage adjustments. This organization has not. Done any significant. Adjustment to market. For their generals. Employees. For a number of years. Because of the financial situation that it was in. We believe that to be a sustainable organization going forward. And to be able to attract the staff that we need to attract. We've got to provide some dollars so we're putting about seven hundred thousand dollars. On top of. What we see the 2020. Numbers to wages to be. To provide that. And then you see the four hundred and fifty thousand dollars associated with adjusted staffing due to the coven. So the numbers that were. In section a. Some of that money is got to be put back in. Assuming that we're going to be. At precoven. Levels for our activities. Employee benefits. We were able to reduce below the budget by eight hundred thousand dollars. We didn't know exactly how we were going to restructure when we put the budget together a year ago. Our employee benefit program. We did restructure used. Richard's group. And we're able to. We believe to bring in our. Employee health insurance. Is the majority of that about six hundred. Over six hundred thousand dollars less. Than what we had put in the budget last year. And because of the reduced salaries the million eight above. We've had. One hundred forty. Thousand dollars of reduced taxes. For those lower salaries. So those two numbers are driving the eight hundred thousand dollar. Performance in. Twenty twenty eight to the budget. When we look at now the. Twenty twenty one budget compared to where we've been for twenty twenty. We're going to see an increase. Of cost in that area. We have inflation on health insurance we've got to. We're a self insured program. So we've got to be careful about. If we've had some people. Unfurlows and so forth that. Haven't used their health insurance now start using it. We've providing about three hundred thousand dollars. Over three hundred thousand dollars for that kind of a. Increase. We have a defined pension program. That for a number of years. We're kind of on a. I'll call it a contribution. Holiday. Our investments were. Running pretty close to what our liability was. But because of some. Efforts are not efforts but some. Actual things occurring in the stock market. We've been told that. We'll have a contribution next year. Over six hundred thousand dollars so we're providing. That as an increase. And then in order to continue to manage. Our cost. We announced in January. Of twenty twenty that we were going to reduce. Eliminate basically our. 401k. Pension match. And so we don't contribute. To that anymore at this moment in time that's a. A temporary thing but. That has a two hundred thousand dollar impact. On twenty twenty one budget. Further reduction because it went into effect in January. Of twenty twenty. So we'll have it in effect for the full year. In twenty twenty one. I think I want enough. But I just. Yeah. Physician fees. When you again comparing. The projected to the what we told. The board a year ago we got about a. About a million eight reduction in that area. I'm sorry increase. I wish it were a reduction. Increase of a million eight. That's the cost over what we said. That's that psychiatric reclass that first went to two hundred and fifty. So it came out of salaries went in over here. Surgery locums. We had to. Make a decision. That we have two general surgeons full time. We made the decision in the year twenty twenty. This year twenty twenty that one of our physicians. Shouldn't be. Doing that anymore. And so we had to. Immediately start recruiting. And we had to we couldn't operate with just one general surgeon. He couldn't be on twenty four hours days seven days a week. So we had to look to a local unfortunately and there that's the cost. Of having that local around for that period of time in the fiscal year twenty twenty. About five hundred eighty thousand dollars. And then the third bullet under a there. Is. Is something that I. I'm sorry I have to list. Because it was a real miss on in the year when we put the twenty twenty budget together. We had two clinics. Urology clinic and the GYN clinic. That were operated as FQHC. Organizations but. And generated expenses for the FQHC. As well as a little bit of revenue but a lot of the surgical revenue from those two clinics. Were reported as hospital revenue. We made the decision in fiscal. Just before fiscal year twenty twenty started. That's why I didn't get into the budget. That those services really belonged in the hospital. It really didn't belong over at FQHC since. Most of the revenue was in the hospital. So we reallocated those two. Services over to the hospital. We did that right before the budget so it didn't get into the budget for last year. That's about nine hundred sixty thousand dollars of expense. That comes over. But it matches up better with the revenues. That we had always had at the hospital side. The comparison then of. The budget to where we've been. Historically in twenty twenty or where we predict twenty twenty to end up. Has a reduction. In physician fees of about six hundred sixty five thousand dollars. Made up of those items that we. We believe we've recruited a full time surgeon. He hasn't started yet. He's in the process of being credentialed. And hopefully if we have a. Positive result out of that. Will have. Be able to reduce the amount of local coverage for both the general and the orthopedic. Areas. We have also some. Especially clinics primarily the urology and GYN. We're restructuring a little bit in terms of their. Coverage needed coverage and so we can reduce some of the local costs there. And then the reduced hospital is coverage when we. Change that change will occur in November of twenty twenty. Where we use the blue water organization. To provide not only emergency room doctors. But a hospital hospitalist doctors. There's a. Economy a scale there in terms of the way we staff. And so that'll produce a hundred twenty thousand dollars. Reduction in our hospital is cost. Over what we are experiencing so far this year. For the year twenty twenty one. Medical supplies and pharmaceuticals. We're coming in about. Seven hundred twenty four thousand dollars under. The budget what we thought some of that is volume related. Our volumes are not the levels that we we thought they were. For the budget and Alan talked a little bit about that. So that's the primary reason why pharmaceutical pharmaceuticals and supply costs are. Are under for this year's for the budget next year we're just. It's an increase of three hundred twenty thousand based primarily on inflation. That we're using for two and a half percent. In a little bit of increased patient activities that we saw in the earlier slides. Management and contracted services. Here's where we get the impact of the new emergency room providers the blue water. Kevin that question that you had asked. In the year twenty twenty budget when we put it all together. It turned out that because of the of the transition from our former. Providers for in the emergency room to the water arrangement. It ended up costing us about a hundred thousand dollars more for some of the. Coverage that we had to have during that transition period. So that's that's contributing to the six hundred fifteen. Negative variance from budget. We also have brought on that new anesthesia group. And we had to use some locums. The arrangement that we had with that organization. And almost every organization that does this at hospitals. Has the same kind of arrangement that is during that transition period. If we're having trouble or they're having trouble basically recruiting. Providers and they have to use locals. The premium cost of bringing that local man is the hospital's responsibility. And so we had that occur as we changed over the anesthesia group. And that's what drove that two hundred thousand there. And then a hundred twenty five for accounting and some legal fees. That were higher than what we had estimated in the budget that we're experiencing this year. Those are not those legal fees are not necessarily the bankruptcy fees. They come in under other expenses. They're just pure legal fees or. Audit auditor fees. That are in the management contract service area. When comparing now projected to the budget. The two major it's pretty flat from twenty to twenty one. But there are two things going on inside that that same number. And we are anticipating that the organization will come out of bankruptcy. By around the first of the calendar year. And that the organization will need the form. Consulting group. At least through a transition period to new leadership. So that potentially. The organization would not have a cost to the have corn fees beyond April 1st. So that's what's anticipated in the twenty twenty one budget. And then there's some inflation and just some existing contractual arrangements that occur that kind of offset. That reduction. Under other expenses. Comparing to the budget again. We've had an increase. We're coming in about a million and a half more. I think hopefully you'll remember. That we reported in the budget last year that we had no. Solid way to anticipate what the bankruptcy fees were going to be. Both court and legal fees. We now know we're about eight hundred fifty thousand dollars of expense in the year. Fiscal year twenty twenty so that was not in the budget and therefore it's a very negative variance. We also missed having the AC ACO fees. In the budget for the Medicaid and Blue Cross programs. We. We dropped out of. ACO for Medicare. January one of twenty twenty. We just missed putting it in the budget. The cost for that. We had some major repairs on some equipment that exceeded what we thought the budget was going to be for the year. Of twenty twenty so that's causing a hundred thirty five. When we compare it to the. Budget to the projected numbers. We think we can reduce. We're taking a good portion but not all of the bankruptcy cost out because we will have some. Bankruptcy costs from October. Probably through. February or March. Before that will drop off so we got. We think we can have a savings of about three hundred forty five. I think that's pretty conservative. And then we just have some miscellaneous items. That we're going to be able to reduce. In the other expense category. So I think. One last comment that I want to make. After expenses is just the one care we referenced at that. The FQHC and the hospital had fully participated in one care in the years of. Twenty eighteen and twenty nineteen. We as an organization obviously both organizations. Believe in the objectives but we still don't feel. Even in the year twenty twenty one that for financial reasons. We're able to. Jump back in for the Medicare program will. Continue to participate for Medicaid and Blue Cross. In the hopes that in twenty twenty two. If the organization. Is out of bankruptcy is. Performing well. And stable that we could get back into that. A. C. O. program for the Medicare. So my concluding comments. Are that one. This is. One of the most unique. Years. In my career in health care and like I said earlier I'm over forty decades. In health care. In trying to do a budget. For two major reasons. The pandemic. Just. I don't know how to. Try to estimate the impact of the pandemic on volumes. And on staffing. We're dealing right now and the whole state is dealing with no country is dealing with. The challenge of what happens if the schools don't go back in. And staff have to find ways. To. Care for their. Their student. Age children. At home. And we've already had people coming to us saying you know I'm just not going to be able to work full time. How are we going to handle that what's that going to do to our expenses where we find. The staff. Even if the volumes do come back how do we do that. So that's been a real challenge and a best guess from my perspective. I think the brightest minds are trying to work on that and come up with an answer and I haven't heard any. But I can rely on. And then the other element for our organization that's probably unique in the state of Vermont. Thank God. Is that we're dealing with the bankruptcy process. We don't know how much of a level. Amount of debt we're going to have to carry coming out of that bankruptcy process. We have an idea of how much in which been built into the twenty twenty one budget. Is how much we think that hospital. Financially can sustain in the level of debt. I mean we entered. This just as a refresher we entered. Bankruptcy back in June of. With over four million dollars of debt we owed CMS over nine million dollars of debt we owed Berkshire bank. And over seven million dollars of debt we owed accounts payable trend vendor trade amounts. So that was a significant amount of debt that we entered. We are not going to be able to come out paying everybody all of that. And still be sustainable. How much we're still working on. It has to be resolved before we to the greater extent before we submit our exit plan to the bankruptcy judge. Because she's going to want to know how much we think we can afford to pay. We know it. It's been built into this budget. But whether we come out with that answer or we come out with a different answer is going to have an impact on what we're budgeting. So that's the other wild card for us in trying to put this budget together. So the last thing is and I said it last year and I thank the community for its support. Last year we're going to need to continue to have that support of the community. I believe and I think a lot of us here at the hospital believe that if we're successful at exiting bankruptcy. And I believe we can be with the level of debt that we can afford to handle that that's going to be a big confidence builder for us in this community. People will see that we're are going to be staying around and that they should come here for their health care needs and not look elsewhere because we are going to be here. I think that a lot of part of calendar year 2019 and even to some degree into the early part of 2020 calendar year. There was some doubt by the community as to whether we were going to continue and therefore they may have looked elsewhere. We need that community support to be successful going forward. So with that, Kevin, that's that concludes Alan and I's presentation and and would stand ready. I don't know how good we'll be at answering your question, but we stand ready to answer the board's questions. And let me see if I can get this off the screen. Thank you, Mike. Thank you, Alan. We're going to start the board questioning with member Youssefer Maureen. Thanks. First, thank you for your presentation and glad to see you guys are here once again in another year and that that Springfield is trying to work its way out of this bankruptcy. One of the questions I have for you is, you know, you've gone through a lot to look at expense cuts and, you know, efficiencies in the Springfield budget. And, you know, we have other hospitals in Vermont that are losing money as well. And one of the things I'm always pushing is cost savings and efficiencies. So, you know, can you give us some specific examples of what you think maybe some of the other hospitals should be looking at or hospitals in general to try to improve cost and efficiencies, you know, in this in this system in Vermont. Board Member, I wish I could give you a cookie cutter approach. I think, and I spend a fair amount of time and have over the last several months on calls with the other 13 CEOs, along with Jeff Thiemann, who leads us through a lot of the efforts that we've been doing with COVID. And trying to prepare organizations to respond to that pandemic. So I have the highest regard for the other 13 CEOs. It would be inappropriate for me to try to tell you that here's the cookbook that they ought to be following. It is, it's hard work. It takes detail effort. I believe every one of those other 13 CEOs are trying to do the same thing. I mean, to try to answer your question with some more than just fluff, which I think that earlier comment was, to some degree, is that we just, we have a senior team who really doesn't assume that everything should be the way it is. And ask the questions all the time. Why do we do it that way? Is there a better way to do it? And, and so, you know, I think where we were, where we found ourselves as an organization back in December of 2018 is actually when at first, as I understand at first really surface, was a certain wake up call for the entire senior management team that we have to do something different. I hate to use that trait comment that they keep doing the same thing over and over and expect a different outcome is a definition of insanity. So the only thing that I can tell you we really did is we just peeled everything back and took a look at everything and said, how can we do this different? The decision on changing the emergency room providers was made before I came on the scene. It was the right decision. That certainly has helped us both in the emergency room in terms of the quality of care that's being provided in the emergency room as well as the coordination within the department within the departments of the hospital. I believe the same results going to happen with the hospitals by bringing the hospitals under the purview of the blue water organization. So I wish I could tell you, you know, you look at this, this, this and you're golden. You just have to peek. You have to peek under the sheets of everything and nothing is sacred. No, and I too respect, you know, the other CEOs and what the other hospitals are doing. What we do see is though in times of crisis that, you know, when when hospitals when you're forced to make the changes that you needed to, you were able to do some some pretty dramatic things in order to cut costs to be there. And that's really, you know, at the end of the day is trying to make sure the other hospitals will be here. And many of them are are losing money and we don't want to run into the situation, but thank you. Can you talk a little bit about the COVID money that you received? And if you are requesting anything out of the 275 million current ask and really talk about it in context of where your cash flow is and what concerns you have if any of the cash flow needs you're going to have in 2021. Because obviously, like we know cash is king and you didn't really talk much about cash flow in your presentation or at all. And that's been one of the driving issues of going into bankruptcy, etc. So you talk, talk about that and make us feel comfortable that you're going to be you have enough cash to survive. Well, let me try to answer your question initially and then obviously with Alan and the CFO he can he can add in because he is with it all the time. But we're, we are not only required but for bankruptcy purposes but we're required under quorum practices, quorum health resource practices to produce a 13 week cash flow and update that every week. We can tell you what our cash flow is going to be and actually we just excuse me updated that Alan and his staff just updated that information through the end of this calendar year. Assuming that that'd be about the time that if we're successful at submitting our exit plan that we'd come out. So we know what our cash flow is going to be and we manage that every day, every week. That is critical. Again, I think the biggest difficult unknown area is is how much the COVID impact of the pandemic is going to have on our cash flow. We were pretty good when we started impacting our cash flows back in March with some number that we just didn't know. We've been pretty good about coming real close to that number. But we also are assuming that it's going to filter or Peter out a little bit. If I can phrase it in that term, we don't know if that's going to happen because we're dependent on those insurance companies and a lot of cases having the staff to process the claims. And if they don't process the claims, we don't get paid the remittance advice, no matter how good we are at billing. So to try to be a little bit more concrete with your answer, we believe that we can come out of bankruptcy at the end of this calendar year with sufficient cash. It's not a great position. It's it's about 30 days cash on hand compared to the roughly 56 we had several weeks ago. We are going to be depleting cash, but some of that cash is bankruptcy related expenses. We believe that we can stabilize the organization at around 30 days cash on hand. A typical critical access hospital runs around twice that amount. So we're going to be running pretty lean. But as Alan mentioned earlier in in his discussions around some of those slides, it's pretty difficult for a critical access hospital to accumulate cash because they're paid their cost. In most cases with very little more than costs and it's allowable costs. So a lot of times it's not the actual cost. And we're, I think, around 45% Medicare reimbursed. So it's doubly hard for a critical access hospital to accumulate any cash. But we think we've with the COVID money that we've received, which we've received about $5.4 million of CARES Act money, that that money has helped us get to a point where we can stabilize if this pandemic is what. Can you ask any more money in the out of the 275. We did submit an application. We do have expenses that we've identified but Alan correct me if I'm wrong there was really no spot that we could see in the application that identified how much money we needed and asked for a lot of information around how much revenue we were generating and how much we needed because COVID related but it didn't really ask how much we needed we couldn't find that spot on the application. So, but we do have a dollar amount. You know, it would probably be in the neighborhood of a quarter of a million dollars that we could certainly use that would help us offset some of our COVID expense monies. Yeah, we've heard that as well that it didn't necessarily have a dollar amount I guess there's going to be some type of calculation want to see. The final area that I want to talk about is, is your NPR. Many of the hospitals are expecting, you know, NPR is on par with maybe 2019 most most of the hospitals aren't looking at levels that are going to be equal to or exceeding the pre COVID levels. And as you know, if you look at the history of Springfield this is this is an area that's been the concern in the past right if you forecast too high of an NPR number and knowing exactly what you're saying about expenses that expenses run very closely to NPR at this critical access hospital. If you miss the top line, you then miss the bottom line, you know, fairly significantly. And I'm having a hard time getting to the number that you have for NPR and I know, you know, you guys are building it a different way but, you know, just looking at some of the numbers that you did put in there and some of the comments that you had. Your forecast is is trending to about 138 per day. 138,000 per day to get to your to your number your pre COVID level was 130 per day and your July through September level was 116 per day. And the 2019 level would be around 132 per day so help me get to 138 per day because I'm I'm keep coming to a number. You're trending at 116 per day would be about $42 million in NPR. Your if you're all your comments talked about you're not necessarily going to get back to all the pre COVID levels for surgery and some of the other areas. And I know that you do have obviously a 4% increase reflected in there on your top line but as it goes down into NPR for commercial that would only be about a million dollars. So I'm struggling with getting to the to the one to the numbers that you have and the concern about that is again if you come in around a 48 million or less, because people are wary about coming back to the hospital you have on the added issue of people who thought you maybe we're going to go out of business. And then on top of that, another concern is that there will be less people participated in commercial if they're moving to Medicaid or Medicare because they've lost their jobs and things like this and COVID so you know all things kind of putting pressure on on the NPR. And I know you have that in the end as being a big concern but my question is really going to be how do you get support to be that you can get to the over 50 million and how are you going to be able to quickly pivot because if you were to lose an additional two or $3 million that could jeopardize coming out of bankruptcy. I remember it you hit on you hit on the toughest line in the budget. We're worried about that number two. I know that's not getting a whole lot of comfort. I think the one factor I can think of that makes it a little different is for us in the year 2021 is we've established the clinics that we had. We're not classified by by Medicare is provider based. And so we've got some additional revenue that's coming from the Medicare program as having those clinics classified as provider based that's affecting a little bit of this year, but a lot of 2021. So that's changing that ratio a little bit. I couldn't tell you how much and whether it makes up the whole difference. But Alan is there anything else that you can think of that is different for 2021. So Mike you did you did hit on it a little bit so you have you have the way the critical access hospitals work and I don't want to get too far in the weeds but as as your cost increased obviously your reimbursement increases but for Medicare and Medicaid but that doesn't catch up for for a while. So in 2018 2019, our costs were much higher. But our reimbursement was much less than we we found that out when we follow our cost report for 2019 just finalized so that I can tell you that outpatient was was about 2% less. So what they do is they'll settle up. We paid you 2% loss this prior year so that cash will then be generated so your net patient revenue will be a little bit better if you will the next year. So the trick is to try to balance that and estimate that net patient revenue. It's it's it's not actually it's more of an art than it is a science it's it's you have to you have to kind of juggle and kind of We have models we have experts that look at that and try to estimate what that cost report settlement is. I can tell you it was very challenging. I don't know if you've heard this from the other CFOs, but the PSN ours were not correct because of the ACO program. So that delayed the filing of all the cost reports and and what I did is it made it very difficult for critical access hospitals to try to estimate what our settlement was going to be which affects our net patient revenue. We have a better handle on it now, but our particular in our particular case we expect to have a better fiscal year 21 with net patient revenue. I know that's a lot said to say that our cost report settlement is now more accurate more more because of the ACO and the PSN ours being corrected and we're able to now Actually do better job of predicting net patient revenue and in our case it's it's a positive impact. Okay, I'm going to pass it on to other board members but I would just ask you to really be looking at what you're trending in for the for July August September as you exit this year. And if you trend that forward to next year, you know, assessing what that would be on on, you know, a per day because we are seeing a lot of the other hospitals. Unfortunately, it's just that people aren't completely coming back yet. And so to assume you might be exceeding 2019 and 2020 budget by that much. Maybe we just worry more about the, you know, the whole bankruptcy. PPS hospital, a PPS hospital perspective payment system hospital, they're reimbursed based on a DRG payment for their inpatient. So they're, they can really improve by reducing costs and in volume but for us, if we reduce costs and it reduces our. Yeah, so that's why when I said earlier it's very difficult for critical access hospital to actually generate a lot of cash and improve. But in our situation because we had such high cost and we were being reimbursed less, we're going to see an improvement in the next couple years until it levels out and then we'll have to. Our reimbursement will come less in the next couple years. It's kind of like a waving. You know, boat down down the river the ocean because you kind of try to get it leveled out and and when we have expenses leveled out and we have our volume leveled out you'll see more of a level more predictable period. I know that's a lot said that it's a very it's a very difficult challenge for critical access hospitals to estimate net patient revenue. And we measure that by how much cash is coming in because that basically is our cash or no patient revenue. And we've been able to do that pretty fairly accurate after we have to correct PSN ours corrected. Okay, I'm going to pass it on to other board members because I know I'm constraints. Okay. Thank you. Thank you, Maureen. Now we're going to move to member homes. Jess. Yeah. Um, okay. Well, thank you and thank you for the presentation and, you know, for the hard work you did during COVID and also for starting to turn this hospital around like Maureen. I'm happy to see you all here this year. Um, I guess I'm going to just pick up a little bit where Maureen left off and just ask rather than go into too much detail here. If you could follow up with us with a better breakdown of the NPR assumptions that are going into 2021. I'm finding discrepancies in the tables in the narrative and in the presentation. There's inconsistencies and I just I'll give you one example in the tables in the submission. The ask was for it for NPR 51.5 million. I think in the presentation, you just had 50.6 million. I don't know what the actual ask is. There's some inconsistencies there. I would love to see the associated delta on that cost report settlement that would be really helpful for me. Like how much is that adding to NPR? The volume assumptions. I'm struggling as well. When I look at the presentation with the adjusted admissions. For example, and maybe it's not, it's not clear to me, but the 2019 actual adjusted admissions you have as 8,020 going down to 6,014 in the budget. That's a 25% reduction in adjusted admissions. But then in the presentation, you also talk about inpatient admissions are going to return to pre COVID levels plus 0.5%. So I'm struggling how to reconcile the 25% reduction in adjusted admissions with a return of inpatient admissions plus 0.5%. Average daily census here in the presentation that you think you were talking around 13 and the narrative, it talks about it going down to 10.5 from 13. Again, another, you know, roughly 20, 25% reduction in average daily census. So again, I'm struggling with how does that reconcile with returning pre COVID volumes. Again, surgical cases going in 19 actual going from, you know, over 1000 to under 900. Again, about a 25% reduction even though you're adding another surgeon, which confuses me a little bit how that would all play out. If you can answer that now that's great but if it just requires a follow up of trying to do a matchup of what's in the narrative what's in the tables what's in the presentation and how you get to that NPR number that you are submitting that would be really helpful to me. I think it's probably best rather than trying to answer it on a fly here. Let's let's work with your staff and get some of the answers to the inconsistencies that you've identified. Okay, that'll be fantastic. I just don't know exactly where what what the ask is. Okay, so my second set of questions is, I do want to try to understand a little bit about inflation and so, and I'm asking most of the hospitals is all it's not all the hospitals this. It looks like you are assuming for inflation about 2.5% right for medical supplies and pharmaceuticals. Did you break that down separately medical supplies separately from pharmaceuticals at all in your analysis. No, we didn't in this particular run on the budget. We just took the two and a half for both. Okay, and the wage and salary adjustment not accounting for any FTE changes but just say for existing employees. What is the wage and salary inflationary adjustment or the cost of living include and market adjustment that you're anticipating for next year. What is the percent increase. The way we went about doing that is we didn't necessarily try to develop what the pay program would be for 2021. We just took a block of money. The senior team right now is in the process of trying to identify what areas are market adjustments. And how much would be left over then for across the board increase. So we didn't we didn't approach it by saying what we're going to have a cost of living increase of 3%. And the leftover amount is market adjustments. What I'm asking the senior team to do is primarily our human resource person where are the areas of the hospital that have the furthest distance from market. How much would it take to bring us somewhere close. We're not going to get up to market somewhere close to market. How much is that going to cost. And then what do we have left over out of the 700,000 for a cost of living. So that's kind of the way we're approaching it and a little different. I think maybe some other folks who don't have the market problem issues that we have. Okay, I'm just trying to get a little bit of a sense, but I understand you're doing it differently. So what percentage of your sort of extent expense budget is typically human capital or wages and salaries and compensation just Well, I think it's 4550%. Yeah, it's usually about 50% in the hospital. Give or take, give or take. Okay. What. Let me just see what else are you assuming for a rate increase for Medicaid. There's an assumption in there for any Medicaid rate increases. Yeah, on the psych unit. I know you've got a separate agreement there but not including your psych unit agreement. I think the way we approach it Alan correct me if I'm wrong is we just took the 4% across the board. I think Medicaid will increase their rates 4%. That would be shocking. Okay. Sorry. Well, my last question is around COVID related expenses that are going to carry into 2021. So this would be screeners PPE any kind of, you know, reconfiguring of workflow testing anything like that. Can you have you tried to carve that out of your budget at all? And if not, could you We haven't tried to identify any additional expenses as a result of COVID beyond October 1. We probably could. I mean, we can, I can tell you that our through June, our payroll cost for COVID was about $155,000. So that would be the months of March through June. And that would cover staff that we had to bring in special for setting up testing tents and all of those kinds of expenses. We could assume that we opened our tent and then I think within about a month or so closed it. Because of the Department of Health said that, you know, they wanted to handle all of that kind of testing. We actually, I shouldn't say the hospital closed it. The FQHC picked it up over on the FQHC side because they found it easier for the patient to be to come into the clinic where they were typically go as opposed to the parking lot of the hospital. So the hospital stopped that but the clinic picked it up. So the clinic's got some COVID costs. Yeah, we could try to put in some assumptions and say of the 155 for the that March, April, May, June period, how much of that might carry into 2021. If we don't have a special PPE expenses that you might have, you know, if not for COVID we wouldn't have this, you know, volume of PPE orders or things like that. I'm not sure but it'd be helpful to know what what the carve out would be for 2021 COVID related expenses. We could try to take a shot at putting something like that together. And my last question is really about just trying to understand how you see the consequences both positive and negative of the separation of the FQHC and the hospital as you exit bankruptcy are there. I'm sure there's pros and cons and I'm just curious as you're trying to analyze that how that how that looks for you in the future. Great question. I get I get quiz like that about once a week from people because I know Gifford is continuing to try with move forward with that model. I think what we found here and I apologize to anybody who I made a friend who was here before I got here. But I think it was too easy when the two organizations were one. It was too easy to not really try to focus on what's it what's it costing for us to do that service. I know that probably isn't very clear but by separating the benefit I see and separating is twofold. One is we have to look at each one of our services the hospital does and the clinics do and figure out can we provide that service without losing a lot of money. And if we have to lose a lot of money, where do we pick it up from because there are services that we can't make every service make money. There are going to be services that we can make a little bit more money to cover the ones that we don't. But by having two separate organizations looking at that individually. I think we do a better job of that exercise and being able to make decisions off of that. I just lost my thought for the other benefit turn it. I can tell you what the disadvantage is going to be potential. And we're working on this every day here and Josh to frame it who is the acting CEO for SMCS and therefore the FQHC. He and I talk about this all the time. We have to work closely together. We have to walk side by side hip attached because as I said earlier very early in the presentation. There are primary care doctors. We can't operate without primary care doctors. They potentially could refer their patients to another hospital but it's certainly not going to be convenient for those patients. If they see a patient up in Ludendere or out in Ludlow or right here in Springfield to have to refer those patients to a different hospital. So they benefit by having us around. We obviously benefit by them being around. So we do have to do things together. I just remember now my second benefit is and I think this is probably the one that really pushes us in this direction. Is who knows what health care is going to be in the future. And so for the two organizations to be together limits. I think both organizations potential for looking at how life could be different for them. A separate you know we can have a future maybe with a different partner in health care in hospitals and the FQHC can do the same thing and strengthen them. Their own organization by joining in with another organization by being joined together that limits you. Because of the rule that I think you all know that the hospital cannot own the FQHC. So with us being coupled together there weren't any other hospitals that could really come in and say we'll partner with you and make you a stronger organization. Because the FQHC on us. But by separating us we open up those opportunities that we didn't have as a combined organization. Great. Thank you. I like the optimism. That's it for me Kevin. Thank you Jess. Next we're going to move to member lunch Robin. Thank you. Hi thanks so much for your presentation today. I'm going to jump right in to keep us on track in terms of our time. I was interested in learning a little bit more about telehealth and tell in your phone. Increase in usage of phone around and during COVID and how that went what kind of implementation you did in that in that regard and then what you're expecting moving forward. Most of that was impacted by the FQHC or I should say the FQHC really utilize that at the hospital. We didn't do a lot of that. We had some of that utilization was increased with our psychiatric care. We were able to have patients seen in our ED. I think you may or may not be aware that we worked with the state and we identified two emergency room beds that were dedicated to patients who needed psychiatric care. We had a positive COVID-19 test and our Wyndham Center wasn't open yet, which it still isn't. We have two beds in our emergency department that our emergency room folks can put a patient who needs those services in. And then we do a lot of telemedicine with that patient to our Wyndham Center staff. If the staff can't get up right away, they can at least do telemedicine. So that's where we really utilize telemedicine at the hospital. I think that went pretty smoothly. I think there were a lot of problems with that and I think it was very beneficial from the clinic side of things. I mean, Josh Dufresne would be a much better person to answer that question, but I think he was able to get the providers to utilize telemedicine quite a bit. And we were able, I say we because we do have to work together here, but I think the FQAC was able to get a lot of their providers working with telemedicine and getting their patients comfortable with using telemedicine so that they got up to a significant percentage of visits that compared to pre-COVID. In other words, we were thinking it was only going to be about 30 or 35% for several months and they were able to get up to 50 and 60%. Wow, that's great. In the months of May and June simply because they were able to use telemedicine and get that visit. So I think we utilized it for a month and I think we continue to utilize it. Great. I was wondering in terms of your staffing, you had mentioned that you did have some staffing reductions in particular area in your slides. I wonder if you can quantify that in FTEs just to give us a sense of. I can, I thought you might ask that question. So I had my human resource person at the hospital. We had 24 staff members. I would have probably pretty close to 24 FTEs I would think, which is about just under 6% of our work staff were furlough in the early months, March, April. The predominance of that were the folks that were in our adult daycare program. So I'd say probably a third of those people were the adult daycare staff who have still not. We still have not opened that up, but we're utilizing some of that staff in other places. We also had 17 staff members take reduced hours. So a lot of that was in our physical therapy area, obviously surgery area. Because we couldn't do elective surgery. That is about 4% of our workforce at the hospital. Great. And then in terms of your planned reductions like your clerical staff and those sorts of layoffs that you did, how many staff. Did you? That one I didn't anticipate that question. So I don't have that number. Okay. Right. But. Yeah, I don't know exactly how many. I'd have to get back to you on that one. Okay. Thank you. In terms of the travelers, it's great to see the reduction in traveler costs. I think that's been overall a concern of the board the last two years across all the hospitals. Are you expecting your travelers costs to remain at the lowered level? Are you expecting that to rebound? We're expecting it to rebound a little bit in 2021. I think we're budgeting a little bit more for travelers, not a whole lot more, but a little bit more than what we've experienced in 2020. Critical areas, lab, laboratory. It's hard to get lab texts. And it's hard to get imaging texts. So those are probably the two key areas that we still utilize local travelers. In those two areas. Not much in nursing. We have a marvelous vice president of patient care services and she has a fantastic manager who manages both the inpatient unit and the emergency department. And we do a lot of floating of our nurses between the emergency room and the unit and back and forth. And they're fully trained to do those kinds of things. So we've been able to avoid having to use a lot of travelers in the nursing area. It's primarily those two ancillary departments. Great. Thank you. I just had a couple more questions. I was curious what assumptions you made around dish payments. You assumed that to be flat from last year. Alan, do you know? I don't know. I've thought my head. I think we had a dish flat. For my recollection, it's flat. We can get back with you on that. But we don't, you know, we don't get notified. And due to the COVID other delaying on getting us our new numbers for for the year. Yeah, so. Great. Thank you. Thanks. Did you factor in in any way the elimination of the Medicare sequestration through the end of this calendar year, either into your 2020 budget expectations or the first quarter 21. So, Mike, let me let me answer that one, Mike. So, again, as I said, we're critical access or reimbursement is actually a hundred one percent or Medicare allowable cost. And that has already been reduced by 2% of sequestration, which is, which is settled in our cost report. So, right, but it's my understanding that the feds eliminate like took that that like allowed you to have the hundred and one for 2020. So they eliminated the 2% reduction. Not for critical access that I, you know, not that I've heard I can get back with you, but our cost report is settled up and let me get back with you because I have not heard that that was But the direct answer to your question is we did not anticipate that to go away. Yep. Yeah, I mean, it was in some of the more recent stimulus bills. So I'm just trying to get a sense of what's in and what's out. Yeah, thank you. And then you had mentioned that some of the new protocols did sort of limit your ability to get back to normal. The new COVID protocols back to normal, particularly in surgeries or whatever, which the increased disinfectants and I'm assuming you're doing screenings and those sorts of things. So it sounds like you sort of assume that as of October that that that that wouldn't have to be continued. Yep. Great. All right, I will pass it to Tom. Thank you, Robin. Tom. Good morning. Thank you both for your, your presentation and for all of your hard work, since you've, you know, found yourself heading down the bankruptcy path. I was just looking in the adaptive submission that your, your dish, your dish expectation went up by about $100,000 from 900,000 to a million just to, you know, that's what you presented us. I'd like to just in a couple of sentences echo Maureen and Jess in terms of trying to tie this NPR number where where I got lost was in your in your narrative you said that the Medicare and that patient revenue will equate to quote the ratio of gross revenues to total revenues in 2020 and the Medicaid and commercial have basically the same explanation as Medicare. But then when turning to the payer mix table, it shows over 2020 that Medicaid is going up 29.4% and Medicaid down 47% from 8.8 million to 4.6 million. So I'm just having a, and then in previous testimony this morning, talking about a 4% increase in Medicaid so I, you know, these top side numbers and are I think do need some work, you know, so that we can understand how the your ups and downs kind of roll into, you know, the payer buckets. I pushed the number on that so my phone wouldn't answer and here we are. Tom, if I could just make a comment, you know, a couple of you mentioned that one of the factors that's kind of skewing that is the five and a half million dollars of care of money is not in our net patient number for 2020. It's actually in our other other income which goes in our total operating income. So when you're looking at 2020 and kind of comparing it to 21, you can easily see that when you look at other operating revenue is 5.9 in the period from March to June. So that's not an internet patient revenue so if you're looking how do they get, you know, from the net patient revenue numbers and 21 from 2020. That's a huge issue that normally we would that would be in net patient revenue but it's not hope that helps. No, it helps. It does help. I, you know, a kind of a fuller explanation across all payers. You know, I think would help a lot. In terms of the question that the healthcare advocate asked about uncompensated care, you're in your narrative you said that the hospital is engaging a new firm to follow up on claims in a timely manner. And then later, our financial assistance policy remain, you said that your financial assistance policy remain the same. I'm just wondering what this new firm is doing. Well, let me let me comment on that Mike so. So in a hospital setting you have what we call commercial and we have self pay and then obviously your third party, which which cover commercial and Medicare Medicaid and self pay so what we've done is we structured the hospital they've created see both to where the self pay is focused on an outside firm and then we focus on the larger claims, but the staff when we came in there were currently not able to one they weren't trained properly they didn't have the expertise in the level to to collect and follow up on those claims. So what we saw was those claims were aging. And as we all know in the industry the older the claim gets the less likely are to collect the money. So we engage the company to come in to help get our staff trained to where we can take over. And they've been able to maintain our cash collection levels in her office. Okay. Thank you. I'll call you 7376. Some, some noise there. I have just a couple of more questions. Quickly. One is in your in your opening narrative. You say in addition to our difficult pair mix we have challenging demographics economic outlook the comparative for health status of our residents and ever increasing social challenges. You know, we spend a lot of time talking about budgets, kind of a tub on their own bottom, but as a larger context to me is of significance where in 2020 Springfields pair mix was 18% Medicaid, 35% Medicare and 47% commercial. And so I'm just wondering, you know, you know how much, you know, more difficulty is your challenge to get out of bankruptcy because your underlying pair mix is probably the worst in the state. You know, near the average or near the best in the state, which is UVM, which is has a 55% commercial pair mix. A 9.9% Medicaid and 29.7 Medicare. I guess my question is, if you if you had the statewide average of the UVM pair mix. What would you like what what this budget submission look like coming out of bankruptcy. It would look a whole lot better. Yeah, it is a challenge board member. It is. But you know what I suspect. And we haven't gotten to the point where we've submitted an exit plan yet but I suspect what the judge is going to look for is in the world that we operate in. You know, how do we assure them the bankruptcy court that that we can manage an organization and keep enough cash flow going so that we don't go back into bankruptcy in the next two or three years. And so, yeah, if we had a better pair mix would be wonderful, but we don't we have to manage what we got. And I think one of the benefits is that, you know, we did we are a critical access hospital who at least can assure ourselves of getting a good portion of our cost reimbursed for Medicare. And so my last quick question is, given the damage that covert has done across most hospitals, in terms of people seeking care there. Are you taking any proactive messaging to try to reach out to the community around you to assure them or swage any concerns that they have about coming to the hospital for new for health care. The activity that we've done to date. And matter of fact, I think I have another one scheduled for tomorrow as we use our social media to try to communicate. We find that's the best. And so I will periodically get on our website and have a disc a call it a discussion, but it's a one way discussion about the things that we do and how we protect our staff. So now we're going to protect you as a patient when you come in and expect these things to happen. I have another one scheduled to do tomorrow. That's the best way that we found it to try to communicate with the people about, you know, your, your concern is valid, but here's what we've done to try to offset that. So, Thank you. Thanks, Tom. Mike, could you update the board on where you currently stand in your ongoing saga with the PPP. Okay. We filed an application early on and and we're cut off at the pass and told by the bank we had filed it with that because the application stated that We were an organization in bankruptcy that we couldn't continue the application. We then filed with the bankruptcy court a request for a judgment that that be That we be allowed to apply because we showed that we could use that money and we indicated how much money it was around 2 million over $2 million for the hospital. The bankruptcy court judge ruled in our favor. The small business administration chose to appeal that and so that's what they did. And so it's now in an appellate court. We have asked for that to be and I'll probably get this wrong. I think it's a second district court or something appeal court. It bypasses the first level of the appeal court goes right to the this next level in order to expedite it and that's where it's at. We have been so you have no trial date or anything you have no trial date we we had a discussion with our bankruptcy attorneys. They were aware of at least one hospital in the country who had this occurred to them. And what the hospital did is they went to the bankruptcy court. They asked for a dismissal of their case which they got they filed for their PPP money got that approved and then within a few weeks after getting the PPP money re entered a petition for bankruptcy. We chose we chose not to do that. Thinking that it's just way too confusing for the public to understand they would read an article that would say Springfield dismissed their bankruptcy case. We have all our vendors wanting us to pay him. We wouldn't have the cash to pay him. We get the $2 million and then we go back into bankruptcy. We just thought that was kind of a awkward way to go about getting the money. So we're going to continue to pursue the appeal. We don't anticipate getting it before we exit bankruptcy. If you know if we're successful at exiting in December we don't anticipate this case being decided on before we exit. But if we could get the money after we exit that certainly would help our cash position. Yes, absolutely. In the past we've heard a great deal about the substance use disorder problem in Springfield and my question is what have you seen as a result of the COVID pandemic? Are you seeing an increase or a decrease in overdoses and suicides? Kevin, I don't feel qualified to answer that question. I sure love to get an opportunity to talk to the folks on the front line. I have not heard them tell me that they're seeing an increase or a decrease more than normal, but I'd like to check with them first before I gave you a solid answer for that. Okay, but I can get that out to you and the board. The other thing my last question is really about your contract with Bluewater and you're definitely expanding the footprint that Bluewater has at Springfield. And I just want to make sure that there are terms in the contract that don't put you in a position where at some point they could come in and demand a large increase because they have that leverage over you. So are you confident that the contract protects you? Yes, it has a term to it. I think it's, I don't have it memorized so don't quote me on it, but I think it runs until around the end of 2022, early part of 2022, I'll have to check for sure. So it has a term on it, so it will end. There is the ability to early terminate the contract if necessary. And there also is a portion that on a quarterly basis we take a look at the performance and how they're performing and have a conversation if they're underperforming to do what they need to do to be able to perform. And to date, there's been no issues. Yeah, you know, I feel confident there are other firms out there. So it's not like they would be the only ones that we could turn to. So I feel confident. Sounds like things are working out pretty well though. They are. They are. I'm very pleased with it. That continues. That's a good thing. Yeah, I'm impressed with their leadership. I'm impressed with the focus that their organization has on quality. I attend every month where there's a emergency department meeting in which, you know, their medical director runs that meeting. I attend those meetings. They're about two hour long meetings on zoom. And so now I'm confident that right now that they're performing right at the level that we needed to perform at. And expanding their footprint to the hospitalist had that negative and I recognized it that, you know, it's bringing them more into being dependent on them for that service. But I think the merits of doing it, which is the better coordination between our hospitalist program and our emergency department. Since that is so key to us being able to transition those people that are appropriate to stay here in a smooth and in logical fashion outweigh the risk that we had of bringing them in to be a bigger piece. Okay. So at this point in the hearing, we're going to turn it over to the health care advocate. I'm not sure I saw Mike on the list. Julia, are you doing the questioning today? Hi, Kevin. Yes, I'm going to be doing the questioning for today. Great. Can everybody hear me okay. We can. Great. So first I wanted to just follow up on the question about the new collection firm that you'll be working with. I'm wondering if when you or the firm contact patients for collections if you're screening people for your financial assistance policy as part of that process. So let me answer that, Mike. So the financial assistance policy has not changed. They're still screening for that. We do have a firm that actually assists the FQAC and us and I want to say they're Valley Health. You may be familiar with them, but they help with the assistance and the exchange market for health insurance. What this firm mainly is helping us out with is the insurance in third party Medicare and Medicaid claims. Okay. So they're working with more with the insurers than with like collecting from patients on the self pay or cost sharing side. That's helpful. And then while talking about slide five, you noted that some of your providers are changing their billing arrangements. And I think you said transitioning to doing their own billing. Is that correct? Yes, that's correct. Okay. So I just have a couple of questions about that process. So first, I'm wondering if the departments that are transitioning their billing practices accept the same insurance plans and rates as the hospital to make sure that patients don't receive any surprise out of network bills through that process. Good question. There's there's two areas that we've transitioned that kind of arrangement that's in emergency department that changed over in April of 2019 and anesthesia that changed over in September of 19 a year ago. In their contracts, they're required to be signed up for all of the insurance plans that we sign up for. And so we cover it that way. And we also make sure that if we identify a patient that fits into our financial assistance program that we communicate with those two firms to be sure that they honor that financial assistance also. That's correct. Okay. That was going to be my, my follow up questions. So those providers are all covered by your financial assistance policy as well. Yes. Julie, my team has a, I would say a task force and we, we are up every single month we are making sure we get an update because of the nature of attending physicians and and low comes that come in. We're constantly updating to make sure our roster is is enrolled so our patients are not getting out of network balance build, if you will, from from us or those other companies that are doing their own professional billing. Okay, thank you. And that's all my questions. Thank you. I see that a member homes as an additional question. Sorry, I realized I forgot one of my questions on my list here. And I just wanted to follow up. You had talked about stabilizing cash. At the end of the year, you'd be at 30 days cash on hand, which obviously is a great improvement over last year, but in the projection for 2021. In the budget, the materials that we got on Saturday, the projection is 15 days cash on hand. And I'm just having heard you say, you know, 30 was what we were hoping to stabilize cash. I'm wondering if you could speak to the project. You know, how are you going to do with 15 days projected cash on hand for 2021. You're catching me off guard because I didn't realize we had taken cash down that low. What information are you looking at? Yeah, I'm happy to tell you it's in the tables that we received on Saturday. It's the balance sheet. And it's at the bottom of that table, which is page four of our the document that we get. And it says 2021 budget 15 days cash on hand. I'm not sure if I how I can describe it any other way is the fiscal year budget analysis report date 815 2020 for Springfield hospital and it's page four days cash on hand 15. So obviously a concern that I forgot to raise. The only thing I could think of. Remember home. Sorry for the echo. Let me mute. Let me mute. The only thing I can do is tell you I'll look into it, but I was just, I'm guessing that the person having completed that schedule and sending it in. Well, hadn't been linked up with our projections of cash that we do on a weekly basis. And so there's a there's a difference. And they didn't have the most current information. So. Okay, great. If you could follow up that would be terrific. Thank you. And member lunch, did you have a follow up question on Medicare and PSNR? So it's my understanding from our executive director that the PSNR issues were not at least not solely ACO related, but maybe Susan could just clarify that. Sure, just to clarify the record, what I heard said was that the PSNR were, I don't know if the word broke if they were they were broken, but that was they were not broken by the ACO it was a Medicare operational issue. Just to share, in fact, yesterday we heard from our contacts at CMMI Fodema that this issue is being resolved and is will be communicating out with our critical access hospitals this week with updates on that. So I just wanted to clarify the record. Thank you, Susan. Okay, at this point, we're going to turn it over to public comment. Is there any member of the public who wishes to comment on the Springfield budget submission? I have a question. Go ahead, Dale. It's all a little confusing. Kevin, this is him. Excuse me. If you could wait, I've just recognized Dale. No problem. Okay. Go ahead, Dale. It's all a little confusing. I'm here. It's confusing to use. I'm okay that it's a little confusing to me. One question, though, that I do have, I heard them say or I heard them say that their primary care practices are not really connected to the hospital. How many primary care practices are in the area? Is there enough to meet the need of the people that live there? And because of the bankruptcy, is there a change in the referrals from primary care as to whether they're referring to the hospital or are they referring to other hospitals? Has this affected that utilization that they are talking about? So, Dale, basically there's only three hospitals in the country that are owned by an FQHC. Two of them are in Vermont, Gifford and Springfield were. Springfield, because of the financial situation that they're in, have broken apart that coupling together and are attempting to exit bankruptcy as two completely separate entities. And I'll let Mike answer the community needs, but from what I understand, the number of clinics that are there, that there's a very strong community presence by the FQHC. But Mike, you want to take that? Sure. Let me try to be real clear. I don't want any confusion in the public. When the two organizations come out of bankruptcy, they'll come out as separate financial organizations, but there will be continued connection because it is important that the primary care doctors have a hospital to refer to and be connected with. So that connection will continue. That will not change. I believe that the clinics have been meeting the needs with primary care doctors in our service areas, and there's multiple areas, not just Springfield. We're in London Dairy, we're in London Low, we're in Charlestown. I probably missed a couple. The referral of those primary care doctors who are meeting the needs of their communities will continue and has to continue. And actually, hasn't the service to the community actually increased because now there's weekend availability that wasn't there before, Mike? Right. There's more hours available for the community to seek their health care than there ever was before. So that will continue. Please don't think that there's going to be a disconnection between the clinics and the primary care doctors from Springfield Hospital. That connection will continue to be there and be very stronger than ever, even though it will be two separate organizations. Thanks. Ham, go ahead. Hi. Can you still hear me, Kevin? We can. I wanted to ask Mike, the first week that he arrived there, he shut down the new maternity unit in Springfield because it was losing so much money, which was very painful for the community. I was there the day he did it. My question is this. Have you looked at the high end of your service lines that might have numbers that have like orthopedics or any other high earning surgical procedure, especially that has low volumes and both low volumes and minimal to no contribution to margin? Yeah. The immediate answer to your question is yes, we're looking at that on a pretty routine periodical basis. The other factors that have to play into it beyond just the financial, and you're absolutely right, it was a very difficult decision for the board to make and for the community to adapt to. And I gotta tell you, the community has adapted to us not being able to deliver babies, but a hospital like us, a critical access hospital, we can operate without a child birthing unit. We can't operate without a surgical services. So not only the factor when we take a look at those kinds of services, in most cases we're taking a look at it as if it's not performing where it should be performing from a dollars and cents point of view. What do we need to do to make that happen? Because we would not be a hospital if we didn't have a general surgery department or even to some extent an orthopedic department. So I hope that answers your question. Yeah, thank you. Okay. Other members of the public? I have one more. Go ahead, Dale. My understanding from last year, I think it was in terms of the maternity going away was there was some talk that there was talk about how would they do this in terms of people in the community that were about to give birth that that were pregnant. How would they be transported to the nearest maternity ward in terms of whatever hospital that is that has one? And they were talking about doing some kind of an ambulance, special type of ambulance that would be a maternity ambulance. Did that ever get off the ground? Did they go anywhere without? How is that working? How is the community being served with those needs? And thank you very much. Okay. You're welcome. Let me let me try to answer that question. It's my understanding that we have made those kind of accommodations. We have not had very many women, maybe a couple who have come into our ED without having a obstetrician. And we've been able to take care of those females and make sure that they get transported in most cases to Dartmouth. We have also continued our relationship with Brattleboro Memorial Hospital. And Brattleboro sends their obstetricians here to our campus so that women in this area don't have to travel to that and see their obstetrician prenatal and postnatal. So we've tried to accommodate that as well as for the women who choose not to have an obstetrician until the day they're ready to deliver, which hopefully is very few. And we've accommodated those with the appropriate transportation mode to Dartmouth. Okay. Thank you. Okay. Other members of the public, hearing none, I want to thank you, Mike and Alan for your presentation. I understand there are a few follow-up items that Alan, you're going to try to clarify some of that financial data. And I'm sure that Patrick and Laurie and Kate will be working with you to make sure that we understand exactly what we're looking at. So we thank you in advance for your cooperation with them as we get all those questions answered.