 I'll reconvene our meeting of August 18th and next we'll be hearing from Northeastern and the Northeastern team on their budget submission. I'll turn it to Mr. McCracken to get the identities and names of the participants from Northeastern and to swear on the witnesses and then Mr. Tester, I'll turn it to you and your team for your opening statements. Sounds good. Great. Thank you, Chair Foster. Sorry, for the NVRH team, could you let us know who will be presenting and answering questions today? Sure. We'll give you the names of everybody here in the room because obviously who answers the question will depend on the question. But we have Mary Parent, our board chair. You have myself, Sean Tester, CEO. Andre Bissonnette, our chief financial officer. Betty Ann Gwakkin, our chief HR officer. Slow down. You want me to slow down? You want me to slow down? Yes, thank you. I can take as much time as you need. Will you can spell those names for me? I think we might become best friends so that would be a great position. Oh, man, you're going out on limb here. Okay, so I'll go back to Andre, A-N-D-R-E, Bissonnette, B-I-S-S-O-N-N-E-T-T-E. That's a lot of scrabble letters in his last name there. But Betty Ann Gwakkin is Betty, B-E-T-T-Y-A-N-N-G-W-A-T-K-I-N. Then we have Dr. Michael Ruse, our chief medical officer, and that his last name is spelled R-O-U-S-E. S-I-C. I use so many S's in Andre's name. Let's see, Julie Schneckenburt. This is a mouthful. Holy cow. Could we have simpler names? Julie is our chief nursing officer and her last name is spelled S-C-H-N-E-C-K-E-N-B-U-R-G-E-R. Uh, remotely and on the phone, we have Laura Newell, and that's N-E-W-E-L-L. She's VP of medical practices and operations. She's joined us from a remote location on vacation in Vermont. We have Diana Gibbs, VP of marketing and community health improvement, and her last name is spelled G-I-B-B-S. And then last but not least, we have Sean Burroughs, our chief information officer, the younger better looking Sean, S-H-A-W-N-B-U-R-R-O-U-G-H-S. I think that covers all of us. How do you spell your surname? Oh, Sean, S-H-A-W-N-Tester, T-E-S-S-N-Z-M-T-E-R. Thank you. All right. Thanks very much. I will swear you all in together if you could all raise your right hands. Do you solemnly swear that the evidence you shall give relative to the cause, no under consideration shall be the whole truth and nothing but the truth. So help you, God. Thanks very much, and we will turn the presentation over to you. Okay. Thank you very much. We'll try to be brief as possible, but there are a couple of things we want to cover in our preamble. So first off, I want to say we're very pleased to be here today presenting our fiscal year 24 budget and answering your questions. This budget is the result of months of work by the NVRAH team with the full support of our board. It represents what is necessary for our community's hospital to best serve our patients, ensure sustainability, and invest in our workforce. We do appreciate the challenging role that you play as regulators and are deeply appreciative of the support we've received from the Green Mountain Care Board staff as we've prepared for today. The mission of... I'm sorry, what was that? Is there a guest on from MSR? I just muted it. I think we're good. Thank you. Okay. Thanks. The mission of NVRAH is being committed to improving the health and well-being for all. And we currently have the following focus areas. Meeting the increasing healthcare needs of an aging population, addressing the mental health needs of our communities and healthcare workers, targeting underlying health-related social needs, including food and housing and security, continuing stabilization efforts to ensure the ongoing sustainability of local healthcare services, and completing a robust strategic planning process in partnership with our board and stakeholders. We as an institution are committed to collaboration and valued-based care. We are a regional leader for the ACO and Blueprint for Health. We're the backbone organization for NEC Prosper, our local accountable community for health. We're dedicated to collaboration with partners, including Northeast Kingdom Human Services, Home Health and Hospice, Northern County's Health Care, our local SQHC, the Council on Aging, Northeast Kingdom Community Action, Umbrella, RCT, our Regional Transportation Authority, the Vermont Food Bank, and more. We are also providing leadership for community health improvement and team-based care. We're committed to making impactful community investments through such tools as community connections, our outreach arm of the hospital, NEC Prosper, the Community Health Fund, our Healthy Sense Fund, and our Unhoused Partnership. We're dedicated to collaborative partnerships to improve healthcare access, including Dartmouth-Hitchcock cardiology services here at the hospital, our partnership with North Country Hospital, including the Sleep Center, and other regional opportunities that we're currently exploring, ENT and Allergy Services with Littleton Regional Health Care, Northern Express Care with Northern County's Health Care, and our partnership with the UVM Pathology Lab. These partnerships enable us to support a thriving, healthy community, and now I'm going to turn it over to my team to share some of that work with all of you. Starting with Diana. So sorry, Ms. Gibbs, we can't hear you. Hopefully this will be better. So just speaking to addressing mental health and substance use disorder from our community perspective, as a leader, MBRH really provides community health improvement opportunities addressing gaps across the continuum of care and facilitating efforts that address health inequity experienced by our population. MBRH continuously monitors the needs of our patients and communities, and in turn develops collaborative solutions both working internally and with our health and human service partners that Sean Tester had already highlighted. That said, we use data-informed approaches and a collaborative approach in addition to determine how best to allocate resources that we have, such as community grant opportunities and our community benefit spending. So some specific areas that we wanted to highlight are maintaining a contract since 2018 with the local recovery center to ensure recovery coach services within 30 minutes to patients presenting in our emergency department, really helping to address the vulnerable needs of the population here, offering brief intervention and referral to treatment. We also provide in-kind space, including rent and utilities for local recovery center, a comprehensive care clinic providing care and treatment for HIV and hepatitis C, as well as Vermont CARES that provides harm reduction services to our community, including Narcan distribution and free syringe service programming. We also offer on-site sharps and medication drop boxes for safe disposal. We also serve as the administrative entity for the Blueprint for Health in our health service area, offering pregnancy intention initiative services, supporting the hub and spoke model and access to medication assisted treatment that are known as medications for opioid use disorder, and integration of community health team staffing to include community health workers, care coordinators, and care managers. NVRH has also integrated behavioral health specialists into our three rural health clinics to meet those short-term counseling and behavioral health change support needs for our community. To meet greater demands for mental health support, NVRH has integrated telepsychiatry for emergent access and recently expanded the emergency department to offer a more conducive space in our mental health support area. Thank you. Next, we're going to pass it over to Betty, Ann, and Julie to talk about our workforce, where we're at today, and some of the opportunities we have ahead of us. Ann, thank you. Just some highlights on the workforce at NVRH. We're a small hospital, as you know. We have 715 employees or 517 FBEs. Our vacancy rate overall is actually quite good. 7.75% is compared to northeast averages of 11%, and our turnover overall also is 13.5% as compared to a northeast average of 21%. When you look at nursing, though, that's where our biggest challenges are right now. Our RN vacancy rate, just looking at the RN population, is 21% as compared to the northeast average of 23%, so we're more in line with the northeast average. And our RN turnover is 12% as compared to 16.9% northeast average. We think that some of the RN turnover, it may be a little low because we do have registered nurses who leave permanent positions and become per diem, so they're still employees, but they're not in their permanent positions. 75% of those vacancies of our openings are in nursing, so we do have some openings in lab and food service in some various other areas, but 75% of our openings are in nursing, so that's why we're focusing on nursing mostly today. Even normal turnover can create a longer-term vacancy because there are so many vacancies, so one person who retires or has to move for family reasons, that just adds to the bigger picture of the vacancies that we have here. The impact of those vacancies for MBRH, we're utilizing travelers like everybody else is in numbers that we never saw before, absolutely before COVID, and we use these travelers for maybe family medical leads or someone was going to take a leave of absence, but now we have 26 travelers on site at a cost of $3.2 million so far this year. There are other well-documented impacts of the nursing vacancies, not just here, but burnout for nurses, nurse dissatisfaction and stress regarding the level of care. The dissatisfaction and stress we hear about, and it's mainly to do with the nurses who have stuck it out with us, and they are disappointed that they feel like they want to do more and they could do more with each and every patient, but they're spread to thin at times and that leads to dissatisfaction at the end of the day. Another impact of the vacancies are the limits and risks to patient care, so sometimes we try not to do this, but if we have to limit bed capacity, that helps to mitigate the risk to patient care, and we try not to do that. So these are obviously short and long-term issues, and we have short and long-term strategies to try to solve these problems, and some of our short-term strategies have to do with wages. In the last two years, we focused on nursing, and we had wage increases hospital-wide. We did a total of 18 percent wage increase for nursing in the last two years. We look at all hospital averages and specific rates. UVM Medical Center publishes their wage ranges, which we appreciate very much. We compete with all hospitals. It doesn't matter the size. Any nurse can go to any hospital, so we have to look at the going rates for all hospitals combined. There's also some challenges regionally with high rates in nursing homes and long-term care facilities, as well as the prison and home health. Those facilities have real challenges, and they're really important jobs, so those rates spike quite often, and we hear about it from nurses who are actually interviewing and looking around. So we have to pay at least market rates. The rates are rapidly changing, and, for example, as I said, the nursing offers from other facilities are absolutely 20 percent over what the surveys say, and we have to rely on the surveys to set our wages. CRNAs, our certified registered nurse anesthetists recently, their wages are increasing in the state, and we had to do a substantial market increase for the CRNAs. Some other short-term strategies. We've increased clinical support for nurses, so we can't fill the RN roles, so we have replaced some of the RN roles with clinical support, such as LNAs and then LPNs, who are two-year nurse professionals. We also, through our recruiting initiatives, we've enhanced our outreach efforts, online targeted ads. We have started a short applied process, which makes our application process a little quicker, and we have worked with Indeed and our recruitment system to do career and resume searches through them as well. We've also pursued international staff, like a lot of other hospitals do. For us, we don't qualify for the H1B visas because we're not a teaching facility, and we also allow nurses to have two-year degrees rather than four-year degrees, although we have pursued green card employees in supporting the green card process, but those visas have already met their cap nationally, so that's not an option for us right now. Then quickly for our retention, we do, we're a small place, so we're fortunate that we can talk directly to people quite often, and through the feedback from staff, we've improved our staffing patterns, we discussed work-life balance, more creative scheduling. Everyone is looking for professional development, it's not always about the money for the existing employees especially, and then they also offer us recruitment ideas. We've leveraged insider travel contracts, we developed an insider travel program, an insider traveler program which Julie has shared with other hospitals across the state, and we have never utilized sign-on bonuses and we're continuing to do so because we, our philosophy is to focus on the permanent wage level. I'm Julie Schneckenberger. Good afternoon. I'll talk a little bit about long-term strategies that we have in place. We've discovered through our recruitment efforts that nurses prefer to talk to a nurse when they're talking about a position at a hospital, so we've added a person that helps with development and is a nurse and goes with Heather to nurse recruitment things. We've also started recently, actually today was the first day of our nurse residency program, we have six nurses enrolled in that program. It's based on standards of care and we have found that the new grads over the last few years during COVID did not get the hands-on actual patient care clinical experience that they would have under other circumstances, so we want them to have a good foundation, a solid group that they can grow with and develop. We offer many of those classes to anybody that would like to attend them that wants to brush up on anything, so that's all published and ready to go. We have two nurses from the ED, two from med-surgeon, one a day surgery all enrolled in that program. We also recently started to work on CAPS programs, that is our career advancement program and we have six people involved in that as well that will take someone from example in environmental services that will send them through an MA program. When they complete the MA program then they can take a course and be eligible to move into an LPN program and then continue on to an RN program. We've worked with White Mountains Community College for this program for several reasons. They have openings where Vermont State University nursing programs do not have the volume of openings that we need in this state. They're 30% lower tuition for that program, so we're supporting that going forward. Then we also work with Vermont State University for the nursing programs. We hold clinicals here for their PN and RN program students and we will do the same with our White Mountains Community College students. We recently changed our nursing education program from a decentralized meaning that every nursing unit had an educator on that unit. We've centralized that recently and it's making things more robust. They support one another through education programs and we have standards of how we orient nurses to the various units. Then we recently, under new leadership, I've redesigned how we run our medical surgical unit. That was one unit that has the most vacancies in it. We've gone to a, sorry, it's a team nursing which is a little different than what we had. We had a clinical coordinator. We've removed that position and changed it to a resource nurse, charge nurse. This gives nurses more autonomy. We've also changed our staff, patient to staff ratio from one to four to one to five so that eliminated some positions and keeps us at a safe nurse-patient ratio. We've also supplemented, when RNs have left, we've engaged LPNs and LNAs rather than an all-RN staff. The FTE has not changed but the cost, if you will, for those care nurses is a little bit less. All right. Thank you. Dr. Mike Roos is going to go through some of the post-acute care challenges we're seeing in our community today. I should mention it's very unusual for Dr. Roos to wear ties, so I hope you all appreciate it. Thank you. Thanks for having me. What do we prepare these budgets for? It's for what we expect to see coming. We're trying to prepare a budget that will respond to what we're going to see coming. What we're seeing now in the Northeast Kingdom, which it has the highest percentage of elderly patients in the state of Vermont, is more and more trouble with getting patients placed. We can take care of patients and get them ready for discharge, but where do they go next? What we find is we're having increasing problems with finding beds in skilled nursing facilities. They're having a lot of trouble with staffing, as Betty Ann mentioned. We've had two nursing homes close in our region since 2020. There's quality issues in the post-acute care setting. Where do these patients go after we have taken care of their acute problems? We're definitely seeing more dementia, chronic illnesses. These patients have mobility issues. Having mobility issues here in the Northeast Kingdom makes it very difficult with the winters and transportation issues. The idea of aging in place is getting harder and harder here in the Northeast Kingdom. We're dealing with all that. We're utilizing care management services to the highest extent. What we're finding is we're having to look to our neighboring state, New Hampshire, for interestingly, Jerry site care. There's a Jerry site facility in Woodville, New Hampshire, Ray of Hope, and another one in Nashua, St. Joseph's. We don't seem to have a referral place in Vermont for that. Because of the skilled nursing facility shortage in Vermont, we're using places like Country Village in Lancaster, New Hampshire, Lafayette in Franconia, Crafting County in North Haverhill, the Morrison's in Whitefield. We're stretched as thin as we can as far as trying to take care of the population we have. We have a lot of mental health challenges here. We have one of the highest percentage usage of our ED for mental health evaluations. We see five to 10 mental health patients in crisis each week in our ED. This causes an increased cost and strains our services, most of which we don't get reimbursed for. We provide patient observers. We've instituted telepsych program that we basically pay for on our own because the reimbursement for those services is poor. We have as many as five mental health patients in our nine bed ED at a time, which means those are five beds that are not available for acute care. So we divert a certain amount of acute medical issues from our ED because of that. The mental health patients in crisis do lead to increased staff turnover and strain our security staff, which we also have to pay extra for. So we have a lot of challenges trying to be able to take care of what we are seeing coming in. The budget we have made is to try to adapt to what we are seeing. Thank you, Michael. And then I'm going to let Andre wrap things up for us. So you've heard from Julie and Diana and Dr. Roost about some of our challenges, some of what we're doing, some of the efficiencies and some of the cost savings as well as some of the investments that we've had to make here at NBRH. In Julie's discussion about restructuring the MedSERD floor, we've reduced FTEs a little bit over six FTEs. That equates to about $600,000 a year. We've reduced some FTEs in our practices. It's about four FTEs. About a year ago, we engaged with a consulting company, AMS, to do labor benchmarking for us. We started implementing that throughout this past year and look forward to implementing more of it as we go forth. It's starting to reap some benefits as we see the opportunities and look at some of their operational efficiencies in benchmarking. At the same time, with that reduction of six FTEs on the floor, we've hired six new nurse residents. That's going to reduce our traveler expense. We've got a reduction from our actual spend right now to next year, about $1.4 million in our traveler line for that. Those are the hard and fast dollars that we can quantify. We've got some other things that we're looking at too that we're doing. We've streamlined patient insurance verification process for when patients come in. We can actually automatically push a button in our Meditech system and within minutes have an insurance verification to make sure that we have the right insurance information for those patients. That's more accurate claims submission and a better turnaround for our revenue cycle. That's actually helped reduce our days in AR from roughly 40 days to 32. We've implemented a contract review process for new and existing contracts. New capital purchase process as well so we can get a better handle on our purchasing of capital. A better line of sight to it. We've moved paper claims, which we've had a number of paper claims that we were dropping to an electronic claim system. And we've got, as Julie spoke about, long-term investment strategy for our workforce through the CAP program. That CAP program is not a one and done. It's not a one year. The idea is to get staff into the MA program. There's a launchpad for LPNs to get into an LPN program to move them to an RN. So the end game is to grow our own. There's not many experienced nurses out there that are able, that were able to recruit or any other hospital that's able to recruit. They're very limited. So I think the strategy is growing your own. And that's where hospitals have to go at this point. The CAP program is unique. We're not just paying for the educational component. What we found when we were speaking to these MA candidates is that and even a couple of the LPN ones that are going to start in January that they could afford to go to school or get the funding to go to school. But they can't afford to not work and go to school. So this program actually bridges that work component. So we will actually be paying them for that time they're in class so that they can afford to live and go to school with an end game of having an advanced degree when they come out. So that's all that I have. So thank you. All right. Thank you all for giving us an opportunity to share a little of our story this morning. We appreciate it. Thank you. Dr. Limburg, are you running this one or is this Mr. Sutter? You're stuck with me. As long as I can be I'll take it. Go ahead please. All right. So thank you for the opening comments and really helpful to hear some of those benchmarking values related to your vacancy and turnover rates. I would just say that that's one place we struggle is to get publicly available sources. So as we explore the possibility of proprietary data sets for that kind of comparison we look forward to hearing recommendations. So overall we see that among COS that northeastern for the NPR growth is clustered right here with Springfield and Grace Cottage and right around that 16 percent mark so 16.33 to be exact with operating expense growth pretty close to that again relatively close to Grace Cottage. So seeing some familiar some similar trajectories on operating expense growth. However here we see you know tied for the first in terms of the charge master increase in the ask for fiscal year 23 to 24 and you know hoping to recoup the majority of that in the actual commercial contracts. And you know in your narrative or in your response to questions thanks for providing those you kind of walked us through the process by how you develop that rate and I thought we might just start there in terms of kind of how you approach that process. So I can read your response if you like or if you want to just talk about yourself. Why don't you go ahead and read through it Sarah. All right. So you say that you developed it as follows. So when you identify a target operating margin of one percent so then after you net out any savings that you've identified you look at your expenses and then look at what NPR you can expect based on your budgeted volume assumptions. Then you look at your change in Medicare NPR based on those factors. Know that that can be a little bit of a tricky calculus especially with the cost report timelines. Then looking at how what you're expecting for other operating revenue and I guess the wild card there these days is often the 340B revenue and what you can hope to recoup there. And then when you did all that you saw hey that's an operating loss of 5.45 million which is not the operating margin you were expecting. So then that's how you figure out that based on the value of your commercial rate at 446,600 dollars per one percent of increase that you needed the 15 percent. So that that is kind of the process that you take right. Is it do I miss any of the steps there? Nope I think you captured it Sarah. Nope you're on mute Sarah. Thank you sorry about that. Okay so that is the process that you took so we can understand where that came from and then when we look here so you know seeing those operating expenses you know among your peers I think that you you know kind of in this above the median but you know not not the highest second highest among cause I think maybe third highest overall. So we heard from Grace about some of the things driving their operating expenses. You've discussed some of the labor challenges. Any other kind of drivers of operating expenses you think are important for the board to understand? Yeah there's some other operating expenses well let me start with the 340B retail revenue. In the narrative they submitted a graph of what's happened to that over the last five years since I think it put 2022 but it's actually since 2020 we had a high of $2.7 million in other operating revenue from that. We're budgeting next year other operating revenue of $300,000 so that's you know almost a two and a half million dollar delta in a very short period of time. So that's playing into the NPR need the other areas of growth which you get the investments that we're doing in our workforce both in like the CAT program education and the salary issues that Betty Anne spoke to. We also have increased in in our supply costs mainly around implants. We do bill for those so I don't look at that as just a pure cost because there is revenue attached to that as well as the the drugs and the drug increase is a good chunk of that is around utilization not around inflation. Inflation is tough to pin on the drugs we do have a couple very high cost drugs that every once in a while creep in we do have one patient that's on a regiment that's for a cost is about $350,000 a year. We had another patient that we thought may come into the fold we did not put that in the budget we have not seen that patient again. Unfortunately for us as a critical access hospital that drug cannot be purchased on 340B program. If they go to a PPS hospital because of their dish status it can be purchased on the 340B program. So those are some of the other areas of of increased expenses and of course the provider tax ties into that but that's a mechanism of NPR. Right right yeah okay and then yeah so that helps on the pharmacy costs so yeah you had mentioned kind of that million dollar increase but we're trying to look over the two years and I didn't quite track that but it sounds like you should be within the range there and then when we look at the your financial performance this is kind of that that gap that I think that you're talking about so you know in earlier years the darker line is the operating expenses was a closer to the NPR line and I think that the hospital industry at large is grappling with that and you talked about some ways you're trying to grow your own and reduce the traveler's expenses and you know seeing that total margin at 1% looks like you know lower than historical values but good to see some rebound in projected for the current fiscal year and then the days cash on hand is certainly concerning I'm sure that's something you're tracking as well just curious how you're kind of trying to balance the need for cash versus kind of operating funds flowing through the system and kind of maybe longer term how you're kind of thinking about restoring some reserves. Yeah the cash has taken a dip you know where in that 100 days cash on hand range which to me is marginal I like to see a much healthier days cash on hand that's a good indicator of the strength of your balance sheet you know looking at a 1% margin for operations is part of the strategy to to start building that back up as well as keeping an eye on the money we do have an investment in making sure that those are throwing decent returns as far as the the npr to expense I think going back to 2019 you know that gap was filled with 340b retail revenue and I think you're going to see that with many especially critical access hospitals where that is going to be that gap is going to start staying open when it dropped to the bottom line because that other operating revenue is not going to be there the farmers kept away pretty good at that number and then when we look at so this is compensation for FTE being a small hospital it's just going to be a lot more volatility here but you know if we look at where you were at 101 per FTE in 2017 if we just trend that forward based on the employment cost index we would have expected something closer to 118 in fiscal year 22 looks like we're closer to 134 I do see kind of increases in salaried staff so yeah I think you covered pretty much how you're trying to approach the benchmarking and in factoring in those but just if you have any comments or or reactions you wanted to provide don't want to offer you an opportunity yeah as far as the benchmarking goes you know most of the benchmarking data that's out there is at least a year old and the market has changed so drastically and quickly over the last you know two and a half three years to keep up with that it used to be minimum wage was $12 an hour four years ago and you know we're talking and you know going back and forth is that going to actually end up being $15 an hour well when COVID hit it automatically went to $15 an hour and then some for a lot of those positions that were entry-level positions but direly critical for a hospital a hospital runs on every position that we have it's not just nursing staff it's not just doctors you close ORs down when you can't clean them you close inpatient down if you do not have a cafeteria to serve food and create food for your patients so that that number alone went up drastically in 2020 and it's just cascaded from there and keeping up with the market the way it's been going with the shortages out there the benchmarks is something we look at but also understanding that that benchmarks a year plus old and how do we get in front of it so we're not that much further behind the benchmark so he has staff I also want to remind you about what Diane shared you know if you look across our open positions um you know 75 percent of them are nursing we know we have a nursing problem and and and we've moved hard to to stay within market on nursing pay but we've also worked really hard to keep up with market changes with all the other clinical positions within a hospital fundamentally you know it is hard to recruit to a rural area like the northeast kingdom and and so part of our strategy has been to to be responsive to the the rapid changes of the market and I think that's part of the reason why you see us a little bit above benchmark however we do not have a problem filling positions like APR and and and physicians at this hospital and and so I think our our our workforce challenges are very much contained to the nursing challenge which we are you know this budget reflects an investment in our our future nursing workforce so that we don't have that problem but um but I think you're probably going to find that the the entire market is going to catch up to to that to that reality here very quickly yeah seems consistent with other testimony we've had um and uh you know you kind of lay out your total compensation change over the two years um but we do see a discrepancy in the admin in general versus clinical um is that uh can you talk me through kind of why that's different back to yeah I'd have to dig into that one okay okay no worries okay I will list the follow-up in your total compensation does that include benefits or is that salary total total compensation yes benefits yeah outside that we have seen benefit growth um in our healthcare spend yeah yeah I imagine so um so uh you know again a smaller hospital here see a lot of volatility and kind of the utilization changes year over year I think we we connected offline that while this looks like a dramatic decrease from 21 to 22 it's actually only one and a half percent so you know the scale here is a little deceptive apologies for that so I guess from a budgeting perspective knowing that you kind of have this hard to predict pattern and utilization you know how do you approach that as someone making these budgets I'm sure it's not easy yeah um if you actually look at the graph it's I mean this is kind of a funky graph for the utilization because it shows the growth from the prior year so you'd want to actually see it go down not drastically up if you go back to 2019 that's the pre-covid year um that that was a drop from 2018 of 10 percent um so our drop of one percent from last year means at least flattening out um which again is an issue when our expenses are going up um there's there's only a couple levers you can pull um when that happens especially given that a number of our expenses are fixed expenses so utilization like that where we've seen some increases in utilization is in our OR um we've got a pain service which I talked about in our narrative which is actually um pretty impressive when you actually have a service that is getting patients off of opioids um you know they're he takes long-term chronic pain patients and is able to either get them drastically weaned down or completely weaned off of off of medications um those are the two biggest areas we do have a little bit of increase in our diagnostic imaging area but you know the ER has gone up a little bit um but pretty much it's it's flat and yeah when you have utilization that's relatively flat and a lot of times that's our demographics it becomes a challenge from a budgeting standpoint yeah understand me um and then as far as you know you are pretty close to a border so um looks like about the 80-20 split when it comes to in and out uh migration for utilization um just pointing out that uh much like uh the white river junction hospital service area which we heard is amazing and very valuable um the st j service area uh has quite a high proportion of uh residents with medicare as their primary payer um and i think what we see here is this big drop uh in spending due to uh medicare advantage um so i'm just curious um how you're grappling with some of the challenges associated with that type of payer um our biggest challenges with that type of payer is their their we get a much greater denial rate from them um one of the other things that we we put together this year was a revenue cycle committee focusing on denials um you know the insurance verification you know trying to make sure that claims uh go out the door clean and come back in clean and we find that um the medicare advantage ones uh are ones that i don't know if it's just the insurance company or if it's confusion on the patients part where they think they have medicare because when they come for a visit they still are they do still have a medicare product that they're eligible for um so it's picking the right insurance company and they'll come in and say i've got medicare and it's really medicare advantage so i think between you know they are a for-profit entity they're not government they're not medicare um so they they do act just like any other commercial insurance company um but i think there's a little bit of confusion that goes on and there's you know there's something like 120 different products out there uh for medicare advantage so it becomes very confusing for specialist patients yeah okay um and so uh it's thinking through some of these cost report metrics so um uh let's see you are uh relatively large compared to the comparators above the 75th percentile but um clustered pretty closely with some of these other facilities um and your case mix index is very close to the north country at 1.3 so just want to make sure that those numbers kind of make sense in terms of acuity and and relative size from where you're sitting yeah they do um you know when you have adjusted discharges for critical access and it looks like it's higher like this um usually it's because they're offering a broader um broader amount of services the medicare case submit case mix index which we submitted our total case mix index which is about 1.15 um so the medicare at 1.3 does make sense okay that is what i would expect we we do have um a pulmonologist on staff that helps um helps be able to keep more acute patients in our our facility fantastic um and you know relatively speaking we've got a very skewed distribution i think we talked earlier about um that you know a lot of these lower lying numbers are probably you know affiliated with systems and that the admin and ratio is uh not representative but you you're right at the median here very close to some of the other um Vermont hospitals um i don't know if you had the privilege of submitting the cost report for nvrh in fiscal year 22 but um you know if there's any funkiness uh especially on line five uh that we should know about it'd be a good time to let me know okay we'll we'll follow up if you have anything after that later on okay and then right right near the median in terms of cash available for operations at the end of fiscal year 22 we talked a little bit about strategy there um and then the um kind of profitability measure we have uh you know just barely break even uh so you know i think that uh 25th percentile um kind of a sign of the times there um and then again just really in with the rest of the pack um at the 13 000 per adjusted discharge which is very close to springfield and uh grace cottage a little bit uh higher than porter um any concerns about the validity of the that measure or concerns that we might not be getting the signal no i haven't done a deep dive into it sarah but that that looks reasonable okay thank you very much um and then the cost coverage one uh so uh looking at you over time so we see um you know fairly stable if not a little bit better cost coverage in recent years among commercial insurance obviously uh tied to costs for the Medicare reimbursement and seeing this kind of drop in the the Medicaid reimbursement that we've seen for many other hospitals i do think that uh you know nvrh um you know has a cost that's pretty well in line according to this analysis with other critical access hospitals but does seem to have a little bit more favorable um payment uh from commercial insurers at 193 of those costs which looks like might be second only to north country so just um you know any ideas about um you know why you might have relatively uh higher reimbursement for that population um other than a potential um next uh this is that's inpatient and outpatient sarah yeah it is yeah would you would like to look at one or the other yeah the outpatient okay we can look at it separately yeah so that's 242 for outpatient what's inpatient looking like and the inpatient outpatient may be different with the other hospitals yeah i see what you're saying so so for inpatient you're about the middle of the pack and for outpatient you're uh again second to north country so it is part of it you think maybe related to the service mix and doing relatively more outpatient than other critical access hospitals yeah it may be may be related to that and also the contracts may be a little bit different um for outpatient between the hospitals okay and it could be a little bit of a difference between the actual payer itself um related to the contracts yeah and i think you know as a regulator like seeing that and then seeing one of the you know the higher rate asks i think is just something that um you know just as where we sit just trying to figure out how to balance those things where you need your operating margin by consumers we don't want to um put the undue burden on the commercial rate payers so i just need to think through kind of how to balance those very difficult things um and finally um so the standardized so again if this would be take all the commercial payments you got from 18 to 22 that we had to i'm sorry 2020 that we have available in vcures and divide by a standardized unit of service and we see nvrh among critical access hospitals at the 75th percentile um on inpatient and outpatient so um you know you know not you know there are some Vermont hospitals that have some higher higher numbers here um but within kind of that middle 50 percent of the data um so again that's super old so i think sometimes the hardest to understand what to do with and are reminding me what's in this i should say what's not in this data set it's the self pay plan no no um self pay no military no uninsured uh we already covered that no and we're missing about half of the self-funded market so that's a big thing that we're missing in the the data set um but we do uh New Hampshire does contribute claims to this so we would get the New Hampshire patients in here all right uh i think that was all i had to cover any responses you want to give to any of the the metrics or information before we turn it back over to the board for questions no i'm good i think so i think we're good okay great all right chair foster all right thank you um board members please go ahead if you have comments or questions i can start for us um thank you all for comment again our yearly ritual um i have a question i have a couple questions um not surprisingly about price and cost so the charge master request is 15 percent um and the way in the narrative it talks about being allocated 16.75 percent for hospital based services and zero percent for medical practices can you just speak a little bit to the decision to do it that way yeah the medical practices are for the most part a fixed fee schedule or in our primary care arena is an RHC fixed visit rate both for Medicare and Medicaid so if you apply a fee increase on those there's there's no net really that comes out of that so it's all shifted to the hospital side um and i'm wondering so as sarah just showed you know the standardized prices based on rand um you're at the 75th percentile for both inpatient and outpatient sometimes we'll see a hospital is higher on inpatient but then lower on outpatient but it was noticeable to me that northeastern was high on both i'm wondering do you try to benchmark your prices how do you think about your your charge master increases um you know do you benchmark them again something yourselves to ensure the affordability for your community how do you think about where your price increases will go each year um historically i think some of them were benchmarked um here i know i'm used to benchmarking pricing um both against uh a couple different ways of doing it getting price data for other hospitals particularly in the state and i look i've looked more around other critical access hospitals and also throw in the tertiary as a as a benchmark there um also using the act 53 website um that's out there using that for the actual um overall some of the services that are selected on that to the benchmark that to try and get the hospital in line with at least the median on some of those charges some of that gets to be really difficult to do to make the change um because uh you know you can change one one lab fee that can have a you know two million dollar bottom line impact pretty easily and pretty quickly so um it gets to be a little tricky but it can be done and i have done it myself in the past so for nvrh how close to the median target would you say nvrh is on most the majority of most frequently used services i have not let jessica i'd have to get back to you on that one um given this i'd say probably a little bit on the higher side but that's anecdotal right um and then i guess on the same if you uh director lemburg if you could go to the cost report on the cost side um so you had mentioned that yeah that's right that's perfect i wanted to look at the cmi adjusted average cost per medicare discharge so if we look at your adjusted discharges first of all you're on the higher side at least of critical access hospitals in the state um in terms of numbers of discharges um but you're also on the higher side in terms of average cost per medicare discharge cmi adjusted so you'd mention that you thought that the the cmi adjustment was valid you're also large on discharges so you've benefit from economies of scale to some degree within the critical access hospital um spectrum so i'm i'm curious you're at 13 000 for the cost per discharge the median's 11 000 so um given the benefits of your scale and the appropriateness of the cmi adjustment i'm wondering what you can how you can help us understand why your cost per discharge are high and what it would take to get down to the median uh without actually looking at the calculation that um comes up with the actual adjusted discharge itself um i i've been in a position where the adjusted discharge and these metrics have swung because um it's heavily reliant on your inpatient discharge is extrapolated out against all of your outpatient services and if you either discontinued or increased an outpatient service it can skew that number one way or the other so i want to actually know what's behind that adjusted discharge number before i would even come close to giving you an answer that um i felt was valid the example is when i was at north country and the the chemotherapy program got discontinued um the adjusted discharge number went up significantly i think it was because the revenues dropped but there's no actual discharges associated with it um you know high high amount of revenues and cost with a very low amount of visits uh as a as a ratio so i want to see what's in the adjusted number um i i was getting worried with the adjusted number because it's an adjusted number it's a backed into number from your your inpatient um discharges and i i haven't looked too deeply into this but a lot of times when you have a higher outpatient mix like an 80 20 versus a 50 50 or 60 40 inpatient to outpatient um ratio it can change to the most numbers just to be clear these actually is calculated from med par claims so it's the average uh cost so they recost the claims uh in med par and then that average amount is divided by the the cmi so that one i hear you about adjusted discharges but that's not a factor in this particular measure okay um well i would love to hear some of your i mean you've talked a little bit about some of your ideas for cost reduction but given you know where you sit with the average cost per adjusted discharge here are there things in the future that we can look forward to um bigger ticket items that will lower some of the costs of delivering care in your community sure it you know ultimately i think it really comes down to building that nursing workforce i mean i mean that's where you see us making the investment in education growing our own uh cadre of nurses nursing professionals to replace the travelers um within the hospital and uh ultimately if we can get back to a steady state with a workforce i think you'll see the cost inflation start them to moderate okay and then i guess i that's my last question um we're trying to gather from every hospital a breakdown of the cost inflation assumptions um and i you know in the narrative it was a bit vague um you know the description of where the big drivers are and you've talked about it a bit more today but i'm wondering if you could submit separately as a follow-up um what are the cost inflation assumptions by how much is our wages and salaries growing for md and non-md labor pharmaceutical growth pharmaceutical price growth medical and non-medical supplies separately and purchased services for example any other buckets that i might have forgotten but that is um it would be really helpful for us to understand where you think the biggest drivers of expense growth are um within each of those buckets so that can be a follow-up if you would be so willing yep yep we can do that so you want the expense growth not just an inflation factor correct well actually i would love to see the inflation factor uh because i'm trying i would like to understand relative to what our benchmarks are for medical inflation and non-medical inflation what are some of the assumptions that um northeastern is making so i would love to see the inflation factor but others might be interested in both so both would be great yep we can do that thank you that's it for me and uh you want the growth let me make sure i understand from 20 um 22 actual to 24 budget because what you're looking for i would love it annually so 22 to 22 to 23 and then 23 to 24 so we can understand what's already happened and what's baked in and what is anticipated for the uh in the submission of this budget okay okay any other word member questions well um could you talk a little bit more on about how you think the medicaid redeterminations are going to flow through in your community i noted in on in your narrative on page 11 you weren't you didn't really include anything on uncompensated care but i was just wondering how you're thinking about that a little more broadly in terms of pair mix shifts and that kind of thing yeah um it's a hard thing to actually put your thumb on because we we don't even know where those patients came from did they come from a medic a medicare um not medicare but an exchange plan um and get dropped and come over and did they lose their job and now they're working again um or are they going to come off the medicaid enrollment and then become self-pay those are the three big buckets and if there's self-pay it could end up in bad bad debt or charity care um the numbers are still unclear uh in total as to what the patient population would become unenrolled and would they be eligible um with the next enrollment frame um so it's a big unknown as far as i'm concerned right now um the the one thing that will happen when that when that comes through is they will fall out of our attributed life calculation for the acl that is the one thing we know we just don't know the numbers um that said i mean we have a lot of great systems community connections we've got a a lot of resources in place to help people with their insurance options as they go through this uh disenrollment re-enrollment process right so i think um the systems we have that we've had in place for years are are well positioned to help people navigate this thanks hi this is dave marvineva a few questions um really appreciate the work you're doing on reducing traveler cost and travel utilization um there were some comments i don't remember if they were your presentation or earlier today but the the complex uh impact on team morale with travelers sometimes it benefits to unload but other times it's it's pretty destabilizing so i think trying to grow your own um bring as many have as many uh nurses you can locally that stay that are invested in your organization to make it a thriving organization keep it a thriving organization is great um can i just ask some question you said there's tuition opportunities for nursing programs uh is that that the hospital is paying tuition for nurses to go to nursing school what could you just give a little bit more information on that okay um the the program uh is for the tuition is that we will either help the student get the loan uh or they would pay for it most of them can't afford to pay for it so they're reaching through vsac and we've contacted a local bank to help any of those uh individuals out who couldn't actually get a full loan through vsac so the idea is they get the loan go through the schooling in year one pregnant from wrong about the end we would pay off half of their loan and in year two we would pay off the rest of their loan um so that is the current program for ma and lpn right both of them both programs at the same time we would be paying for for their time while they're at school as if they were working and that's the biggest um barrier that we found with these students uh actually being able to start their uh education and in some cases even completing it we've we've got a couple who but halfway through and just could not afford to live anymore and had to drop out of the program so that that's what we're helping them with it sounds like a great program especially in your region it's really an important way to build a thriving economy um another question i had it okay so no i was just going to add to that dave um you know we really didn't touch on the one of the other problems we have around workforce is is housing yeah and and housing is a tremendous barrier to our ability to recruit people from out of the area and so uh that you really compels ourselves you know we we are doing efforts we are working in partnership with our community to to expand uh housing development opportunities in the area um there's some undeveloped land here on the hospital campus that we've committed to doing a housing development on um that's a kind of a win-win because uh we're trying to do this without putting hospital dollars into it but using a hospital resource undeveloped land to support development um but uh at the same time it really pushes us into leaning into growing our own nursing workforce with the people who are already living here and so i think that that's a real benefit for the for the people who live here in our communities already it's great it's great it's it's it's i think it's a challenge throughout the state throughout the region and i think that's a a good way to approach the solution um you mentioned that you've had a pretty significant drop in 340b revenue we've been hearing about this from multiple hospitals but this year sounds substantially larger two million dollars over the course of a year is that what you mentioned i believe could you describe or yeah over over three years so it's it's the we've got two retail pharmacies in the area uh Kenny drugs and Walgreens um we also have the FQHC that is next to us who uh they use a mail order retail pharmacy so that kind of dilutes some of it um and the drugs that are going through those retail are the drugs that the pharmaceuticals have been targeting to reduce for reimbursement um and and we also have had one of our pharmacies Walgreens in St. John'sbury close uh back in March um and and that's actually created some other pharmaceutical challenges for the patients in the area um that i've heard of you know up to four to five day waits to get their prescriptions filled uh which is a challenge okay but that two million dollars is that's over that's uh combined over three years that's not annualized right right that's from 2020 to 2024 okay sorry it's uh it's not yeah we don't have anything built into this uh the FY24 budget but uh one thing that we are exploring it's really part of our strategic planning process as well as working with communities to meet the need but um is we're exploring the possibilities standing up our own retail pharmacy and nvrh branded retail pharmacy that would uh really do two things uh number one and most importantly is is reached this um the field of community need because we're down to one pharmacy here in the town of saint j and that pharmacy cannot keep up with the volume of scripts um for the community uh and number two is um it's an effort to try to recapture uh some of this lost uh 340b revenue um i don't think we'll ever get back to where we were just a few short years ago but um but but it is an attempt to capture some of that okay um one thing that stuck out to me in your narrative was uh your labor cost tables on page six and page 20 which sort of have some similarities um on page six it looks like from 22 to 24 you've got nine fts of general admin and seven fts of hospital admin increased um in patient care you have about uh total from looks like 23 is down a little bit but up up about a little fewer than that about 14 um with total salary increases is seen on page 20 where you have about two million increase for those general admin hospital admin and two million increase in the patient care um you know from from our standpoint we don't like to see ratios where admin is growing at the same amount as as patient care could could you um comment on this at all you want to comment buddy in you have anything yeah without digging into that detail the comment um does this have to do with some of those reclassified positions at night i think that that's part of it yeah if you could look more into that also it's the general and administrative on that page six you have a 8.8 percent increase in the average salary but then benefits per fte but in the clinical it's only a 3.2 percent and you know again you mentioned the 18 percent raise for nurses so um i'm just trying to understand what those how to how to how to think about what these like big general administrative salary increases with small clinical salary increases yeah i don't think that we'll have to look into that that doesn't make sense to us because the the the investments we've been making and where we've really been pushing to keep up with market has been on the clinical uh compensation side so we're gonna have to dig into that and get back to you that would be that'd be really helpful um and then and then the one other thing i was looking at on exhibit 10 which is the one that you resubmitted hold on i gotta get up the resubmitted one here let's try to understand you know there's when you actually exhibit nine uh commercial in the net patient revenue fixed protective payments commercial revenue looks like when i just did it it looked like it's about um you got my percentage this year i think 37 percent increase from 22 to 24 and your commercial revenue and i was looking down at exhibit 10 trying to figure out the breakdown of this and it looks like at least in the first group there in exhibit 10 where the total change in npr fvp for commercial from budget 22 to 24 is like uh nearly 12 million by rate and by utilization it's only uh 2.8 million from that same time frame and i'm trying to understand that with when you have 11 projected increase in ed visit volume and 4 overall utilization projections how you're you know that that's going up so little compared to utilization it's so much compared to rate and if that's just reflective of the large rate ask i would say that that is reflective of the large rate ask um to to to dive into this deeper we want to take it offline there's a lot a lot here but when you say offline like follow-up questions or follow-up yeah yep or okay i would love to understand this more because um it seems that if you have a lot of utilization growth that maybe you're good you could cover some of this budget gap through utilization without doing it through rate which does put a lot of pressure on on for my repairs that's all i have for now thanks i think i just have one or two um on the nursing challenges you've had and the staffing challenges you've had they seem pretty acute compared to some other hospitals you know some have been quite successful some have had less success in that realm and i was wondering if you could speak to um why we're seeing that kind of disparity in what you attribute the more challenge the higher level of challenges you've had what do you attribute that to well i'll start then i'll let julie and betty and uh fill in i i think part of it is probably demographics um so uh you know we shared that the northeast kingdom is the among the oldest region of the state of ramot right and that that also includes our working force so when i started here in 2018 we did an analysis of our nursing workforce in particular in 2018 over 35 percent of our nursing workforce were baby boomers um and then what we saw as we came through the pandemic is that um many of those nursing professionals who maybe had planned to have an extended career or give a few extra years um many of them retired or left out nursing workforce probably earlier than even they planned to which created a a larger gap for us as we were coming through the pandemic and i think it's just been much more challenging for us to navigate our way out of that um as as we've come through the recovery i don't know julie you or betty and have anything to add or talk um trying to um get people to move to the area um so if we have a limited population of people who are nurses who are living in this area um some people are working here and then others are working at um the long-term care as i said and the nursing homes uh some people travel to um to Dartmouth um and um and that's pretty much it it's the the long-term care and the other um healthcare organizations within this general area that are not hospitals um and then Dartmouth is one of our main competitors um for employers um but um so for for this segment of people moving to the northeast kingdom there are a lot of people who want to move here but um there are the housing is limited and there is um limited opportunity for that income level we don't have you know condo complexes we don't have apartment complexes if you move here you are buying a house with a parcel of land and at that income level you're not going to get like a single um nurse to move here for that so that's so that's been a challenge as well I'll just I I know uh Owen it's somewhat anecdotal but uh we were trying to fill a position for uh it was actually an APR uh APRN in the ED this past spring and we interviewed this person they they seemed like a perfect fit they had family in the general area so they wanted to be closer to family they were an avid mountain biker and wanted to spend time on kingdom trails they came to the northeast kingdom regularly to um to um for uh you know for enjoyment of our outdoor activities and um as we were going through the process we great interviews it looked really good and at the end of the day I asked him I said so what do you think because this how's this looking for you and he says you know Sean this is this is where I want to be this seems like exactly the kind of institution I want to work for but I'll be honest with you I don't think I'll be able to find a place to live have you been on Zillow lately so that night I went out to Zillow and this was back in I don't know March April probably and I did a search in like kind of within 15 mile radius of St. Johnsbury and I did a search for a house between I think I put in 200,000 to one million dollars and once you took out like the raw land listings there were less but I think there were less than six houses on the market and if you looked at them half the houses half of them you'd look at and you'd know you'd have to put a quarter of a million dollars into because they were so bad in such bad shape so that's you know that that is just exacerbating these these challenges we have hence our effort what you see in this budget is our effort to really invest in our own workforce locally and I take it you know I've been to St. Johnsbury it's a lovely area I encourage people to move to St. Johnsbury in the Northeast Kingdom I love it and I think people that do move there will also love it well they're gonna need their own motorhome yeah I don't live there but it is a nice place but I is it your testimony that these issues that are in St. Johnsbury in your area are different than what you see in you know Brattleboro or or Bennington or Morrisville or other places in Vermont in terms of the demographics and the housing challenges you know I can't speak to the housing challenges in those other areas all I can really speak to is our own experience here in the Northeast Kingdom Fair enough and my last question during the last hearing we had there was a public comment in the observation from the public comment was that we in the public comment there's view we had too many hospitals and that there needs to be a reduction of around 154 beds statewide and as you know the Act 167 work is getting underway and I was curious your view on that comment and then second whether or not if there was an opportunity to reduce costs at your facility where would they be and what would you do if there was an opportunity well I'll start with the comment regarding the the number of hospitals or number of beds in in the state of Vermont I can't speak to the rest of the state all I know is what we have here in this community and what we need in this community now uh this hospital is our community hospital and it is incredibly important that we serve our families friends and neighbors here you know this hospital is the hospital where my children were born where my grandmother received her end of life care I know the people in northeast kingdom and if we didn't have these beds in these services here in the northeast kingdom it would be incredibly challenging with the transportation system we have with the weather we have with the environment we have to make sure that my family friends and neighbors got the care that they need and deserve that's why these rural hospitals in these underserved areas are so incredibly important I don't know Owen have you driven from Montclair to St. John'sbury since the flooding I have not driven from St. John'sbury to St. John'sbury since the flooding that it root to is a pretty rough road right now and and you know that that you know impact access to health care services and and I can't imagine you know we already have problems you know over the last two years our ability to transport transfer critically ill patients to other other facilities tertiary care facilities Dartmouth UVM has been extremely challenged because of their own challenges with staffing and resources and that doesn't even get into the issue around EMS we count on a strong and robust EMS system to do two things number one is when a person is having traumatic event whether it's a STEMI whether it's a car accident we count on a strong EMS to quickly respond and get the patient to our emergency room stable enough where we can provide life-saving care then we can get that patient quickly to tertiary care facility right well with the challenges we've had on transferring patients there are times when we're when we're tying up one of our EMS ambulances sending a patient to Albany Medical Center what is that three and a half hours away Mike yeah yeah um uh Portland Maine uh we sent them to Rhode Island Hartford Connecticut Bay State Springfield Massachusetts so you think about that you take a truck out of our area for you know typically it would be a down and back to Dartmouth an hour down half hour there hour back that's two and a half hours now we're sending that truck to Albany that truck is out of our area for the entire day that impacts care delivery so what do you do like what are you going to do beef up you know they can't find staff to to staff the ambulances I mean I mean this is a knock on you know they're knock on a sex test this bed base is critical to serving our community's health care needs now I'm not going to get into hypotheticals around opportunities to cut because we have put together we trust this process we have put together a budget that we believe meets this community's health care needs we've developed that in conjunction with our board of directors that is made up of members of this community and we feel that this is the right thing to meet those needs in this community I would hate to speculate on what what we would have to cut if if we had to you don't have any other questions I'll turn it to the health care advocate thank you appreciate it can folks hear me okay yeah okay just a brief follow up on we appreciate member mermi's line of questioning we had similar cost concerns but I wanted to follow up on exhibit nine director Lindbergh if you wouldn't mind putting that up it seems like you're projecting to increase your uncompensated care particularly the bad debt for 24 budgeted relative to 22 and 21 actual and we've heard from other hospitals around the Medicaid determination I know you referenced that earlier but I'm just wondering if you could expand a little bit about that projection what went into that I think that the projection is generally done based on our run rate we know that and this is most of the hospitals I think across the state where the free care has actually decreased especially through COVID for many reasons so it's based on what we're currently experiencing and then run out you know and part of it is also trying to get our navigators a little more engaged with our patients who could potentially qualify for free care and Sam I'm sure you've heard this a number of times from other hospitals getting the patients to fill out the applications is our biggest challenge I've worked with with your colleague Mike Fisher a few times on patients who have we have had issues getting that information and sharing with him some of the challenges and he's seen at first hand thank you I appreciate that in your narrative you talked a little bit about expanding your partnership with North Country I'm also working with the Office for Rural Health Access to do a regional develop your regional capacity and do a needs assessment I'm just wondering if you could expand on that a little bit more I know it's probably early stages but I'm just curious what that will look like in practice well yeah we're actually so we've engaged through the Office of Rural Health Access we've engaged a consulting firm who's helping like really look at you know based on the area the demographics the current capacity and what the current healthcare services available are and then matching that up with national benchmarks to determine what we what we need what we need to grow and it's it's we're about 75 percent of the way through our analysis North Country use the same firm and did theirs I think they got an update last year and once we're both once ours is complete we're going to merge that information into um into a complete picture for the Northeast Kingdom following on from that is really the where the the work is in in and exploring collaboratively how do we adapt and adjust to to to meet those needs that are identified as part of that analysis thank you so we have sure um were you able to leverage some of the magical funds that John Olson helps provide to help pay for that okay awesome that that's just a really less less Santa Claus John's been great yeah that's great yeah for any other critical access hospitals that aren't aware I think it is a really efficacious way to leverage some of that funding so sorry for the public service announcement oh it's been great and yeah okay um any public comment seeing none I'll turn it back to you mr tester and your team for any closing statements you may want to leave with us um I just want to thank you for the time today I we really do appreciate it and we look forward to uh you know the conclusion of the whole process we'll work with uh Sarah um and follow up on on some of those follow-ups that came out of today and we'll try to turn that around for you as quickly as possible thank you great thank you all very much for the submission presentation and thank you director Lindbergh to you and your team for another day of hard work and a lot of prep is there any old business to come before the board or new business and is there a motion to adjourn some moved second all those in favor hi hi hi hi and we are adjourned thank you