 I will bring the meeting to order. My name is Robin Lunge. I am a board member here at the Green Mountain Care Board. Claudine, are you all set? Yes, ma'am. I'm ready with you. Okay. I will be acting as chair today, as Chair Foster was unable to join us. So I think what I'd like to do first is just welcome everyone, and then Bob, do you have your team with us? I do. Okay, great. So I'm going to turn it over to Russ McCracken to swear in the witnesses. I believe we've already sent Claudine a list of folks, so you don't need to spell your names, but it will be good for her to be able to identify who's speaking. So Russ, take it away. Thank you, Board Number Lunge. Mr. Adcock and Ms. Westcott, will you be the only two witnesses for Springfield today? Yes. That's correct. Great. So I will swear you in if you would both 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. I do. Yes. All right. Thanks very much, and I will turn it over to you for opening remarks. All right. Thank you very much. Is Sarah running the slides? I'm trying to present them. Can anyone else see them? Yes. I can see them perfectly. Thank you. I was just trying to determine who had the clicker. So we thought first off, thank you for letting us present and talk about our hospital this morning. We have had what we believe is a unique history here at Springfield, particularly over the last five or six years, and that unique history that we have continues to be something that we work on to address every day. It's very central to all the things we do. So today it'll be Cata, our CFO and I presenting, and it's a picture of our gorgeous front lobby in the springtime. So it looks good. No snow. So if you can go to page two, Sarah, please. Again, I want to keep everyone in perspective about the last five or six years and the things that have happened to us here at Springfield. We are a 25-bed community-centered critical access hospital. We also have a 10-bed distinct part psychiatric unit, which is located in Beller's Falls. So it's about 15 miles from the hospital, but it serves a very important need for inpatient psychiatry in this portion of the state. Again, we have emerged from Chapter 11, but the hospital continues, we continue to manage our situation as we try to move from being financially vulnerable to sustainable. A good bit of what we'll talk about this morning are the things that we're doing this year to move us there. So our goal is to meet the healthcare needs of our local community, and we understand that the social determinants of health in our community are challenging, and it's very important that we have access for this local population here. We think that that is going to improve access, make it easier for people to seek care that need it, and also less costly. And as we look at the cost slides, I think that we agree that the cost slides validate some of the things we thought about our care versus other options that are available. Our primary service area has a great deal about migration, and the next statistic, 21,000 Springfield residents spent $176 million outside of our service area, and those are statistics from the Green Mountain Care Board that Chair Foster presented to our governing board meeting here in March. So this was something we knew, but this number is really hits us hard, and we know a lot of that care is tertiary care that we can't provide. We also know that one of our goals has to be to bring our local community patients back for the care that we can provide that's most appropriate. So we'll be talking a little bit about our strategy to do just that and as we move forward now. Again, and we continue to be a partner in population health strategies, and we participate in the ACO. ACO and are working with one care to reduce ED utilization in our marketplace, and we've seen we've seen some improvement in that particular metric. And we're a strong economic contributor to the community. We have 379 people on our payroll. And, you know, it's a huge economic impact here in our area of Springfield. So moving to slide 2, this is slide from the analysis, and our team found the comparative analytical data to be very helpful for us this year. Clearly, we didn't have as much time to study this as we would have liked in advance of the budget, but the data really was, eye-opening for us, and in most cases, it's substantiated what we hypothesized to begin with. And so in this line, I just want to show how we fare in terms of cost, allowable cost, and how much of allowable cost we're reimbursed for the different payers. And you can certainly see that our commercial outpatient is very important to us because we're about break-even on Medicare, covering a lot of our fixed cost, and then Medicaid, we're below our allowable cost lines there. So we thought this slide was really important. And it also, I think, is important to draw a comparison here about when patients from our primary service area. And in the previous slide, we just showed that that was $176 million worth of care that we're very cost competitive. So if we can move more of that care back to our hospital and be local, we think that that's going to increase affordability and benefit our patients in our service area and in the marketplace here. The next slide, please. So again, sustainability remains our goal. It's been a slow climb back from our hospital being so vulnerable, but we are making progress even though it's been a slow climb in quite a few steps. So we are working to respond to the needs identified in our community health needs assessment. Those three priorities were cost, access, and mental health and substance abuse. And again, as I mentioned earlier, we are the inpatient mental health provider for our geography with our Wyndham Center. Talk a little bit about access, particularly we are doing a lot of work around specialty care access. And we believe a lot of that out migration is being is being driven by things that providers and care that's not accessible in the community now. So we're doing work to recruit and bring more of those providers back into the marketplace. So people will have options here locally for those type of specialties that we have had a shortages of and we also are pretty proud of our our FQHC partner here in town. They are also experiencing quite a bit of success recruiting primary care providers now as well. They have eight new providers joining them this year and six of them are primary care providers. And we believe that's going to also improve accessibility and address needs on our community health needs assessment, which by the way, we partner with them. So we do it with our FQHC. So they're looking at the same data we are in mapping their strategic direction as well. We know that we have a lot of ongoing operational transformations that are opportunities for us. You know, right now we're in the midst of a financial assistance review, which we think is going to be important, particularly with the Medicaid unwinded is is being faced with here in our marketplace. We're looking into what are the access barriers. And in a lot of cases here, we believe it's been access to providers and specialty care and technology. And we're working on all three of those things. And again, we're collaborating quite quite a bit on mental health and substance abuse. Our clinical providers meet monthly with our our community partner on mental health and so basically we have a three part system here. We have a CRS that is our community resource. The FQHC has the behavioral medicine outpatient practice as part of their clinic and we provide the inpatient psychiatry in the service area. So we work closely with those partners, particularly on specific cases, you know, making sure the right patient is in the right place for care at the right time so that they get the most benefit. And again, our sustainability, our work is ongoing with this and it's our priority that we work on every day. So next slide please. So again, our sustainability journey has been a lot of little steps, but we're continuing to walk up the staircase. We have a very challenging healthcare environment as do all of our college hospitals in Vermont and then across America. It seems like every day you read a headline about another hospital having difficulties either with their sustainability or that they're having to reduce or change their service mix, even though it might be needed in the community that may not be able to afford to maintain it. So this is not just a Springfield or a Vermont problem. It's a national problem, but I mean we are a small hospital. So we're very diligent about managing our ongoing daily expenses and making sure we have the right resources available for our patients every day. And again, as I mentioned earlier, we do a lot of collaboration, particularly tactically with our FQAC, ACRS and turning point, which is a substance abuse provider here in our marketplace. So we do a lot of tactical work, particularly with individual patients to make sure that everyone is getting the right care. We're working with the ACO and of course our partnership with tertiary providers. We have a great relationship in terms of where we send people that we can't take care of. Although I've got to say in this past year, we've seen a lot more patients be referred to areas that are less familiar to us like Albany, Hartford, and even a couple of cases have gone to Boston due to availability of beds. Our lack thereof in our area. So our strategy for this business plan really focuses around rebuilding the services that we need to bring patients back to our hospital. And during the last year we've increased coverage in podiatry and in urology. And of particular importance, we have brought on two full-time gynecologists, which are now in growth modes with their practice. Because, you know, we lost a lot of that volume when our childbirth center was closed a few years ago. So we're not going to return to obstetrics, but we still have a lot of gynecology primary medicine that is needed in our marketplace. And our two practices are getting very busy. We're also adding a part-time urogynecologist. It's going to come on a part-time basis to do some cases that now must be referred out of our service area. Those are cases that we can do here with the right coverage. We've added hours in urology and we have a lot of good news over in general surgery. We have added two permanent part-time providers to our surgical panel. And just this week we have agreed to bring another full-time surgeon into our hospital, which has been an area that has been a challenge for us in recruitment over the last couple of years. So we feel like we're having success in general surgery. Kind of a little bit of a sat-back in cardiology. Dartmouth had a cardiologist here who was an outstanding provider. He relocated due to family concerns out of our area, and we were working with other partners to restore that service. I believe that we will be successful in doing that on a part-time basis. And then as I mentioned, our primary care provider is having a lot of success filling their open positions as well. I put diagnostic imaging on here. We have a lot of opportunity in imaging because a lot of our equipment has aged out during the last five or six years while the hospital has had financial difficulties. So we're upgrading our MRI. We're reinstating our nuclear medicine program because our nuclear med scanner was ready for the Medical Museum. And so now we're replacing that. For an MRI, our urology group alone referred 150 MRI scans out of the service area last year for urology MRI that we were not able to do. And we will be able to do that with the new scanner as well as some other scans that we can't do now. And then again, over on the operational side, we're doing a lot of work on our revenue cycle, and that starts with patient access and a review of our financial assistance process to make sure that we are identifying patients and qualifying them for assistance that is available and to make sure that we're getting the right information on admission. And a lot of this is also about just best practices and making sure we're running the hospital like we should in terms of capturing all the charges, making sure we have the right clinical documentation, the right coding, and that we're able to successfully manage our revenue cycle, appeal denials and prevail in those denials. So those are big operational issues that we're working on right now. Next slide, please. I want to go back and we saw earlier how much volume is leaving our marketplace. And we know a lot of that is tertiary, but we also know there's a lot of appropriate care that can be provided in a critical access hospital that we are not taking care of. And we put this slide up because I know a lot of times we talk about our volume projections being optimistic for our hospital. And I wanted to bring this slide in because I wanted you to see what our volume numbers were five or six years ago. And you can see that we had a lot of, a lot more medical inpatient admissions. Of course, there were child birth and childcare center missions in there that we don't do now, but you can see that inpatient admissions, emergency room visits, operating room, surgery office visits, I mean, go down the list. Everything, just about everything we do, we did a lot more of this five or six years ago before the hospital had financial troubles and before we had COVID. And we think the numbers demonstrate clearly that this volume is still in our marketplace. We just are not capturing it. So that's going to be one of our directions this year is to put those assets in place that are needed for us to perform the care that is appropriate for us in this setting and bring those patients back. Next slide, please. Just so you can see what's happened since our last budget cycle, you can see we've made great strides in all of our key metrics except for inpatient admissions. And, you know, that one, that one, we know that less people are being admitted as inpatients. Just so you'll know that 25% that were below budget only is 16 patients a day. So it's not a big number because all of our numbers are small, but that's the number we're working on as well to make sure people are being admitted appropriately. Our emergency room, we emit about 7% of the people we see, which is a very good number. It's a more aggressive number lower than most other critical access hospitals. I just wanted to correct you, Bob, and saying 16 patients a day. It's actually 16 patients a month. Oh, okay. Sorry. Sorry. Thank you, Kate. I get a little carried away when I get on a roll here. I'm pretty passionate about what we're doing and what we're playing to do. So you can see that we are moving the dial in many of these areas, not still where we would like to see it be, but we're still walking up that staircase. Next slide, please. As we move forward, again, we're going to keep going, being very aggressive with our expense management areas. Our expenses were actually down year over year, except for travelers, which was the big glaring area. This is probably not a new story. You probably heard that from our colleague hospitals as well. Primary care access challenges hit our community health needs assessment every time we do it. Our FQHC partner is doing a lot of work to restore that accessibility with their recruitment. And again, rebuilding that community confidence and letting people know that the hospital is on the road to recovery and that they should come back. Our adult daycare program took a lot of volume reductions during COVID because we had restrictions with how many patients we could see in the area. So now we're building that back. Lots of ongoing workforce challenges. We have a 2% cost of living adjustment budgeted in here, which it is very costly for us to try to remain competitive in the salary wages and benefits area. So we're doing as well as we can with our tight margins to do that. Post-acute placement. I know all of our colleague hospitals have a lot of trouble with post-acute placements. We do too. It doesn't feel like it is disruptive with us as it has been with some of our colleagues. One thing we have seen a lot of this last year is difficulty with tertiary placements to our normal partners. It takes those because of their capacity. And as I mentioned earlier, quite a few patients have gone out of the service area to Albany, Hartford, Boston, those kind of places because there weren't beds available closer. And a by-product issue that that is raised is availability of medical emergency transportation. So if we transfer somebody just a 2-hour trip, it's sometimes we have a challenge getting an EMS crew that can do that transport for us. And then disruptors, you know, they're always going to be disruptors in the marketplace. We've certainly seen our primary care partner at the FQHC reports that they have seen a lot of conversion to telemedicine, particularly during ski season when we have a lot of guests in our region. And, you know, we're not sure what's going to happen otherwise. You know, will Amazon get in healthcare in our area? So anyway, we're always on concerned about people that will disrupt the marketplaces we know it today. Next slide, please. Again, this is kind of what we've been saying. We're still focusing every day. All the things we're doing are around our community health needs assessment, which is increased access and our collaboration with our primary care partner. As you recall, we don't have any primary care providers as part of our system. They all work for our FQHC partner who was previously before chapter 11 was our owner, as you remember. So now we're not, we don't have an ownership relationship, but we continue to be close partners and coordinate very closely all the time. And so we want to work on increasing awareness of our local services, particularly as we add the surgical specialists that have been in short supply in our area. Our two big growth areas this year are going to be in general surgery and gynecology, and we actually have those providers recruited now. So these are not plans we're talking about doing or wanting to do. These are plans we have done and we're just getting to doctors on board now. Our revenue cycle improvement. Again, these are best practices that we need to be doing to improve, you know, how we charge and bill for our services and collect those. Continuing to grow inpatient in our psychiatric program. Pursue grant funding, which has been a huge plus for us the last couple of years as we've gone through our turnaround mode. The grant funding has been very important for us. And then continuing our expense management like we do every day recruitment. And again, especially recruitment is really important because if we bring a general surgeon on, it is a member of our hospital family, you know, that is much less expensive than us paying the third party for locums coverage. Plus that doctor will be in our community and we'll be building a practice rather than just covering emergency calls. Travelers, they're on everybody's mind. How do we reduce those? And we're working on both on the recruitment side and renegotiating those contracts and lowering the cost of what we are paying for those. And then recruitment and training for our own staff. We were very successful. Someone recruited our recruiter a couple of years ago and we were successful in re recruiting our recruiter to come back. And so now that's starting to pay some turn around that that's paying some dividends for us right now. So she's been with us since early summer and we're now starting to see. See the recruiting pick up because we have full time asset devoted to that. Next slide please. And again, you know, just to clarify, you've seen our proposal, our charge increases 6.9% we know we're ahead of the two year target. But we want to point out that most of our NPR increase this year is utilization and not commercial charge increase. So we've only asked for the absolute minimum that we thought we needed and we're relying heavily on growth and bringing our own patients back that are in our market and providing the assets to do that. So with that, that concludes our introduction. I appreciate it. The chance to be able to tell our story at the beginning. So thank you board members. You're welcome. Yeah, sorry. And Sarah, no, go ahead, Sarah. All right. That sounds great. So we'll go over the review tool. Let me just change my presentation screen. All right. So thank you for your opening remarks. I think you covered presuppose some of the questions I was going to have, but we see here that among critical access hospitals. Springfields operating expense growth at 6.4% is among the lowest of the critical access hospitals in this time period. And I just was curious to hear a little bit more about how some of that support in financial assistance review might be contributing to some of that expense growth trajectory. Well, I'll start off by saying, you know, we work very closely with our community partner here, Valley Health, which is Valley Health. We're very closely with them on the financial assistance side. And I'm going to let Kada speak to the financial assistance policy and the work we're doing around that because we want to make sure that we get people identified and get them the help they need in our service area because there is quite a bit of help available. Hi. We are going to be doing some work coming up next month with we've we're going to be working with a third party vendor to review our financial assistance policy. And also to our current policy and also what that looks like moving to Act 119 so that we're in compliance with that policy by July of next year. We think we're going to see with moving to that policy more people eligible for free care. Right now are the highest income level that a patient can be eligible for free care is at the 300% level with Act 119. That's going to raise that level to 400%. So there's about there's the 300 to 400% income level range that we're not capturing right now in our policy. So moving to that Act 119 I think our policy will be more generous. And we're working we work very closely with Valley Health Connections who helps patients apply for financial assistance. They help patients enroll in insurance whether it be Medicaid or on the Vermont Health Exchange. And they're also heavily helping us with the Medicaid unwind patients as well. That's great. So apologies because I misunderstood I thought the financial assistance was directed to Springfield Hospital but you're talking about financial assistance for your patients. So I got that question was probably very confusing. So so two things I'd like to follow up on there is you know just anything that you found particularly helpful in that expense management. Because I'm particularly interested in your comment that you know nationally hospitals are working on this tension of not providing the services that they want to just because of these financial constraints. So kind of how you're balancing that and how that's going down to your expense line as you tackle these very difficult conditions. Well that you know thank you for asking that Sarah. I think for for our standpoint you know the hospital has been through these four or five years of very challenging financial times. And so we have been forced to manage the hospital very conservatively during that time. We have we have made quite a few expense reductions and now those are arm wrestling. Most days with inflation and some of the other factors that we can't control obviously a place where we've had a lot of additional expenses this year have been in contract labor. We've had inflation around personally everything we use in the hospital and we've had to make increases in our wages to remain competitive. So I think that what we continue to do is just manage every dollar very aggressively every day. And you know I mean I don't I think we're just I think I think we've just conditioned everybody here to be very cautious about every everything we spend. So we're just and so now we're looking at at how do we reinvest you know what reinvestment do we need to grow the hospital back to where it was before. And that's why we're investing in the recruitment of the providers. We're starting to replace aging equipment and we've been very fortunate with some of the grants we have because we have several major building projects going on that are primarily being funded by grants. We were successful in getting and so we're trying to also update the building and keep the building up as updated as possible to. But I think we're just we just are very very it's very tough to get anything approved Sarah. And just back to the unwinding that's been a topic. How did you kind of approach that puzzle of what's going to happen with the redeterminations. I can speak to that. Are you referring Sarah in terms of the budget or. Yeah yeah for the yeah for the fiscal year twenty four assumptions. Yeah. Okay yeah so our assumptions was that there was going to be no impact. Basically we assumed the same pair of mix mainly due to the unpredictability of how many of those patients would either. Be reenrolled in Medicaid and enroll in Medicare or be eligible for Medicare or commercial insurance or you know go to private pay or not be insured. So it's really it was really so unpredictable that we we just assumed the same pair of mix so basically no impact on our budget. Okay. And so we'll move on to the factors here. So the cost inflation was within benchmarks and just turning to labor for a second. I believe we've uncovered that this is essentially not meaningful because the FTE's have not been updated in our system for a few years. So I just want to let's get that up to date so we can look at this more appropriately. But I think you kind of covered your approach to trying to manage labor. Anything else you wanted to highlight in terms of the twenty four budget related to labor. Any. I don't have anything to add. I mean when we were looking at this the budget tool for labor we noticed that we were kind of in the middle of the pack as the other hospitals. In terms of our own budget you know that late labor is increasing obviously due to. You know our COLA two percent market adjustments. We have the collective bargaining unit unit. I think those are like the major increases to our to our budget next year for wages. We also have some FTE's that are coming over from the FQHC onto the hospital. That was part of the shared services agreements. Yeah. What will the functions of those positions be. I just froze. No worries. We can hear you now. Can you hear us. Yeah. OK. The positions that are coming over for shared services what's the nature of those positions. Those are IT positions. And they'll still be serving the FQHC. You're able to provide that. Those are now going to be serving just primarily the hospital were in the past. It was a shared service where IT was employed by the FQHC and shared services with the hospital. Now they're having their own staff and then some of those staff are coming onto the hospital as full time FTE's. This is more kind of that splitting process. OK. Thank you. And as far as utilization goes I think you kind of hit the nail on the head and I'm glad that that you found some of this useful. As you know you do see quite a bit of dollars leaving the Springfield service area. Now not all of those dollars that stay are necessarily going to Springfield Hospital. We know that's you know that just means the provider is in the same HSA. So I would just say you know since you are finding some utility in this if there's you know further breakouts that might be helpful. I think our data team would you know be interested in ways they can make it more more useful to folks like you. And others not just you. And then when we go to the cost report section. We see that Springfield is among you know the right around the 25th percentile in terms of size. And due to the limitations of the tool you're hidden in a few places. But we know your case mix index I believe is hiding right behind North country here at about one point three. So given that you're you know when you adjust that then you're the one among the lowest in the. I think you're actually hiding behind North country at ten thousand there. So seeing that that relatively higher acuity and providing at a lower cost. So you had mentioned that kind of confirm some of your suspicions. So what led you to the suspicion that you might be a low cost provider in your area. Well I think Sarah it's more of a comparative more of a comparative thing because you know you know we we know we send a lot of care out of our market area for tertiary things that we're not going to do that won't be appropriate for us to do. I don't see that really changing. But you know there are a lot of cases did into our appropriate for critical access that we could take care of and I think we can do it better faster and cheaper. And you know when we look at the hospital slide of you know what are the costs that at the other hospitals you know where most of our tertiary referrals go. You know those costs are going to be a lot higher in an academic center than in a critical access hospital. Yeah I mean you know you have one of the more favorable you know in bidders per adjusted discharge. So you know that is might be argued as one measure of you know potential efficiency or profitability. So you know that seems like a really strong result given where you are in your chapter 11 recovery and also doing it with a you know relatively small amount of cash on hand. You know I know that you're kind of focused on trying to rebuild some of that cash for investment and whatnot. So kind of what how are you thinking about that in the long term to kind of get back to a more comfortable place for your cash on hand. I'll pull that up here in a minute. Yeah. It sounds like it will come with the volume. Is that is that the fair assessment. Yeah. Any other. Oh go ahead. Hey does the mastermind on the cash forecast model. But I mean obviously if as we focus on strengthening our margins and growing our service lines and improve our operations we think those things will all contribute to to strengthening our our cash position. Okay. Thank you. And then don't want to miss the admin ratio. So this is one where some you know we've heard some. Comments about some of the limitations of that data source and I believe you are also hiding behind someone here aren't you right at the around that 21% so yeah it does. You know that would be right with these other hospitals on the lower end I would say. Of the kind of hospitals around your size so you know and apologies you just happened to be hidden on a lot of these variables so we'll kind of work on that process improvement. And then I think you highlighted a lot of what I was hoping to address on the cost coverage in terms of seeing that pretty tough result of not having the inpatient costs covered. I also see that you know when I see those dips in 2020 years I'm guessing would be not impacted not only by COVID but also the chapter 11 is that accurate. Sarah some of that 11 dip might also be when we had the the Wyndham Center offline. Right. We used it for the state coped behavioral med facility for a while and during that time. We were receiving like grant income from the state. Basically it was kind of like a standby fee so we weren't we weren't booking that patient revenue it was it was more like a. I think we booked it like a grant. But in my mind it was more like being paid an on-call fee because it was so we would have the facility available as needed. Did I do that right cater to that explain that. Yeah. In the last half of fiscal year 20 and in the first six months of fiscal year 21 is when the the psych unit was just for COVID patients of which we only had about one patient a day if less than that. And we did receive grant funding for the state basically to subsidize the program with it being reduced to just to about a patient a day. So so wouldn't be reflected in claims or it was just a grant income. Okay. Thank you. Yeah. Appreciate that. Yeah. I think at least just I think Rand analysis just showing again that you know if you take all your commercial payments and scale that by a standardized unit of service that Springfield is relatively low reimbursement relative to other cars at 15,000 per discharge inpatient and 277 outpatient which is near the 25th percentile. Like all of those on the Department of Health was doing a lot with relatively less compared to some of your comparators in that analysis. So that is what I had acting chair lunch. If you want to take it from here. Great. Thank you, Sarah. Okay. So we're going to move to board questions next and I'm going to ask Dr. Merman to start please. super well organized by theme. So I'm sorry if they kind of jumped from place to place a little bit today. One of the questions that I have for you regarding your budget submission is you were talking about your, also in your community needs assessment was discussed the need for more specialty care that's easily accessible in your region. And you've discussed increasing your access to gynecologic care, general surgery, podiatry, urology. Are there other challenges with cardiology? Are there other areas that you could see your community needs over the next couple of years that you would be interested in trying to recruit towards that are beyond this budget submission? Well, one of one of those, Dr. Merman would be oncology because we did have a very good satellite program with Dartmouth. And then they were forced to move those providers back to the main hospital. And we were still some of those patients are still being seen at our location via telemedicine. But I mean, that is one, you know, that's one of the areas that we would like to have that back because it's so hard for that patient population to travel for, you know, infusion therapy. But as far as other specialties, I think these are things we're just having to research. I mean, we do have a good bit of outmigration among many of the medicines of specialty physicians as well. You know, do we have enough to have a part time provider where patients can be seen in Springfield? We're doing research on that in several of the medicines of specialty areas right now. OK, so just to actually my next question was about oncology. So maybe I'll pick that up and then expand a little bit more on that first question. But so it looked like you have this telemedicine and then you thought you mentioned that you do have infusion services. But are you saying that the patients that receive telemedicine for Dartmouth get their infusion services outside of the area? There are some limited services we're able to provide here. And some of the physician visits are done via telemedicine because the patients either can't get to the doctor or they don't have access to, you know, to broadband internet at their at their home. And so they can come here and do a telemedicine visit, which is more convenient. And so we do have some limited oncology and limited infusion, but it's greatly reduced from what we used to have, because we did have we did have a provider coming every week before. OK, and then it's a patient. So so some and we're giving some other infusions that are not oncology, you know, some other, you know, infusion type therapy in that center as well. They're not chemo agents. Yeah. And if a patient needs radiation therapy, do they where it lives in your Springfield region? Where would they have to go to receive radiation therapy for, say, cancer treatment? Most of those patients would go to Dartmouth, although a few do go to Rutland, I think. OK, just because I was just thinking about that, because, you know, that's, you know, often these patients will have Monday through Friday sessions for six weeks in a row. And it's a huge transportation burden. I don't imagine you had radiation therapy prior to. No, no, no, we didn't try to understand the the complexities of travel from patients from your area. Yeah, so we had so those patients, you know, go to Dartmouth, they go to Cheshire, you know, but we have not ever done radiation therapy. So we don't I'm not I don't foresee enough demand to do that here to to do that. So and before I go back to the first question of the other question I had on. Patient travel from your area is is our dialysis patients do. Are you able to have outpatient dialysis in the Springfield area? Do people have to travel for that as well three days a week? They have to travel for that. We do not do not have a chronic center in Springfield, and we do not do any acute in the hospital. We're do you know where the closest outpatient dialysis center I wouldn't think you would do acute. We're pretty limited in acute inpatient dialysis beds in the region, but for outpatient dialysis is that do you know where the closest center would be at a Springfield? Maybe Claremont. OK, so across the river, but yeah, not having to go all the way up to Dartmouth or I would think it would be it would be probably a lot of those patients go to Dartmouth or Cheshire, I would think. OK. And with regards to the other services from the community needs assessment or other assessments, I had a question for you regarding your inpatient volumes. Are there specific service specialty services that would allow you to keep patients at Springfield Hospital as opposed to transferring to a tertiary medical center just because they need consultation from a specific service? Are there are there any services that if you could expand would allow you to keep more inpatients appropriately? Of course, at Springfield Hospital as opposed to need to transfer them for, I don't know, an endocrinology consultation or an ID consultation or something of that sort. I mean, I would think I would without any data because I don't have data on this, but just me guessing I think the two areas that would allow us to keep more patients would probably be to have a cardiologist here all the time and to have pulmonology here all the time. OK, as when we had cardiology, it was a clinic. It was a clinic based service. He was here one day a week. Great program, great doctor. It was a big loss to us when we lost him. But, you know, I would think those would be the two biggies. OK, yeah. I mean, I asked the question from the perspective that, you know, there are the tertiary centers are just having a really hard time managing the large volumes of transfers and your story of how to transfer patients out of the region is a common narrative that we're hearing. And if there's any and it appears you actually have bed space there to keep more patients and compared to your prior volume. So, yeah, that's that was sort of the the the basis for that inquiry. We have we have beds. The challenge, of course, is the staffing and we are working over on the recruitment side. But that's that's a tough, a tough, you know, thing to move right now. But I would think it would be cardiology and pulmonology. Just me without any without any objective data to prove that that would be my speculation. OK, I guess one more question I have written down on regards to the sort of this theme of patients having to travel out of the area for care. And again, this is really just with trying to understand what is or isn't available and what the burden is on patients who live in the area, but births. If you know where the closest hospital or the few closest hospitals that patients who live in the Springfield area go for childbirth now that you are unable to provide obstetric services anymore. Well, there's there's four hospitals that are that are in the region. None of them are particularly close. So it would be Dartmouth, Rutland, Cheshire or Brattleboro. And, you know, those those would be the closest ones. Although I would I would have to also guess that a lot of the OB is going to Dartmouth as well. Or Cheshire, I would think, you know, in the southern part of our market, like the Bellows Falls area, you know, a lot of those patients do go to Brattleboro or to Cheshire. When we spoke earlier this year at the mid-year kind of update, which was really informative and I appreciated that discussion I think there was some discussion about this new designation of a rural emergency hospital. And I must admit, I don't remember the details of a discussion from that time. A lot has transpired from them and I didn't review my notes. But have you reviewed this designation and the sort of potential benefits or or alterations that would would have come with this with this Texas nation? Well, we we haven't we haven't worked on that a lot because particularly particularly back in that time, there was some ambiguity about what the standards were going to be. However, you know, we think if we we don't what from what we think about that now, we don't think that that would be an appropriate transition for this hospital due to the volume that we have here. Because right now we're we're averaging about 35 ER visits a day. And, you know, our inpatient census with observation in swing beds is is probably around all all heads in the bed are probably about 10. If we were a rural emergency hospital, all those patients would have to be transferred somewhere else. And we wouldn't also be able. We do about 100s, you know, we're trying to do surgery that's appropriate as well here. We wouldn't be able to do any of those cases. We wouldn't be able to do, you know, we would basically just be an emergency room in a holding area under those standards. You know, the standards of as I understand them for that classification of hospital. And can I just throw out like a hypothetical question, which say, for instance, that you were to change to a rural emergency hospital. Do you have any idea of what the transportation availability would be to transport 10 patients? That 10, I mean, it's not 10 admissions a day, but it'd be 10 10 admissions to other hospitals or those surgical volume to other hospitals. Do you have do you have transportation area or do you have any idea of what the transportation burden would be to do something like that? Well, we I know it would be it would be very high because the nine one one in our community is run by our partners at the Springfield Fire Department. They do a fantastic job, but they are also really, you know, in terms of capacity and recruitment. You know, they're able to run nine one one for our our town. But I mean, if the emergency transportation requirements, if we were in a rural emergency hospital, it would have to be much different than it is now, and that would be quite costly. You know, there would be a lot of money involved to subsidize that type of system. Don't know what don't know what the specific dollars would be. I mean, somebody probably knows what the average cost of an EMS unit on the road is. I don't have that. I don't know what that is, but it's a lot. Yeah, in the problem, a lot of the EMS providers have had to, by the way, has been staffing and recruitment as well. So we have some providers that are willing, but they don't have the staff to don't have the staff and I transport here in Springfield would would would take that unit offline for a nine one one transfer. One question that brings up, which sort of relates back to your hospital function is the staffing or recruitment. One thing that we've heard from a lot of different hospitals is just basically the lack of availability of housing and how that has really been challenging. I mean, this is actually not just a Vermont issue. This is an entire regional issue. Friends in Boston, California. A lot of people say the same thing, that there's just no housing so you can't recruit somebody and everywhere in the country, the interest rates are high, the rents are high, so nobody wants to move. A lot of hospitals have had grow your own nursing other tech programs. I understand that you've gone through this massive restructuring and a lot of financial challenges over the last couple of years. But do you do you have had any opportunities to have grow your own? And I use that sort of an air quotes, you know, staff development programs within Springfield Hospital is try to, you know, provide economic opportunities for people who live in your area, a career advancement that are already connected to the area, probably already housing in the area. Is that something you've been able to do and why? Why not? How's it going? What are your thoughts? Well, we all we are doing it and we're looking to expand doing that. I mean, we have partnerships with several of the local programs with River Valley Tech Center. We've had partnership with our nursing assistant program with them. We also collaborate with a heck on their train training and recruitment. And right now we we are we have to our are in new grads working in our emergency room that we are. We have them on a program for them to be our nurses. So they're in a development program. OK, I think so we're doing as much of that as as we can. You know, we haven't. We've obviously have some challenges around how much money we have, but we would like to do more. We would like to do more of those partnerships and help more people that are native to our area stay here and be trained. Yeah. I think another thing that probably came up when we spoke in the spring and I wonder if you have any updates and thoughts of it is there's just generally speaking, fair amount of discussion around the state for the need of geriatric psychiatry inpatient admissions and the significant burden that this has on other hospitals. And for some reason, Springfield often comes up in these conversations, which I guess there's some thought that you may have capacity for something like this. I guess my questions are within this topic is, you know, what are your thoughts on this topic? And is there a model of financial sustainability within inpatient geriatric psychiatry that Springfield could envision? Well, you know, that that's a good point that you bring up. We've had discussions about, you know, our should our program be focused on geriatric psych. And that's something we have discussed and looked at. Haven't reached a conclusion on that. One of the barriers we've had to it is, you know, again, our psychiatric unit is on another campus, not at the main hospital. And so it's the it's providing the medical support that those patients might need, you know, like having an internist or a gerontologist available, you know, to round on those on those patients as needed. But no, it is something we've looked at. And we've also, you know, thought that we possibly could have a larger psychiatric program, except for the fact that as a critical access hospital, we're the maximum we can have is 10 beds. Yeah. You know, so. So, yeah, we talked about that. And OK, so. I know there's a lot of rules around inpatient psychiatry facilities and because your. Facilities off campus. You're saying that still counts for the 10 patient capacity that you could have without a waiver. Correct. Correct. It's a distinct art unit. It just happens to be located in Bellas Falls. So it's about I think 15 miles from the main hospital. So it's within the radius so it, you know, meets the licensure requirements. But it's it's, you know, we don't it's not that we don't have the same level of medical support at that facility as if it were a unit in the main building. OK. But no, we would we we this is a discussion, doctor, that we haven't reached a conclusion on yet. We're still talking about it. OK. I think I had one or two more. Was. This some nuke med. Imaging study numbers. I assume that's mostly nuclear stress tests on that graph from 20. Or the chart from 2018 to 2024 budget 2023 you had up earlier. This is about about 900 or 700 or something down to 300. Yeah, we have a we have a pretty conservative projection in year one. I think it's about two scans a working day, which we think we will actually should do more than that. And, Kate, can you come in on the mix? There is a fair amount of nuclear cardiology in there. I'm not sure what split was. Kato was to develop the projections for it. I don't have the the mix in front of me. I'd have to get back to you on that. But when we were looking at the nuke med test from 2018 and what is projected for next year, we've been offline for nuke med probably for about three years now due to our outdated equipment. So we're getting a new machine. I want to say I think it's next month or in the next couple of months. And so we're starting that service back up again in this next fiscal year. And so we're being conservative in our budget and budgeting about two patients a day, which we think is conservative. We think it's going to be a lot more than that. But I don't have the mix of of what, whether it's stress tests or what it is in front of me. I was just part of me was wondering about that because it sounds like you don't have cardiology access right now. So I was trying to figure out if if those projections are affected by not having an available provider to read it or if it can be kind of like a VRAD, like a remote read for a stress test. Yeah, those will be those will be those will be read electronically off site. And we've we've had quite a bit of conversation with our emergency room group, you know, the absence of cardiology. We do not believe will affect those projections. OK. And then I guess we've talked about that quite a bit. And my one last question kind of relates back to our budget tool that your operating expenses are quite low, increased compared to other hospitals. Your MPRPP has grown a lot compared, which looks like utilization and returning to trying to kind of regain trust within your community that you've discussed. Your day's cash on hand is. Low. And your rate requests asked for essentially a break even budget with no margin. I'm just trying to figure out, you know, did you consider similar hospitals that we've been reviewing have tried to factor in a margin of more than $100,000, you know, in a budget like this? Did you consider a higher rate request and why not? We went through so we did, but we went through a process in the spring where we had a price sensitivity analysis done that looked at all of our charges at a charge level, by payer, looking at the individual contracts that we have and what we could, what kind of an increase we could get out of those contracts. And so what we have for a rate increase of 6.95 percent is really probably the highest that we can really go without, you know, if we went for a higher rate increase, we really wouldn't be able to generate more reimbursement from that. So the 6.95 percent is kind of our maximum of what we could ask for, because I think we're pretty much capped in our contracts if we went much higher than that. So. OK, well, thank you and thank you for your your submission. I just wanted to call out one thing that I found very helpful. It was just your your your cost inflation section was was quite brief, it was very succinct and very easy to read. And I thought it was just very well written, so I just appreciated that. Thanks. Thank you. Thank you, Dr. Merman, board member Walsh, do you have questions you'd like to ask? Thank you, acting chair. Just a couple. It's tough going after Dave. The the rural emergency hospital designation, I, you know, it's it's still emerging and coming to fruition, and I'm certainly not an expert. But I think there's added flexibility and added funding for transportation. And so it may be something to spend a little bit of time considering. Certainly I'm in no position to give any advice. But I think as feedback has come to that program, it's been modified and enhanced. And so it's just something to to think about based on the interaction with with Dr. Merman. I agree that the section on cost inflation was very well written. I appreciated that. I also wanted to applaud your expense management efforts. It was interesting to listen to that because with our costs, so we could certainly see it in the cost per adjusted discharge and in the ran data. And I think you'd be applauded for those efforts. It shows up back in that data. It'll be interesting to me and I think the rest of us to see how that moves forward. I was hoping you might describe some of the steps you're taking to understand your community needs and how you're monitoring the impact of your efforts. Well, we of course just just did our our three year survey last fall. And so we ours ours is is pretty fresh. Although I have to say that it's not a lot different than it to one prior to that. And what are people concerned about in our marketplace? It's it's access. How are there going to be providers here for them? What is it cost to access them? And do we have what about mental health? If I need myself or someone I love in these mental health services, where can they get it? So I mean, ours really hasn't changed very much. We just think I will say is we are we now that the pandemic has subsided. We're spending time out in the community, attending community functions, engaging with other groups and those type of efforts. So we're getting a lot more feedback. And that's been particularly helpful for me because as you recall, I've been here now a little more than two years. In most of my first year to a year and a half, we were like quarantined. And so we were afraid for me to be roaming around talking to people. And so now I'm out a lot more and I'm building relationships in the communities and getting to know people and and giving you having a chance to get input from people in the community. So I think our community needs needs assessment mirrors what people are telling me. And I think people want to seek care and want to receive care here because it's more convenient, it's easier. You know, hospital is pretty easy to come in and out of if you need something. Yes, so we are we are doing that. And I think we're planning some forums and some focus groups in the fall to to do some more listening because I think we need to we need to have our ears open and listen more. Terrific. Yeah, that's that's where I imagined you'd be going and so I'm really happy to hear about it. Because with the expect expense management that you've done so well, right, that kind of the holy grail is if you can really target what your community needs while managing your expenses to deliver those the care that they need, that's that's going to be sustainable. But if we're if we don't have a good handle on expenses and you're you're growing just in an attempt to continually grow, then things can get kind of out of hand. And you can't there's a mismatch with what your community may need or what it can afford. And if if a community can't afford care, it won't be able to access even what's there. And if they can't access care because they can't afford it, then they stay away until it's desperately needed, then they can't pay their bill. And so it becomes a sustained the affordability is a sustainability issue. It's not a trade off. And so I applaud your efforts with expense management and really hope you hope you keep diving in to the community needs. And of course, we've got the Act 167 rolling out and we want to understand what's going on in communities and help facilitate that process, but the focus groups, interviews and really trying to target efforts and maintaining your expense expense management. I just think you're on a good track if you can if you can keep doing those things. So thank you for presenting to us today. I appreciate all the work that you guys have been doing the last few years, turning the ship around. Thank you. And I appreciate that compliment and that is a compliment for our hospital family here, because, you know, the our hospital family, they're very, very conservative with the money we spend. They're very tight because they know they know we've had financial troubles. And if we have to spend money, they want to make sure that everybody's very cognizant of that issue here. And so that is a compliment to our hospital family. So thank you. Yeah, you're welcome. Deserved. Great. Thank you. I'll turn now to board member Holmes. Great. Thank you. And thank you for the presentation today. Just a couple of quick questions for you. I think some of them are follow-ups from some of my colleagues questions for you. You have an inpatient unit that you staff for 15 beds, yet your average daily census is around seven to eight, it looks like, from the narrative. So I'm wondering how many days a month does it exceed 10? Well, you know, that so we have one inpatient unit other than the psychiatry and so on that unit, on that unit, we have a lot of things going on, even though it's a small unit. So we have traditional inpatients there. We also have swing bed patients that are on that unit. And we have observation patients that are on that unit and patients that are going back and forth between all three of those categories depending on what, you know, what's going on with their condition and in their payer. And so so we're managing that every day. And we do have, you know, we will have patients that, you know, as the surgery numbers go up, most of our surgeries are outpatient. And when you look at our outpatient revenue, you can see that that really, that really stands out when you look at that over in the hospital report section. However, we do have some people that stay as observations and we do have a small inpatient census budgeted as mostly driven by the increase in surgery that we've budgeted for this year. But I'm not sure if that answers your question. Well, I'm trying to understand why you staff for 15 when it looks like you're under 10 most days, I just don't know if that's, you know, there's other is there volatility in those numbers such that you might have 12 some days and and four other days. I'm trying to figure out why staff for 15 when you're under. What's what's happening is we're flexing that staff. So we 15 is kind of the maximum amount we could go if we brought everybody in at once, but we if the inpatient census is low, we may float provider, you know, nurses and technicians from that staff, we may float those to the emergency room if they're busy or we may float them somewhere else. And so there's a lot of flexing and adjustment that goes on. I mean, we may have somebody from one of the perioperative areas that is ends up covering in the emergency room, for example, if we're short. So we move in people around quite a bit and our hospital family is pretty they're pretty understanding and flexible of that. So my hats off to our to our guys for doing it. So so I would say that 15 is a maximum. It's not a fixed number. OK, I guess, you know, a lot of our questioning is probably around the concerns. There's a lot of financial vulnerabilities, obviously, that Springfield has experienced over the past few years. So I do echo some of my colleagues questioning around the rural emergency hospital designation, just exploring that further. I think exploring Jerry Syke becoming a center of excellence for Jerry Syke is definitely worth exploring. You know, we have significant needs in the state for post-acute placement. Obviously, your expertise in mental health and your excess seemingly excess bed capacity seems like this would be an interesting avenue to explore. I want to ask a little bit about given the volumes that have been shrinking and you're already small size, do you have you established or do you follow any minimum volume requirements to ensure quality in the surgeries that you're doing? Are there minimum volume requirements that you have in place, for example, for knee replacements for hip replacements for other types of surgeries where we know that there's a volume quality relationship? Do you have established minimum volumes? Well, we really we really haven't done that. The orthopedic example you used is our busiest service and usually we're doing the two primary surgeons in that specialty or do about 25 surgeries combined a month. And so that's pretty big volume for us. Some months they might go up into the 30s during ski season. You know, those are usually our busier months. So the answer to the question is we haven't really done that. Both the doctors we have are very tenured and very experienced. So they're very, you know, their current competency to perform those surgeries is very high. Let me ask another question around. You mentioned that one of the major contributors to fiscal year 24 other expenses was advertising and marketing. So I'm wondering if you could give us a little bit more detail on how much you're spending on advertising, marketing, why this is a significant other expense? What the need for it is? You can talk about that. Really, it's kind of a I'm not I think it's truly a relative measure because we really couldn't afford to do any marketing before. So we're reinstating some some conservative marketing that we're doing. And a lot of that is focusing around letting people know what services we do have, for example, orthopedics, podiatry. You know, we didn't have a podiatrist in Springfield for a long time. And I think the provider will be here. He's came part time around the holidays. I think that'll be two years during the holidays this year. So we didn't have a podiatrist. So we had to do some work to let people know that that service was here. And so what we're doing is pretty conservative. And I would say it's a relative measure because we weren't able to afford to do any before it's OK to can speak to the dollars, but they're not in absolute dollars or not very large. That'd be great. Yeah, our budget for advertising next year is one hundred and twenty thousand dollars, which is higher than what we've spent in the past. In the past couple of years, we've spent about seventy or seventy five thousand, so we're increasing that by about fifty thousand for next year. OK. OK, great. I think between the others, I think my questions have been answered in the presentation. Thank you. Thanks. Great. Thanks. So I had a couple of follow ups that I will ask as well. And in follow up to Dr. Merman's questions around births, my recollection is that Brattleboro was coming up and doing some visits at Springfield or in a in the Springfield area. Is that still happening? Has that changed? Obviously, they're not doing the births there in Springfield, but they were trying to see patients so they wouldn't have to travel. They have a couple of providers that have remained on our medical staff. They they have were forced to move their office back to their main site. So they are they are not they're not on site now. But but, you know, we we are there. They have remained on our medical staff and have agreed to accept referrals from us. OK, great. Thanks. It's interesting to get that update. So one of the areas that you've mentioned in passing is that you are that part of your efforts to increase volumes and keep people in your communities through improving your operations. Could you speak a little bit more to what operational improvements you're targeting? Well, again, it's just it's just everything we do every day. You know, how can we continue to evolve the hospital and improve the operations? A big part of what we're working on this year is around our revenue cycle. And we've made a lot of progress the last couple of years with the revenue cycle. But again, in terms of looking at and again, the three areas we're working on right now. Involved revolve around looking at our financial assistance policies and are those to write policies and are we following them appropriately? So that's one part of it. Another part is our patient admissions and access process. You know, are we are we doing that following the best practices? You know, we have a lot of great people here and they've been here a long time and they've been through a lot of challenges. So we want to make sure that people have we're keeping up with all the training and education that is necessary. And the third area of that is our charge capture process in to make and make sure that we're identifying all the things that we do that should be passed over to the bill on the revenue cycle side. And we want to make sure that we have all the charges correct and the codes are correct and that all that we're following all the best practices on how we do those things in the hospital. Thank you. So in terms of the charge capture process, is some of that connected to you had mentioned increased denials and certainly we've been hearing from other hospitals that with increased Medicare Advantage penetration that there's been some increased insurance denials. So are those two connected or can you speak a little bit about what you're seeing in terms of denials? Yeah, that's part of the process. That is part of our process. And with our since our inpatient, you know, I think our process with our inpatient denials works very well. We have a lot of outpatient stuff. So, you know, chasing down denials on a lot of smaller outpatient claims is is a little more is a little more challenging. So, excuse me, we are seeing that is that that is part of the process. And I'll let Katie speak to that since she is very involved in this process. Thank you. Yeah, your question on Medicare Advantage denials, we are seeing denials from Medicare Advantage plans, particularly like UnitedHealthcare related to their prior authorization requirements. So we are seeing a lot of that, I think, our overall denials. We're seeing kind of decrease over the last year or so due to improvements in our internal processes, but we are seeing some denials on the Medicare Advantage side of things due to those prior off requirements that traditional Medicare doesn't necessarily have. Thank you. So you had mentioned part of your recruitment efforts are connected to replacing providers that are currently locums. Could you just speak to which of your recruitment efforts you currently are budgeting locums for? Are how are you? Are you changing those budget assumptions in next year and just kind of walk us a little bit through connecting that to the budget? We do have I'll start and Bob, if you want to jump in, if you have anything to add, we do have reduced locum costs in our budget for next year for surgery locums and we have to to replace that cost at a lower cost to contracted general surgeons. So we do have a savings there. I want to say it's a couple hundred thousand dollars. We do still require locum coverage for days, there's certain days a month that can't be covered, but we're definitely we definitely have a savings in next year's budget for reducing those locums and taking on two part time surgeons. Thank you. In relationship to sort of the budget trends the last few years, I was noticing in the PNL statement that your current projection for fiscal year twenty three is under budget compared to the twenty three budget and is coming in a little bit higher, a couple million dollars higher than twenty two and then what you're requesting in twenty four is a significant jump from your twenty three projection and I know you have outlined your utilization assumptions and a lot of that is driven by that. But I think also last year you had spoken quite a bit about trying to capture more utilization and it it looks like you certainly were successful to some degree, but not as much as you had hoped. So can you just speak a little bit to that and why that jump feels realistic to you? Well, you know, we've had we've had a we've had a pretty tough couple of months here in the summer. You know, obviously our first quarter and second quarter were a lot stronger for us, but I mean, again, I think this is related to increased access with the providers, you know, having having more availability, more appointments. And if you look at our growth in our office visits in our specialty practices, I mean, all of those have far exceeded the budget in prior year, except for general surgery, where we only have the one full time doctor who is part of our family. And, you know, that's what we were targeting with those recruitments is to have some doctors here, one that are not there less expensive because they're not low comes, but also because that will be their practice and they will have their own patients and have office hours and that sort of thing. So I think it's a win-win all the way around for everybody. And if you look at the surgery volumes, we're budgeting and you can you jump back and compare that to what we had five years ago. We're still budgeting well below what we had five years ago. And so, you know, recapturing the confidence of our community, having providers who are here and have access that are our providers and not just people who are here in case we have an emergency room call, you know, so. Thank you. And I think one thing to point out, sorry, one thing to point out when looking at last year and what where we were at, which was about a million dollar lot or a million dollars better last year. And that's because at the time we had a hundred thousand or sorry, a million dollar USDA grant that we had recognized last year. And we haven't been able to recognize any grant revenue yet this year. We are expecting a FEMA, a grant from FEMA this year. We're not sure about the timing of that and whether we're going to be able to realize that this fiscal year or next fiscal year. Thanks. OK, I'm I'm wrapping up. I only have a couple more questions. So we've talked a little bit about your service area and keeping your your patients local. We're I'm also wondering if you have explored and I know this was a topic of conversation in the past, increasing shared services or coordinating with other hospitals or entities in your region to reduce duplication. So, of course, Claremont's not that far away. You know, I grew up in Brattleboro, Springfield's not that far away for folks who are able to travel and certainly Dartmouth in the scheme of things isn't isn't isn't a bad drive from Springfield. So could you speak to whether you have plans to think about how you might work together with others in your region? Well, that is something we do all the time. So whenever we have a need, that's what I do is I call everybody and determine whether or not there's an opportunity for us to collaborate in partner and we have existing partnerships in place. I mean, our pathology group is UVM. Our radiology group is Dartmouth. Our cardiologist until he left was Cheshire. We had the OB doctors here from Brattleboro and we still we still work very closely with them. We are in discussions with other area hospitals regarding the opportunities to return cardiology to our hospital. And those conversations are with other local hospitals that have those services now. And we've also had we've also had some discussions with Rutland about because we have swing beds and, you know, they have some patients that have post-acute discharge planning challenges. And so, you know, we've had some discussions with Rutland about about our availability of swing beds and their challenges with post-acute referrals. So so we we talk to everybody and partner with everybody wherever it makes sense. And so we we are very open to do that. Thank you. And then I think my last question would be your thoughts about potentially increasing use of telemedicine or other technology to keep folks local. You've mentioned giving us a couple of examples, including oncology, where you use that. Could you speak to to that modality? Well, we have recently expanded our telemed services with Dartmouth. And we, in addition to the oncology program, we added three other programs through a partnership with Dartmouth. One of them is for the nursery. And and so even though we don't do obstetrics every now and then, we'll have a baby in the emergency room. And so we have a telemedicine. We have the Dartmouth service available to us if that's needed. We also have added psychiatry as telemedicine. Although we don't that's pretty much a backup because we have our own behavioral med providers. And then the one that is off to a pretty big start is we added teleneurology, which is primarily for strokes. And we are seeing quite a quite a brisk use of that service. And it's mostly been in an emergency room, but a few of them have been in patients as well. And so so now we have the telemedicine link. And if someone is we believe is having a CVA, we have access to their specialist on that. Thank you. OK. Do any other board members have any follow up questions they want to ask? Can I just ask a quick follow up on the telemedicine stroke question you just were talking about? Is that I'm sorry if like I'm torturing people like through clinical of information and this just but I'm just curious. Is that allow you to keep acute stroke patients who don't require TPA or intervention at Springfield by having that capacity or maybe or even before did you be able to keep patients without a neurococetative capacity? Well, I think I think theoretically, theoretically, the answer to that question is yes. It is so new. We we are about to go back and do a clinical analysis of our first quarter. We just started in in like April or in March. I guess it was in April we did it. And so we're about to do a review of those cases to determine what we can learn about the patients and the outcomes in that. So I think theoretically to answer your question is yes. What is our actual experience been? I don't know yet because I haven't seen any data on it. But obviously it's better. Obviously, it's better for the patients because we have world class stroke care that are involved in the cases now. Thank you. OK, we're going to turn to health care advocate questions. Sam, are you our questioner today from the HCA? Yes. OK, take it away. Thanks, acting chair. As a caveat, if you hear some weird sounds is our black lab sleep barking next to me. So I apologize if there's some background noise. I just wanted to good morning, everyone. As a high, I just want to highlight and commend Springfields on the bad debt and free care changes that you talked about and particularly in regarding the compliance to that 119. But we notice that your charity care is projected to increase to point nine. And that's a big increase over FI 22. And the bad debt is going to go down. So that's a trend that we obviously like to see. The first question is really a clarification in your response to board questions on facility fees. You said, quote, an estimate of the total sum of the facility fees billed and collected for patients accessing the ED was around three million and potential payments around one point three million. Are you saying that you build that and fees, but only anticipated collecting a certain percentage of that because of contractual discounts or free care and bad debt? So I wonder if you could just talk about that a little bit more. Yeah, the three point four million in facility fees was the charge. So what was charged to the insurance companies and the one point three million is what we receive for payment. Got it. OK. Is there any difference in the facility fees charged by payer or no? Like, do you sort that out differently in any way? No, you can't you can't change what you charge. You have to charge the same thing to all insurers and accept if you're self-pay, then, of course, you can apply for financial assistance and get the amount generally built. Great. Yeah. Thank you. My only other question is relates to your community health needs assessment, which indicated that one of the top three concerns you've identified is affordability of prescription drugs. And we noted that you attribute your 340 B to the general operating fund to support the hospital. I'm wondering if you guys have any plans in place to help patients with pharmaceutical costs like social workers who help patients apply for manufacturer assistance or anything like that. We refer a lot of our patients to Valley Health Connections, who we work with. They have a lot of resources to help patients afford drugs. They help them apply for different programs that you can either get free medications or also there's vouchers that are given out to so they can buy medications. So that's mainly what we do is refer to Valley Health Connections and they're they're super helpful assisting patients with that. OK. Thank you. I appreciate it. Back to you acting chair. Thank you. OK, we are going to turn to public comment. If you are here and would like to make a public comment, please use the raise your hand feature. And when speaking, please state your name and spell it for our court reporter. We'll just give folks a moment to try and find the raise your hand feature. OK, well, seeing none. Sarah Lindberg, I just want to check and make sure you don't have any further follow up before we move to it. Yeah. Yeah. Thank you very much. OK, so we'll turn it to you, Springfield team, for your closing remarks. Thank you, acting chair. We again appreciate the opportunity to get a chance to tell our story. So thank you for that. And I want to thank and recognize our hospital family for the work that they do here every day. Again, the hospital has been through a lot of challenging times. And we have a lot of people here with us that have stuck by the hospital. And so we can be here to take care of their friends, family and neighbors here in our area. So I want to I want to recognize our staff for the work that they've done because they're the ones who have brought us through these difficult times and are continuing to carry the load as we as we take these steps to move forward. So I want to I want to thank our team for the work that they do. So well, thank you for joining us today and sharing the information on your budget. We're going to recess now until one PM when we will reconvene for North Country Hospital.