 Okay, so we did get some feedback earlier today that people were having trouble hearing, so I'm asking everyone, including board members, health care advocate, and the hospitals, to please speak right into the mic and speak loudly and clearly. At this point, if the court reporter could swear in the witnesses. To my hand, do you swear the testimony you're about to get shall be the truth, the whole truth and nothing but the kiss. And whenever you're ready, I see. So my name is Tom Frank. I am the chief operating officer for North Kutty Hospital and currently serving as the introduction executive officer. To my right is Andre Vissanette, our chief financial officer. To my left is Abel Cochran, our VP of patient services. We have some guests with us today. Tracy Paul is our executive director of finance and accountable care. Wendy Franklin is our development officer. We have Anita Flagg is our controller. Amy Joan Morse is one of our accountants and our special guest is Gary Gillespie. He's a member of our board of trustees, so thank you folks for coming. Before we kick it off, I just want to thank the folks who got the chance to come up to this North Kutty Hospital. We really appreciate you guys knowing that. And for those who haven't had a chance, we certainly would love to see some more people come up and visit us up in Newport. And that would go for the advocates as well. If you're ever going to stay at a hospital, we'd love to have you. We're pretty proud of you all. So I think that you all know we're located up in Newport, where we have a service area of about 30,000 folks. We have the most isolated hospital in the state of Vermont, highest poverty rates, lowest health status. And what's also very challenging for us is we're 45 minutes to the nearest critical access hospital, two hours from the nearest tertiary, and that is on a good day. The 2018 county health rankings for Orleans and Essex counties. Unfortunately, we're at last enough for home doctors again this year. You can see 13 and 14 Orleans and Essex. 2018 county health rankings for Orleans ranked last in Vermont for health outcomes, quality of life, border fair health, poor physical health days, poor mental health days, and low birth rates. So as you can see, we have some challenging folks that we're trying to do our best to take care of up there in the Northeast Kingdom. Just a quick overview of our structure. We're actually country health systems Inc. And under that we have our hospital, 25 bed clinical access, we have a 20 bed nursing home, and we're in a collaborative limited liability corporation, NVRH, Northeast Kingdom Health Care, where we provide sleep services and we're expanding to some pulmonary services as well. One of the questions that we are asked every year is, you know, submit our projections, initially back in July 1st, which are built in April and May. And as you go through the summer of those projections holding, for 2018 our projected operating gain was $694,000 as submitted. Through May year to date, our operating gains are actually at 390,000 positive, the budget's 166. So a year to date in May, our net revenues are actually down slightly 347,000. So as the Go-Kart 2019 budget back in April and May, we built it at a $950,000 operating gain. Based on those other four items, I would say that currently our projections are holding throughout the summer, which we still have a couple months left. So our hospital issues, risks and opportunities. Increased volumes associated with mental health issues and opioid use. I'm sure that that's a very common theme throughout the state of Vermont, so I'm going to show that something that you guys hear quite regularly. One of the things that we're doing to address the mental health issue, especially in our emergency department, is we're building three specific rooms for our mental health patients to be held in the safe environment. Ava, you might want to jump in here because, you know, we have quite a bit of problems. We'll try to care for these folks in our emergency room along with our other patients. We have an incredibly busy emergency room, referring back to the fact we're so far from the hospital. So that's something that we're investing in and we'll talk about that in capital. Ability to Retreat and Retain Workforce. This right now is one of our number one issues that we have. Our market pressure is on compensation, only going to increase with other factors that are going on in the state. You know, last year we lost about $2 million when I'm online, so we had to take some very hard, we made some very difficult decisions and one of those was to hold the line on salary increases for staff. All that does is it gets us a short-term gain for a long-term pay, and we needed to increase what we needed to do, folks, because we're beginning to lose quality staff. We also had to make some market adjustments this year, which contributed to an increase in what we needed to try to hold on to these folks. Also, based on where we're located, limited availability of qualified staff. So there are times that we might have to overpay for a particular specialty, a clinical person in order to get those folks in the door. It's also, it's a very different country for our business. Ability to maintain positive margins for reinvesting the organization. As I said last year, we lost about $2 million. This year we have a positive, we hope to hit budget, which is $650,000, I believe, and next year $950,000. That's just about a 1% margin. And those dollars do get reinvested directly into the organization and equipment and services. Continued increase in regulatory pressures at federal and state levels. The bearer billion, our dish payments from the state, you know, the constant threat of 340B going away. There's talk of critical access staffs potentially being in jeopardy as well. All those factors contribute to what we consider obviously a significant risk. And then additional resources require for population health. We are in the middle of changing from reactive to proactive care. And obviously when you do that, that's going to lead to some additional FTEs and additional cost associations that happen. We'll talk more about that in upcoming slides. One of our largest initiatives and probably the largest initiative of the hospital who go through is converting its electronic health record. This year we went live in Athena Health on May 15th. We took really four disparate EHRs and merged them into one. That was organizational-wide. At the same time, we also converted our accounting system. There's probably no easier way to level a playing field and do it, doing something like that organization-wide. So that is, we put that up there as both a risk and an opportunity. We look at Athena Health as a huge opportunity. One of the things that Athena does is it's cloud-based. So part of the risk is it's really more of an opportunity. It's moving costs from what was traditionally a capital structure to an operational structure to your bank service fees instead of appreciation. We're anticipating efficiencies out of Athena, both from the software itself as well as changing our processes to make them more efficient. So we're looking at process improvement efficiencies, building and collecting efficiencies. So looking at, you know, reducing dollars that are actually not increasing volumes and just collecting what we should be collecting. What we should be collecting from each of our payers. And in the long run, hoping to reduce FTEs through attrition, through these efficiencies. Every time we try to look for reducing FTEs, it's because somebody left to go someplace else or if they're looking to retire and we just wouldn't be replacing those positions. We continue to evaluate and implement new staffing models. Our current one that we're looking at right now is our MedSurge and ICU, which we're looking to change the patient flow in the process on that football one floor, but it was divided by a wall, basically. And merging those into one area, almost having convertible rooms so we can gain more efficiency through our staff and better patient care as well. We participated in the New England Alliance for Health Group Percident Collaborative, it's NIA. We're increasing compliance around 340B and cost reduction opportunities. One of the things we've done this year is we've actually put in the budget and additional FTE to help us with 340B compliance with every year. They ratchet up the compliance efforts from the federal end to see if they can reduce their payout of 340B, but also looking for better contract opportunities with pharmacy contracts, even if it's one drug, it can save you some money. And then we've been doing this and continue to look at financial and operational valuation of all of our services. That's difficult to do from a critical access possible standpoint, but it's something that we need to do with our service lines at that moment so we can see which areas are actually costing us a lot of money, which areas are making money, which areas are breaking even, and just doing the valuation of that. Major budget initiatives. Evaluate Medicaid risk contract under one care amount. We've been in the Medicaid component of one care for the last year and we anticipate on staying with that one more year as well. We are just starting to sort of get in the flow of how that's working from a fund flow perspective, what we need to meet the expectations for being in just the Medicaid, and we're actually hiring an additional FTE to help us work with the one care folks. As I mentioned, implement Athena Health EHR. That has the potential to really, really help the organization immensely, both with quality and financially. Unlike most vendors, Athena Health is more of a partner than a vendor. We don't cut them a check for $3 million and pray that we have an EMR that works. We don't pay them unless we collect the money. They've been working with us for about a year to implement and we just cut the first check for Athena last week. We really do consider it a partnership. We have a ways to go, but we're getting there. One of the key things from our perspective financially, I think if you read the news, you see that when folks switch over to an EMR, there's the real opportunity to lose significant dollars the first year or so that's under a new EHR. Two months in with Athena, we were at 80% of our cash collection goal. We have high hopes that we're going to be able to work very closely with these folks and they're going to help us turn things around. One of the things Andre mentioned was the opportunity from an FTD perspective. The first slide I showed you today showed that we were the most wired. We weren't receiving an award from the most wired. So I consider that both a blessing and a curse. We have an extremely expensive IT model that we have in place prior to us looking to the cloud. Over the last year and a half, two years that we've decided to make a change through Athena, we've lost five individuals out of our IT department purely through attrition. We've not replaced one of those positions. Improved population health data and infrastructure that goes hand in hand with Athena and our ability to produce quality reports. Evaluate population health, medical home organization structure and resources. And that's one thing that we continue to look at on a regular basis. Develop strategy to mitigate financial risk, reserves, i.e. reinsurance, etc. Those are some of the things we're looking to do. Access. One of the questions was with respect to three nights available appointment. We only look at that on an as needed basis. We don't look at that on a regular basis. The key for us in primary care right now because that's the area obviously where most organizations that are struggling getting patients in the floor. We're still able to see most of our patients can make same day appointments. We have a model that I'll talk about later on in the slide. We've changed completely the delivery of care in primary care. It's a team based model versus simply a doctor sort of sitting alone off and trying to do their own things. More to come on that. One of the things that we're really seeing in the Northeast Kingdom is the continuing retirement of physicians. Over the last two years, we've had two more community primary care providers retire. At this point in time, that means that 98% of the positions in the Northeast Kingdom are employed by the hospital. At the APN Quality Measures, there's 13 of them. Eight of these measures is one of the questions. Eight of the measures we either met or exceeded the Vermont Statewide Rate. The ones that we exceeded were the percentage of Medicaid out of the adolescents with well care visits. Thirty they follow up after discharge from mental health. Diabetes, HPA1c, poor control, appropriate asthma medication management, percentage of adults reporting that usual primary care provider, as Tom just mentioned, prevalence of chronic care disease, HDN, that's related to drug overdose and rate of growth in number of mental health and substance use related ED visits. The slide that we did not meet, initiation of alcohol and drug dependent treatment and engagement of alcohol and drug dependent treatment. Those two, we actually got a grant for alcohol treatment last year. And we actually moved that grant over to the Northeast Kingdom Learning Services. And they have initiated a relatively new program with that grant money to help address this problem. We're partnering with a lot of folks in our area, Northeast Community Services, the recovery groups, some of the independence in the area that work on behavioral health and substance abuse and looking towards prevention measures. In a slide later on, I'll talk about the Upper Northeast Kingdom Community Coalition. And they're also looking at how we address mental illness and substance abuse issues within our area. Then we have prevalence of chronic disease, COPD and diabetes. And number per 100,000 population ages 18 to 64 received medication assistance treatment. On the last one, we have one physician that is now certified for the medication assistance treatment and two more that are getting certified. Once all three of them are certified, they're going to really start engaging in this program. All-hair model. As I said, we're entering the second year of the Medicaid only. And we have some significant positive developments out of that. Obviously, one is predictable payment. Two is proactive versus reactive care. As I said, that's what we're transitioning into. Potential upside risk. And being able to collaborate with other hospitals even more so than we already do. Those are some significant upsides. Some of the unknowns are possible concerns. As I said, we've dipped our toes in a Medicaid, but we're not quite ready to jump in all three yet. Of course, it's the cost of supporting one care infrastructure. This year, we have a bill of about $300,000 that just to support the infrastructure to be in Medicaid. Increased cost of supporting reporting and care requirements. Right now, we're going to have two systems that we're going to be entering all our information into. That requires bodies to be able to do that. There isn't one simple way to do it. And as I said, we're adding an FTE there. And it'd be a small player and influence downside risk. I think besides quarter, we're the only critical access hospital that actually dipped our toes in the ACO's best year. So having the ability to influence the overall downside risk when we are on the smallest hospital is something that we are obviously a little concerned about. I'm ready to go on. So from Maynard's advice, I took the Dremat Care Board technical staff file as the analysis. One of the things I wanted to point out is from 2016 to 2018, if you look at our MPR growth, it averages about 1.5%. The growth from 18 to 19 is slightly under the Dremat Care Board's guidance at 3.1%. And the bottom line, as Tom mentioned, we lost almost just under $2 million in 2017. Our budget this year was $694,000. Our projection was at $950,000, and our budget next year is at $950,000. And as we went through, whether our projections are holding for this year, I feel confident that they are. I think we're in a good place, and we actually have almost a $3 million turn around is quite substantial. The other thing is, on other operating expenses, there was a question as to what we're driving. Some of that, a big part of that change is the Athena Health cost. I knew up in that line, which was the capital delay. So we have been historically adding a $1.6 million a year capital expense for IT. Next year's capital expense in IT is about $600,000, so we're going to be able to cut that in better than half. But we obviously are going to see a transition to operating. The significant expense drivers in our budget next year are compensation and benefits, as with everybody. Locums and travelers, we have been flowed with this. That sometimes we can brag that we have no travelers and other times, two months later, we have six travelers with some attrition of particularly nursing staff and some of our other professional staff. And then our EHR capital cost, those are the three significant travelers in our financial system. Another question that came up through this process was our bad debt and free care. This is a slide that I've shown before at this presentation. Over the years, our bad debt and free care, I look at them combined. So the free care is in the purple, the bad debts in the red, and combined is in the green. If you look at the trend back from 2012 to today, you see a downward trend. 2012 and 13, we were almost $5 million in combined bad debt free care. We're budgeting just under $3.9 next year, a million dollar decrease. Those are on gross charges. So that includes fee increases over all of those years. So if you factor that in, that downward trend is even more so. I'll put the balance sheet in here. This again is the sheet that comes out of Adaptive. The significant change over the years has been in our board designated, which is really our investments. Next year, in the 2019 capital budget plan, we have two significant projects. One is Tom alluded to, is termed as the behavioral health project, our ER renovation to help better take care of our mental health patients when they come in. Right now, the way our ER is set up, it's kind of a circle. And we can have those patients in any one of those rooms. There's nothing segregated. We try to have them in some specific rooms, but when they become very voiceless and sometimes violent, and you have children coming through there, it becomes a significant issue, both for our staff and the families and the patients of those we're looking through. So we put $1.2 million into that. In our lab, we have a lab renovation project. We put $1.5 million. We're looking to pull that out of our investments not using our operational input for that. Cost containment. Obviously, like most hospitals, we have to focus on how we control our costs, as we possibly can as the view of the services that we do. Over the last five years, we've engaged in an organization called Premier Labor Benchmarking and Management. The idea there is to sort of benchmark ourselves against like hospitals across the country to try to meet both productivity expectations for our staff within the hospital and also costs. When we began this project, we benchmarked us. We were in about the 75th percentile of expense and the 50th percentile of productivity. As an overall organization now, we're almost 50-50. So we've saved probably $2 million in this project over the last five years, simply by benchmarking staff and through attrition to try to better align the staff with the services that we have. 340B contract management. We just hired someone to actually really focus on the 340B, the cost of the drugs, how we're important to get it set up. Nursing intern program. We'll be able to talk about that because that's a pretty interesting thing. So we continue to hire nurse interns every year. New graduates usually five to eight a year, depending on the year. We really focus on hiring folks who have either been raised up in our community or have very strong ties to our community so that hopefully retention is a bigger factor. We continue to look at ways of supporting them for about seven months while they're in their new role because evidence-based shows that that's important for especially new graduates to have that kind of support in order to stay in the nursing workforce. And we've been able to retain most of those folks over the last three years, only I think we've only lost one or two. So that's been a good program. Collaboration with other health organizations. I have a couple slides coming up on that but I'll get into detail with it. Andre, I'm going to let you talk about the new women alliance, the health contract and the supply chain. Yeah, when we first got into the new women alliance for health, it was purely off of the supply chain management and contracting goal. Since we've joined with them, we've found that there's many other contracts and services that we were doing that we could actually get reduced pricing for. So we have aggressively and there's still more out there. Some of the things we've moved over, we were doing our telehealth group, yeah, we're doing our telepharmacy through NIA. We actually have gotten contracts for things as simple as our copiers to be reduced when we run it through the NIA group purchasing. So it's been a very valuable move for us and we've got some unexpected gains out of it now. Facility efficiencies. Just something as simple as changing everything over in the organization to LEDs is saving significant dollars and it's being very energy efficient. But I'm not mistaken, our parking lot lights used about 1,900 watts of power. Changing those over to LEDs, it's 100. So those types of small things that we're looking at are really saving money and I think improving efficiency there. Primary care delivery model. It's both cost containment, it's all for a population count. Several years ago, like most organizations, we had a separate internal medicine group and a separate family practice group with duplicative infrastructures, et cetera. And what we did over the last few years is we combined those two groups into one primary care. It's on top of that, we've also developed what's called the T-Base model where we align an advanced practice commissioner with a primary care physician and provide them support with a lead nurse for each group. That marks the sort of supervisors of that team. That allows us to take a look at, when we look at how a physician or a mid-level is seeing patients, that panel of patients is now looked at from a team perspective, not as an individual perspective. It's allowed us to hire less physicians and see more patients with those groups working together as a team. We've already talked at length about Athena Health. So, major collaborations. We don't look at our other hospitals in the state in this competition. When we look at those other hospitals as partners, our unique location really makes it, we don't have quote-to-quote competition. Our only competition is ourselves. If we provide good service and we provide quality outcomes at a reasonable cost for our community, our patients stay in our community. Don't want to travel. We have folks that have never left in our East Kingdom. We literally have patients that have never been to New Hampshire, never been to Canada, and we literally stay in our hospital in the required services. So, we have to look elsewhere for help and collaboration because we can't do it all ourselves. We can't be everything to everybody alone. So, when I look at some of the major collaborations we have, UVM Medical Center, outpatient, HenoDialysis, Nephrology Clinic, Clinical Pathology. We get all of the pathology services for UVM. Urology. You know, we need urology but we can't afford a full time urologist to be contract for two days a month. Neonatal Intensive Care and Transport can be worked with UVM. Collaboration of COBE, Clinical Quality Initiatives. We're also fortunate enough that we can sort of work with Dartmouth as well. So, we can sort of help cherry pick some of the services we get for each. So, for instance, with Dartmouth, we use cardiology, the stroke and the stemming collaborations. We currently have a cardiologist who works for us two days a month is retiring. I've already reached out and worked with Dartmouth to replace that individual with the Dartmouth position. So, they'll be, we're working on a recruitment that will be in our organization two days a week. Oncology through the Norris Cotton Cancer Center. Telemedicine, Teleneuro, Telepsych and Telepharmacy all come through Dartmouth. And, of course, I'm going to mention the FQB purchasing alliance for health. Other collaborations that we work with, we work with hospitals outside of Vermont as well. Northern County's HealthCards and FQBHC and I, Eric, I apologize. You know, we've invested in dental clinic in that community down in Orleans, but they haven't had that for a debt just for years. North Michigan Human Services is the main mental health agency. Not only do we have a psychiatrist that comes into our clinic once a week, we also have a four-day week where a practitioner can contract through that agency. Northern Vermont Regional Hospital and, as we said, with NBRA and St. John'sbury, we have a limited liability for providing sleep and now pulmonary services. We're actually expanding the LLC in St. Jay and working on plans right now to do so. Upper Connecticut Valley Region Hospital in New Hampshire. We have a general surgeon over a long-stated general surgeon who's retired and so it required us to recruit another general surgeon. Well, low and behold, not knowing that we'd be able to do this, we're able to get a general surgeon before our surgeon retired. So working with the folks over in New Hampshire, they need a general surgeon. We have a general surgeon. So we're sending a general surgeon there once a week. That's going to save us about $130,000 a year in expenses to offset that cost. Littleton Regional Hospital, we have a full-time quarter-pointed surgeon who's come on board in the last six months. We have more volume, per se, in the kingdom that one physician can handle, but we don't need two. So we contract with Littleton for two days a month over what previous surgery we've come up from Littleton. In addition, we have this is a very busy slide. I apologize. But we have the Upper Northeast Kingdom Community Council which has the unfortunate acronym of UNIC. But UNIC has been great because our vision for it is that all of the groups at the bottom here that are working hard in the community, both within the hospital and on the right-hand side through public health are all working on the same goals and the community health needs assessment. But we needed a group of folks at UNIC that were the movers in their different areas of responsibility who were able to give forward funds and designate resources to do the work and to help drive the work and also be informed by the work that was happening in all of the other community coalitions that were going on. So UNIC has a grand goal of our next generation whose dreams our community supported is the month's healthiest and most successful generation. As Tom said, we don't look at other hospitals' competition. We borrowed heavily from NBRH and the Lower Northeast Kingdom group, all of those folks and what they've been doing with collective impact in their areas. And we've seen how they're starting to move the mark on some of their healthcare outcomes. We're pretty excited about that. We're not too different from them but we do have some distinctions. So we're creating the same kind of group in UNIC to do the similar work that they've been doing and hopefully we'll also see some changes and not be last on the list of them not. But that might take a generation so don't hold for it next year. Thank you. Andre. Okay, healthcare reform investments is a quick slide. You know, we have nothing or a shattering for the .4% investment. As Tom mentioned, our ACO dues have gone up almost $300,000 and we've hired the ACO care board to hear that Tom and talk about the health and primary care. And like every hospital we did our community helping with assessment this year with gathering qualitative and quantitative data and demographics looking at what our community said where their highest means and we are now focusing for the next three years. These five goals they're not too unusual. They're not that dissimilar from last year except for the addition of supporting older homeowners aging in place. What we did do is change how we looked at these. We wanted to make these positive instead of negative so they're all about supporting substance-free lifestyle and mental wellness, supporting tobacco-free lifestyles and healthy eating and physical activities and access to medical and oral health care. Okay, capital benefit. $6.2 million overall it's going to be funded through Operating Cash Flow which we normally do and investments as we talked about earlier for those two major projects. There are no evidence for difficulty. And our brief list of our significant equipment and facilities replacement. $708,000 for surgical services. It's time to replace our ultrasound with $365,000 we have two machines. Building management control system. This is something that this is the brain of our facilities. Most people don't think of building as having any computer attached to it but this is our computer management of all of our HVAC systems in our facility. Salometry that's come to the to age to be replaced. You know my only comment here is you know helping them on together and that's true we can't do this alone. Especially this on our location. So good question. Thank you. I'll grab it. This is to make sure I'm not culprit and not speaking up. Thank you for coming down. I know it's a long drive. I was happy last year when I first came on the board to go visit you and I'd be happy to do so again. I'm sure you're happy. First of all I really appreciate you starting at your presentation grounding us in your population because you do have the most challenges of any county or area in the state in terms of your population health headwinds let's say. I was also happy to see that you had added issues around seniors to your community health needs assessment. When I reviewed your Healthy Vermonters 2020 profile there were two areas that stood out to me related to seniors which were ED visits related to falls and deaths related to falls. So I was going to ask you about that and why it wasn't in your community health needs assessment but I see that that's been updated. So that seems like a good addition. I think really my one area that I wanted to ask you about specific to your budget it looked like you had kind of a high number of FTEs that you were looking to replace something like 18. I think and I wondered if you could speak to that and if it's realistic to think that you can attract that many new positions in one budget cycle. Yeah, that was a question throughout the budget process and please let me clarify what we're looking at. Thank you. It's actually not budget to budget. Budget to budget or FTE growth is just under six. And what Robin's talking about is our what our current projections are being 21 it's almost 21 FTEs from projections and actually those are vacant positions when you have positions an FTE have become vacant throughout the year if it's vacant for six months that becomes a 0.5 FTE in your projection. So to be fully staffed at 100% FTEs I don't think you're going to find any household that's going to be that way. We did build in some salary that I didn't have we didn't build in any FTE like we didn't build in salary like to account for that. The other side of that coin is the stomach part positions that become vacant like that we have to have somebody there. So that's where the locals come in. So you see our local number actually is it is quite a little bit higher than the budget. The only thing I want to match that is one of Robin's challenges is to recruit them. And maintain quality staff. Great. Thank you. And I also just lastly wanted to give you kudos in for quality improvement in your APM metrics and your presentation was very clear in your documents and that was very helpful. That's all I have. Okay. Tell them. Let me get this. Thank you. And like Robin I would be very glad to visit you this year. It's a special part of the world and the drive-up there is very critical maybe a little long but one might enjoy the coin both ways. I'm a far snows. I'm a miner I like to sell. So my questions are first about tying out some of the numbers here and looking at your utopia growth in NPR at $4.2 million with $2.3 million of that coming out of great increases both mostly in commercial obviously and some in Medicare. So the Medicare the two I'm most interested in is the Medicare increase you have at 1.2 percent and I'm just wondering how you get to that number is that because have you gone through the critical access process and you know what that number is? Yeah. So if we if our fees actually go up a little bit we're still getting around a percent of charge for Medicare for that special number. Do they build anything extra into that? The one that really caught my eye was the Medicaid increase which is here in the staff analysis at 13.2 percent 2019 proposed over 2018 to today and that seems like a big number to me. I see that your dish payment is going up prior to that. But is but that's still a big number even being net out of the dish number. Is that so what is your basis for calculating and there's no rating piece associated with Medicaid. So it's all either utilization or basic utilization. Yeah. It would be you though three components of the utilization the dish our dish went up $450,000 and on $8 million of net that is a pretty decent percent as well as whatever the delta would be from our for member for my amount out of the ACL which happened to open to those to see what the three components are. So those are the three components that we're talking about here. Thank you. Question on bad debt. You said to us that you that $347,000 about of your bad debt is is pretty 2016 that you're carrying on on your book. But that and that of that before that year for 2016 you had just a little over a million dollars in under plan. So I'm just technicality here. If you're telling us it's under plan it's not part of that. Right. So if it's depending on how you look at the bad debt but what we have is we have payment plans with our patients and we have as you just stated a large amount of money we have we use an outside avenues and outside statement company that helps us manage those plans and we've got about twice as many patients on payment plans as most other hospitals do. We try to do that to help accommodate our patients to be able to pay for their bills over time. All of those patients are religious with their payments. One of one of the things we've done in the past is usually from January 1st to April 15th if they can come up with paying that off we give them substantial discount on whatever their balance is. So yeah it's it's technically we wouldn't consider that as bad that they're actively paying the clients so that wouldn't be like that. They may be reserved and they're not reserved because of how we do that but technically we wouldn't be like that. I was just looking at some of the volatility around bad debt and in 2016 it was 3.46 million actual 2017 2.087 million actual and it dropped to 2018 budget down a million blocks and is there that kind of volatility in your bad debt or Yeah when we submitted the budget last year our bad debt decreased and I didn't really have an explanation to that. Other than we've got six navigators at our hospital who would do a phenomenal job getting our patients on in order to either medicate or on the exchange or setting them up with most payment plans. So I'm not sure how that bad debt dropped last year we have seen it come back up this year and I've been looking into it I still haven't come up with an answer as to why that is happening. But over time that's why I kind of put that slide out there over the years we have but it shows it going down so from year to year it's got a little bit of volatility. So there was a one year that's one when you're there that you can't really explain just how it happened. Yeah just how it happened. In terms of on the utilization page there are zero travelers noted and Robin noted some of the staff turnover and when I was up there we talked more about travelers. So we're on your budget page and from your budget data do you carry the information for travelers so that is that something that we can distinctly see as part of your budget? I'll have to look into that to see where if it's broken out specifically some of ours. Yeah. I just noticed in your presentation you're looking forward to travelers. Yeah and I don't think we put the the FTE for the travelers in just the dollars. No. And this is you've had on your 340B revenues you basically a flat line down between over 2018 and 2019. Yeah. Even though the trend has been somewhat up over the years is that do you think it peaked out there or what? Yeah we're starting to see a flat now. I don't know if you're aware of this but Walgreens bought the the right age in the state of Vermont and that transaction went through in January. We became registered for 340D with Walgreens effective February 14th we've still not seen any money coming through for that but we're going to all I'm anticipating seeing is a shift from the right age number to the Walgreens number and from what I've seen the patients pretty well flattened that was pretty saturated. We only have three major pharmacies in the area that are associated with the 340D now it's the Kenny Drugs right age of Walgreens and then we've seen some migration from Kenny Drugs and right age in order to the Walmart. We're staying in three or half of that. And finally in your staff turnover you said I think you had like two primary care positions have been there for a very long time over the time are there any kind of savings from that or is is it the difficulty of finding replacements and at your hospital so difficult that what you've been spending is what you have to spend. So we do have an open recruitment right now for a primary care position to replace those two folks that have retired in the last two years but when we went to the when we really delve into primary care it went to that team-based model we actually had two of our own dogs who had retired or who didn't have to replace but we're seeing such increases in the audience of primary care as I said a thousand new patients a year that with those two folks retired and they're under full recruitment we've had some great candidates come through we had two on Friday we have an element coming in next week so hopefully we're going to get that position good luck with that Thank you First I want to compliment you on your turnout and financially you know I think that especially with your debt being down a little bit in MPR this year and still turning in a projected return profit after $2 million last year is a good shift Just wanted to ask a couple of questions on the ACL and the reserves because you talked about reserving on your balance sheet for the risk and did you roll that for the P&L at all? How are you doing that and what is that for 18 and 19? Yeah right now we reserve every year a certain amount for our Medicare cost report we currently have four years of cost report outstanding and I'm sorry four years of what? Cost report Thank you Yeah so they haven't come back to an audit and close them out for four years worth so we have some access reserves from those prior to years that were closed out so I would use those reserves for this year's ACL reserve so you're not rolling anything through the P&L as an expense because you have access reserves correct and then where are you booking the ACL participation fees is that netting out of NPR or are you doing that in expenses? that yeah it's netting out of NPR netting out of NPR yeah under the of need and maintenance agreement did you have to write off any capital and stuff you've had booked previously that was capital or what you've been about this I'm sorry that was I didn't know previous that was capital previously I know we've not had to write anything off like as far as terminating an asset before end of life is what you're asking about yeah we've not had to write anything off at this point most of those are servers that were for our legacy systems and they reached their their light end of life span per se so at this point we haven't had to write anything off okay and when you look at the cost savings from the protection we get from the NENA and you've already shown that you haven't placed some of your IT staff how can you go about that more strategically rather than just through attrition look at you know what are you going to get the cost savings how do you reach out to get them you know rather you talk about having retirements or attrition but unfortunately the people that go aren't always the ones that need to be today you're absolutely right you know a big chunk of savings from an expense perspective that we haven't even talked about we didn't put on slides is really through the maintenance agreements for their disparate softwares we no longer have so all scripts paragraph which is mcassan and uh meadows when you're not paying those those manual or monthly fees you're going to get significant savings because with respect to attrition you know I guess the several ways to look at it you know where we're located you know we're not just the health care provider for that area but we're also the center of the economy and you know we have the highest rate of unemployment so we take very seriously the concept of having to potentially do a layoff or eliminate positions and we've made those tough decisions over the years and if things came to be necessary you know to get to a certain point we would look at that but we we average about a 15 percent turnover in labor per year anyways and so every single position that comes up is part of that premiere benchmarking goes to a resource management team even for a replacement that either has to be denied or sent forward to the senior team and so every single position our organization that's open comes to the senior team for approval so there are there are quite a few positions that we'd be saying how to thank you thank you adjust thank you so again I was going to congratulate you for the turnaround and thank you actually for the period you are and here are budget guidance I hope it takes you alright if you try to follow very much appreciate it so one question you had a slide up there with the APM measures that your that fall under the threshold of your you know have some strategies to work for us one of them that I didn't hear much about was the prevalence of COPD who were there any strategies to try and address that and given you know at Newport at 10 percent the state is at 6 percent it seemed a little bit high so I was wondering if you had if you're just not talked about it I mean I I I think the biggest thing that we're looking at is is all of our efforts around supporting a smoke-free lifestyle and that or tobacco-free I should say for all uses of tobacco and all of the prevention work that we're doing and we're looking at some pilot programs for instance to decrease smoking during pregnancy for or actually eliminate smoking during pregnancy for those who smoke during the pregnancy as a pilot program on that a lot of other prevention of efforts with other community members that we're working on towards that because that's really I think because we also have one of the highest rates of smoking in the state so I think they kind of go hand in hand okay secondly so we just heard from a hospital about the crippling effects of drug costs associated with oncology some of the critical access hospital that it has on oncology and I you know I'm wondering if you can just speak to the you know the collaboration that you have with Dr. Pitchcock and how that may mitigate some of the drug costs that maybe other hospitals will be seeing and how that works I'll just hear more about that so we no longer offer full oncology services at our hospital we eliminated that service yes two years now a year and a half ago and at the same time that Dartmouth was going to terminate the relationship at our hospital with oncology for two reasons one the cost of the drugs to us we were losing significant dollars every year even with the physicians coming up in Dartmouth on that program we only had 30 to 50 patients so obviously you're not gaining any efficiencies through volumes Dartmouth determined that we didn't have enough patients for them to be able to provide the service to us any longer so we've worked specifically with Dartmouth in St. John'sbury which is 40 minutes 45 minutes from Newport is the Norris cotton cancer center and so all our patients were able to transfer their care to there in addition to that for our patients because we made that typical decision we provide gas cards we provide help the best for possible candidates so that they can get back and forth from Newport to to St. John'sbury very very difficult decision but you know when you're talking about you know turning things around by nature or maintaining a small margin you know we are looking at services on a regular basis and unfortunately with Dartmouth pulling out it just it doesn't practically bless the peace in here okay thank you you are a self-insured care place yes for a health insurance yes so just wondering if you have considered the one with your carrier to become attributed to your self-insured employees having your employees become attributed to one carrier we have not spoken directly with with our carrier as you know one carrier is trying to get them pulled into the ACL so that's that's you can see discussion right now so it's under consideration yeah and we had actually talked about that two years ago trying to hurt ourselves but there's some orisa issues with that which we want to clear clear of unfortunately yeah my last question is at that so you have a new EMR and this is actually a question about you know as we think about integrating healthcare and having all the data being shared with providers acts and being able to access patient data across the entire system our beehive is incredibly important and having as many patients in the beehives is really important to the working of the entire healthcare system and so I'm wondering now that you have the new EHR system hospitals can play an important role here in emerging electronic consent through the ADT interface and I'm wondering if you would be willing if you're in your budget in this season to commit resources to help with the implementation of that and understanding is it's about 48 hours of time to get that electronic consent up and running and but it could have big implications for getting more patients on to the beehive so I mean we'd consider anything that's going to help obviously the patients you know the question for us is the cost associated with that one of the reasons we went with Athena at least you know one of the projects that they're working on is having the ability to exchange information with Epic and so that's one of their future projects to partner with Epic and being the the two large tertiaries in our area are both going to be on Epic that was one of the reasons we did choose Athena I'm not sure if that's answering your question specifically well this is about the electronic consent form that would be built into the particular aspect of your interface to be able to get patients when they come in to your hospital automatically you know be asked to consent and have the consent electronically transmitted to Vital to allow their data to be shared with Beehive yeah I know we've been electronically connected with Vitalhub yeah for years and the whole primus when we go to the state I'm with I'm with I'm with I'm with Athena because that would continue and potentially get easier and better this is specifically about patient consent this is the patient consent yes this is the patient consent trying to we're trying to the state is trying to increase patient consent just like yeah patient data is on there and my understanding is that there is a method by which hospitals through their EHR could improve that process by implementing component of their ADT system of their EHR to be able to allow that to be easier so I'm just but we we could get back to me yeah I think I think from where we all stand is we can make it easier and electronic I'm all for it I'm sorry if I don't know that I've that's okay no worries I I it's fine get down to the IT work for me you know I don't if you're all right yeah okay well thank you only two hospitals have done it so far so I'm trying to find out what the the the appetite is for the other hospitals so thank you okay Pat do you have questions I'm all set thank you great this point we're gonna turn it over to the health care advocate Julia and Eric okay can everybody hear me now just barely okay I'll try to talk about even though I'm really close to apologize so my name is Julia Schump I'm the office of health care advocate at Vermont legal aid our office advocates for reminders in health care policy and we also work with individuals who are having problems accessing health care so our office here is regularly from people who are having trouble affording the care that they need I'm wondering if you agree that affording health care is a bigger challenge for many of us I do think it's absolutely I think not for probably most people even with insurance that health care is a challenge I know large insurance plan with our close response with corporate etc so yeah absolutely it's a challenge can you describe some of the more early challenges faced by patients in your service area I'm really sure as you talk all day yeah you know we we hear stories like this almost every day you know people making choices about do I buy my medications or do I put food on the table for the children do I pay my health care bill or my even if we have a payment plan do I pay that or do I pay car insurance so that I can get to my job I mean it's just constant the the family's battles with all the social determinants of health that are going on and all the decisions that they're trying to make it's a daily battle so we've heard hospitals often qualify for free care as some of them provide patients who can't pay and that bad debt is money or by patients who couldn't pay but she's not so I'm wondering if you agree with that characterization that's probably pretty accurate I think there becomes a fine line there between whether somebody can pay is willing to pay or won't pay and it doesn't matter what their economic status is so I think there's a word of the final can you tell me how you assess for Wunder's ability to pay when you're studying prices for services we really don't look at the affordability of somebody able to pay when we set the prices as you probably heard you will hear from all hospitals no matter where these schedules are set off with historical rates right go back to old methodology we have made attempts at reconfiguring some of that so at least it makes more sense to be in our diagnostic area in our lab area those are two areas that we need constantly to hear from patients about I try that they're very expensive tests to have done so when the board affirms the commercial rate for your hospital do you consider that to be a set rate or a ceiling that you base the restrictions off that I consider that as a set rate so under the topic can you talk a little bit about the harm reduction services that are available in the area for active substance diseases or so things like syringe exchange in our kind of situation yeah um the the work yeah we do have we do have in the hospital where where folks can drop off their their used needles but we don't have a true needle exchange where they get that but there are Narcan is available both through the recovery center through most of our pharmacies with prescriptions by the docs so there's a lot of that going on but I don't know if we have a specific program which one would you be looking for and to do it? I was just wondering in general what kind of harm reduction services that you have so yeah and most of our harm reduction services are lifting up with their recovery community a more very focus on prevention and focus on harm reduction and and just the you know the broad spectrum of where where folks are their recovery journey whether it's earlier whether it's you know they're into it and do I remember correctly that you are looking at opening an urgent care center can you talk a little bit more about that and then what need your community that is secure to meet? so um we are looking at opening an urgent care and our hope is that that's going to happen during the year you know several reasons why you know so we don't have primary care hours after say 5 30 at night and we don't have an over weekend so folks are having ending up having to utilize our emergency department for earrings and sore throats and those type of things and so obviously we want to try to put folks with those type of situations where they should be and that's the urgent care really starting the week and that goes across all lines that goes commercial self-pay dedicated Medicare you know being that we have such a small you know patient base you know it always comes down a little bit to finances and so we're going to move forward urgent care which our plan is to do so we important to do so it could very well be a lot needed for the organization but as a service to the patients you know it feels necessary to do but that doesn't mean that would be staffed by providers who are already employed by the organization or to be recruited as a staff so based on our hours of operation that we're thinking which is basically you know you can look at 10 to 12 hours a day that would be necessary to hire at least one or two full-time nurse practitioners who can use a nurse practitioner model or a PA model versus a physician model and then supplement that with our own nurse practitioner who's offering them potentially the ability to report some extra hours that's the plan right now Thank you. That's all the questions. Thank you. So this time we'll open it up to the public for any comments or questions. Dale speak very loudly Dale. Okay Wow I got like ABC but I'm going to try to one is I was reading on med schools the way the article read it was showing concern that new doctors right out of med school or new are not really being trained and how to deliver rural healthcare which leads to one financially can they even afford to go there to a kind of interesting from a recruitment point of view even if you recruit them they have no idea how to function within that environment and then you add the social determinants of health which the article only alluded to as existed didn't even suggest that they understood that at all that's one I want you to take on how much of a challenge that is for you the other one was similar in that electronic health records don't really measure your 30,000 so your take on whether or not you feel those measurements accurate accurately reflect your challenges and give you meaningful results that actually reflect what's going on in your community the other one I'm curious about is you said nothing is available after 5 p.m you don't have anything but the emergency room and same on weekends I thought there was a federal program to actually fund services but maybe it's not in rural settings so that you could have a 24 hour care delivery system I don't know how well it would serve you but I thought there were funds for that well if there are funds available for that I'd love to know about it you know right now when we look we do amazing jobs I'm going to start with the third question first now we do an amazing job in our country to find everything you know where we still have the possibility of that because where we are in our population and you know what we have for a commercial service base which isn't much so that I can't give you a firm answer to but we can certainly look at it as part of our version of care analysis but right now I don't know any program specifically to do that so your first question with respect to rural health you know you may not believe this a lot of our docs come to us our primary care docs because of our rural needs because of the scope of practice that they can do at a hospital that we don't have a multitude of specialists that sometimes they can simply send down the chain that they actually have to provide that care and they have a full service not only that our primary care positions are the most part work in the hospital as well so they'll serve shifts as hospitals etc and they have to have special training in order to do that when a new physician comes on board in our primary care area they are attached to the medical director and a mentor and that physician mentor works closely with that individual physician to do the best to make them as successful as possible it's a pretty unique program that we've just put into place actually recently so far I don't see that this is successful we also don't put you know on a new physician you know our expectations new physicians are going to build a payable patients over three years so for an experienced physician seeing 18 to 20 patients a day a new physician coming on board in the expectation maybe see 10 or 12 patients a day just to get the comfort level and basically sort of being able to ramp themselves up so that's how we do it and it's amazing how many primary care folks want to come to us because of our role in the world of nature yeah I'd like to add to that that we also have rotations of med students that come up through our primary care practices so it's not like they're not exposed to the rural setting so we do accommodate for that as well as we probably have 15 or 20 percent of our employee physicians who are from so they know what they want to see they're from the area or from a rural area and when they come to us they look for that I'm sorry he was on the electronic health records the electronic health records do they work effectively for you for the population you work with and reflecting their health care needs so it's measuring their health care needs it's giving you relevant data back that tells you about your patient or is it missing a lot of things that you know is going on well you know I'm going to answer that question yes and no you know the politically correct answer would be that you know medical health records is the greatest thing since sliced bread the true answer is that it can take away some care but where we were at with our three or four disparate systems that was definitely uh had an impact on you know our ability to truly get the full story on every patient being on the one record we truly believe in a truly hoping that is going to give us much more of a sense of each patient's needs and will help us provide better care that that's our goal okay other questions or comments from the public okay seeing none I'd like to thank the North country team very much we'll take a five-minute break and invite the people from the Northeast to come forward we also have rotations of mass students that come up through our primary care practices so it's not like they're not exposed to a rural setting so we do accommodate for that as well as we probably have 15 or 20 percent of our employee physicians who are from so they know what we want to see from the area or from a rural area and when they come to us they look for that and I'm sorry he was on the electronic health records the electronic health records do they work effectively for you for the population you're working with and reflecting their health care needs so it's measuring their health care needs it's giving you relevant data back that tells you about your patient or is it missing a lot of things that you know is going on well you know I'm going to answer that question yes or no you know the politically correct answer would be that you know medical health records is the greatest thing since life spread the true answer is that it can take away some care but where we were at with our three or four disparate systems that was definitely uh had an impact on you know our ability to truly get the full story on every patient being on the one record we truly believe and are truly hoping that is going to give us much more of a set of each patient's needs and will help us provide better care that that's our goal okay other questions or comments from the public okay seeing none I'd like to thank the north country team very much we'll take a five minute break and invite the people from north east to come forward