 Good morning, everyone. Welcome to the street bottom care board Today is the final day of the area, so we're pretty happy about that Of course, let the hard work begins afterwards But this morning I wanted to first turn it over to Susan Barrett for an executive director Thank you, Mr. Chair. I wanted to let everyone know that our September schedule is on our website So please have a look at it and I'm just going to Highlight the many meetings we have scheduled in September for you now And if there are any questions, please reach out to us So we'll be meeting again next Wednesday, September 4th at 1 p.m. In this room On the agenda are the FY 2020 hospital budgets and potential votes Then we have on Friday September 6th a data governance council meeting In this building on the 4th floor at 1 p.m. And then we come back to the pavilion auditorium Here again on Monday September 9th at 9 a.m. Until noon to again discuss FY 2020 hospital budgets with potential votes and Then in the afternoon of Monday September 9th. We meet in room 10 at the State House From 2 to 4 for our general advisory committee meeting Then we come back here on Wednesday September 11th again We have time set aside if we need it or the FY 2020 hospital budgets and votes and we are very last scheduled potential day of discussing hospital budgets and potential votes is Friday September 13th, which I don't know if we should read into that too much, but that is the date And then The and at the end of today's meeting we're going to hear from the hospital budget team about the next steps But the orders the the rate and the NPR will be Sent out to the hospitals by September 15th, and then the orders will be sent out by the end of September the written orders and then then we're beyond hospital budgets at that point and we here on September 18th from UVM Medical Center on their milestone report for their psychiatric investment. We also here at one care quarter quarter to update and then That meeting starts at 1 p.m.. Then at that evening on Wednesday September 18th in our Green Mountain care board offices. We are conducting a primary care advisory group meeting which starts at 5 p.m.. And Last but not least on Wednesday September 25th at 1 p.m.. In this room. We'll be hearing of the curers That's our all-pair claims database The curers in action Examples of how Vermont's claims that are used to understand and prove care So we'll have a panel discussion on that and then I think we're going to need a vacation So it's all on our website, please Thank you There won't be any vacation because I want to give a teaser trailer to October 2nd Because October 2nd We're having a panel discussion here On an issue that really has been seen in every single possible That's work for us and it's an issue that threatens Access and threatens quality and it also threatens cost as we try to compete with others Sensor is not an adequate supply Toxin nurses and other medical professionals. So that should be a really good presentation on October 2nd So with that I'm going to turn it over to Joe and his team but before I do I'll ask Sonny the court reporter to swear you in Joe Other hospitals and HSAs are dealing with Vermont Join this morning my far left Teresa Tabor who is our controller My immediate left is when the fielding was the vice president of financial planning for government Is not help the larger help system that we are a member of and to my right Who you all know David sample my So we'll jump right into it here. I know that we have had under my leadership A tendency to run very long By that today, but I'm sure we'll have a lot of good discussions. So no promises Our agenda and as directed by a three month care ward. I won't review each item right now. We'll get to it An aerial view of our shot. I like to point out our solar field. We are Incredibly efficient hospital and stewarding our natural resources I don't think we can pick up it's too pixelated the sheep the flock of sheep that we have every year that Does our mowing for us people love to park up there Our mission to improve the lives of those we serve we are kicking off another strategic planning exercise right now Incorporating some of the language and taxonomy around our system strategy that we've worked on at the system level for the last year and a half our Mission or purpose statement will remain the same. I think it's simply a powerful Our work chart is as you can see here nothing has changed Last year I want to make a quick note out of our assisted living community the historic homes of remedy And right in downtown Windsor We it's a tough business to be in we found a way to make it work And I think importantly especially in the setting of the affordability questions that we have in the state around health care and Extended care We've been able to make it work with the majority of our patients being on Medicaid As the primary care part of that has been working with diva to get waivers for sicker patients We found that the trend is and it's an admirable trend is that folks are staying at home longer Because of wraparound services 24-hour care And then making the jump immediately to a nursing home more frankly to a hospital When they get too sick However that leaves out a vast population of the monitors that don't have the ability for 24-hour care and don't have Long-term care insurance to help pay for assisted living So we run a pretty lean Operation there, but we've been able to stay full and we look at the more Higher-end assisted living facilities around our community and White River and other places They're empty because frankly for monitors in our region don't have money to be in an atmosphere Very high-end Facility so I just wanted to point that I've taken a lot of work And it was a business that I wasn't going to be sustainable for a long time But we've been able to keep it going and actually Get into a much stronger position So our most valuable assets are 490 ploys that's part-time full-time per diem in 183 volunteers for across our three clinical sites And that's the Windsor of primary care clinics in the our full hospital in Windsor our primary care Pediatrics and PT clinics and Woodstock in our ophthalmology optometry practice in Hanover, New Hampshire I'll make a quick note that we recently went a system-wide Employee engagement survey with press game every system member Dr. Pitchcock help help through it and we had the highest employee engagement scores of any facility in the system And we're in the 85th percentile nationally on our engagement. So I think we are being seen regionally as a strong and stable place to work that cares for its employees Shung through on that survey say the most The best part of the of our individual surveys was that In the patient safety and quality module there were a number I want to say somewhere between 10 and 15 questions about the culture of safety and quality at the hospital Every single respondent from our hospital Check the degree or strongly agree box. There was not one dissenter. No one was even neutral It's a culture shift that we have focused on the last five years And again, it was very apparent to all that with our survey results so since 2014 which is when the ink drive on our Affiliation agreement with Dr. Pitchcock. We've had about 6,000 referrals overall from all outside hospitals and over 5100 just from Dartmouth Pitchcock We've had about over 1700 admissions for post acute care to our swimming to keep rehab units and about just under 1,500 admissions directly from DHC Year-to-date as of June of 19 our average daily census was 20.1 on swimming acute and 8.3 on acute rehab. Those numbers are very similar year-to-year We built out our capacity in the last few years and have been able Stay about those levels Quick summary of this slide is there really aren't any sections of departments in the hospital We are actively working daily on system integration. I Said this at prior presentations here It's not all rainbows and unicorns The pads are bumps and bruises with integration, but overall it's been an immensely positive experience for our hospital. I think our general stability in the region financially and clinically bears that out Being part of a larger health system has allowed us to enter risk programs with one care of Vermont knowing that We've got help if you need it That has been reassuring our current services and our clinic and hospitals are as listed everything in red is direct clinical support with providers Docs associate providers coming from Dartmouth-Hitchcock health. We are hoping I get the year to complete a joint recruitment of a neurologist to help us serve our acute rehab patients most of our acute rehab patients are Patients that came to us from Dartmouth-Hitchcock health with traumatic brain injury after a stroke or some debilitating neurologic disease and we We waste a lot of time and money putting people in it was to get them back up to the neurology Appointments at Dartmouth-Hitchcock so working with their section chief Jeff Cohen. We've identified a couple Physicians who hopefully will be bringing to the area and spending time at Montesquad What you don't see up there are Really many surgical subspecialties and still not are Really not an out portfolio at this point which as you might imagine can make Revenue challenging at times. I don't have a couple orthopedics or neurosurgery or other surgeons that are You know making hay for us in the long term to help cover up our warts So our challenge is make sure we don't have any warts make sure that operationally we're running lean and Keeping our expenses under control So I will also sit with it before I hand off to Dave in a bit You can see our NPSR budget to budget growth 7.4 percent and the rate Requested it goes from 2.9 to 3.2 in the changes as listed there at point 3 percent some of the hospital issues we're facing and I Can't believe I'm saying this but it seems our workforce issues are stabilizing In the While well Dave caution me not to say anything I can't help it. I just feel like we're in a bizarro world We're considered You know we're offering comfort packages to new employees especially lower employees on the lower end of the pay scale That are actually better than some of our surrounding hospitals Now that's taking work over the last few years to get there but We've never been in this position before so I'm glad I'm glad we're able to pay our housekeepers a little bit more and get our nurses Especially our nurses up toward a market range that said You know our performance this year has really limited our ability to make any market adjustments for our folks and We'll talk a little bit more about that later in the presentation, but we've moved Mission critical positions have been filled by permanent folks. We're less reliance on travelers You know we we have hired a few folks from Springfield Few folks from Valley Regional there tends to be a somewhat mobile workforce that doesn't move around our three hospitals that are all about 20 minutes apart from each other and regional instability in In both Claremont and Springfield it I think has led to some exodus of workers from those regions As I said we have over the last few years They've been doing market merit raises each year for three years and made significant retirement contributions A lot of that really was catch up in nature because for years we weren't able to do anything And I've already mentioned about our employee engagement scores is something we're very proud of Primary care provider turnover made significant. This slide is largely a carryover from last year We have successfully hired three new primary care doctors two for Windsor one for Woodstock So that is great. Unfortunately. We lost a primary care doctor in new term as well So we're still net positive on FTE as far as gains in our primary care But we still have about a thousand to fifteen hundred patients that are in the ether out there folks We're previously got their primary care with us, but his primary care providers moved on So our project over the next six months with our new docs is to bring all of those people back into the fold because we're also finding that Hey, guess what? Those folks are still attributed to us even though we haven't seen them or there But they've been waiting for the new primary care physicians to arrive I'll comment that we do have wage pressures as all our all institutions are desperate for primary care and we're continuing to try to come up with a Solution to the position of provider for now problem. I should say that it's it's not just provider But it's also nursing. It's healthcare burnout in general one investment we did make is We brought a chaplain on board for the hospital and increased her FTE and the work was less around our patients We had more than enough chaplaincy available for our patients It was for work with our employees to build resiliency. So we've carved out her time To do that work and we're probably going to do a small physical planned adjustment in our chapel space Which is never used to become really more of a site for wellness Can help to hold some resiliency workers on the ECO engagement side again under under risk You know, we're dealing with a few issues. I Think we might care board the representatives from CMM I specifically Fatima and the folks at one care for helping us work through these issues, so they've been they've been challenging and They revolve around the cost report issue that you all are well aware of and then frankly just the 2.2 million a potential downside risk for our programs in 2020 I'll be very honest our board my board of trustees was Not willing to go that route it took a tremendous amount of discussion a little bit of leverage some Conversations with DHHC leadership Myself all of you feel like it's the right thing to do to be in the program to stay in the program as we are now We're all three programs But our board with their fiduciary obligation to a duty to Steward our financial resources We've got a lot of pushback Little hair I have left Significantly decreased over the last month or so as I think the folks are on my table here can attest to But the issues are as as we know We have a small and for covered lives in all three programs for 20 There's probably two five and six thousand lives in Medicaid example I'll use is we had about a thousand Medicaid lives in 2018 one one pediatric patient who had substantial Orthopedic surgery at Dartmouth Hitchcock pretty much blew out our cost our expense in that year and if we have our attribution right that same patient is at an outside hospital in another state and probably Blowing you get going on our cost is what just one patient who's it's kind of a long health care struggle for that So that's hard there's not enough lives to spread that risk around And then we have you know a little point of contention between myself and again I'm the vice chair of the one-tier board. So a bit of a walking conflict of interest But we had to assign what we've called the orphan risk of a very large Primary care practice and whitewood rejuvenation that does all its specialty work Imaging lab work at Dartmouth Hitchcock because they're a lot closer than they're in my scuttle We've had no historical relationship with them now. Thankfully. They're a great practice with great docs that do Excellent work for their patients. So it could have been a lot worse, but it's we as the River HSA our tip have that practice on all its attributed lives And all the expense that is occurring kind of outside of our part of our grasp Staffing recruitment and retention may continue to improve dealing with wage pressures and ability to keep competitive packages to our employees is something to keep a close eye on on the housing front we Did invest in a condo at the mountain at the former musketeer resort And we've kept that largely occupied with Either short-term housing for people that are moving into the area to take jobs for us and are waiting to see what community that actually going to settle in To bring Locums for anesthesia out there. We also renovated a building on our campus to create a two bedroom apartment With a common living space and we get that full of the lead at least on the weekend So I think it's a novel approach to the workforce We've had to attract some of our technical positions or folks that fill those technical positions from as far away as Manchester, New Hampshire and areas south and We can provide a place to stay for three or four days while they're up here. I mean that goes a long way And then they put the last bullet I'm controlled We continue to balance DHH system needs versus our needs versus ACO needs and State budget guidance, that's just an ongoing balancing act that we perform every day We are still dealing with patients that stay with us who nursing home will not take I put the word limits in there and quotations because There's really no limit. It's just self-imposed. We can only take so much Medicaid And I understand where they're coming from they've got a few full lights on the doors open as well And as I said, we remain the highest referral recipient in Dartmouth-Hitchcock Health for sub-acute patients that remains One of our strengths and inside the system. We have increasing dependence on other operating revenue I think our budget bears that out and our reporting on down 340 b meaningful use funding to help care reform program revenue and then we continue to bring in significant amounts of grant funding year-over-year in fact Substantial grant from the couch family foundation to support our family wellness program, which is remarkable and I would encourage any board member Or staffer to come down and take a look at what we're doing for our high-risk families in the Windsor and Woodstock areas Opportunity we are actively engaged in Regional planning as I mentioned earlier in the presentation. We've got three critical access hospitals within 20 miles of each other With varying levels of financial distress at this point we really have to work on a Better model of care for our 400 square mile region that these three hospitals serve There is Unneeded capacity probably at two of the three hospitals or I should say underutilized capacity And just make sense for us to kind of right-size clinical services And try to find a way that we can get all all three hospitals to a point of financial stability And I'll say that Dartmouth-Hitchcock struggles to Exit to extend their services to three hospitals I'll use the example of oncology based on one oncologist to us actually one and a half oncologist I'm not a scutney to send an oncologist to Springfield They send another oncologist to Valley Regional while Dartmouth-Hitchcock has a reputation of being this big behemoth Their oncology section can't afford to keep sending three people to three hospitals 20 miles apart We need to come up with a better way and the urgency in Springfield is felt by all of us. We're all feeling it And I'll say that leaders from all three hospitals are Talking having active discussions to figure out how we can do things better We are continuing to work on improving our primary care operations. I already mentioned we brought three new docs and and it's a unfortunate that I have to report that A lot of the enthusiasm we had around our pharmacy or pharmaceutical formulary and PBM revisions have not been borne out. It's been It's been slow going. We're going to keep chipping away at it. We Still think that there is a larger health system solution We think there's greater power in purchasing as being part of a larger purchasing group But we just haven't seen it yet. We're gonna we're gonna keep working on it. We haven't Lost anything we haven't really gained it And again, it's I regret to report that because there was a lot of enthusiasm About that last year so at this point I will hand over to today So financial health indicators a lot of my slides are things you've already seen in Materials that you've received. So there's there's our financial health indicators and I have questions for sure We can talk about them later and Same type of deal here our profit and loss statements. Essentially, we're looking at the 1% operating margin for 2020 and That's what it is cash flow statements Same kind of discussion here. It's just really born out of our Penal and balance sheet And then the 2020 balance sheet a slight improvement from 2019 And again, it's a lot of these things, you know, a lot of our risks and issues are also Opportunities and vice versa. And so I will be careful not to be repetitive Very next few slides. We've talked about the workforce pressures We've done a couple things to try to improve Work situations without throwing money at it Joe reference the on-call space that we have built out on campus We now have a couple of unique shifts that we're doing with some technical folks We have a radiology coverage from Friday Essentially at 5 p.m. Until Monday morning at 7 a.m. Or somebody is basically living in one of the apartments that we've built out and is essentially on call Has a certain amount of scheduled hours during the day over the weekend But it's on campus for the entire week and the reason we did that was we had a lot of pushback from radiology staff which I'm sure is commensurate with everybody else's experience where, you know, call on weekends is a downer and And you know with the weather and the weather having to pack up and get back into to take call for CT at 2 a.m. In the emergency room We felt like there was the need to be a better way to manage that so we built this weekend coverage model and The engagement in that department in particular was very strong in our engagement survey. We talked a little bit last year We're into playing stages of expanding respiratory therapy to three shifts fine because call is counter and So we figured we'd skin a cat a little bit differently We provide three shifts of respiratory therapy coverage And our hope was that some of the patients from our service area and other service areas around us Would be able to come and we'd be able to accept more admissions that we have not been able to accept in the past Because we did not have three shifts of What we found out is that that has paid for itself essentially during course this year and the employee satisfaction And that was for a third therapy department has gone up dramatically because again We don't have the ongoing call if a chance we ended up having to take a vent patient or a complicated patient Then people are more in doubles and it just really was not a good work experience So we've tried some other ways as well and just form money at things Joe's talked about primary care subsidy the ACO reserves and cost report impact is An issue that we're continuing to work through and to try to get to the bottom of that, but it is clearly an expect striver for projected 2019 and is built into our budget for 2020 Swing bed cost report issue There was an interpretation from Medicare and their contractors in reviewing cost report submissions That they wanted swing bed counted a certain way during that settlement process Our 2016 cost report was being audited earlier this year And they have changed their position on how they would like to settle that out for us It was about a three hundred ninety two thousand dollar hit and that is probably going to affect every critical access hospital in the Hampshire Vermont main and Will likely continue to be ongoing into the future so we've had to recognize that risk for 2017 19 and we've built that into our budget for 2020 Pharmacy inflation, I think you've heard enough of that so I won't belabor that And then one of the other interesting things is kind of one things. It's a good thing and it's a bad thing Move towards acuity Respiratory therapy that I just mentioned is probably the best example of that because we've been able to provide these services Our level of acuity has gone up this year and we're able to take patients They're a little bit more complicated than we were able to take previously because we have free shifts of coverage And so that's a good thing. It may cost us money. We had to pay for a third shift We weren't paying for but the flip side of that is that we were able to drop patients back to their home community for Those services and it's two three admissions a month. It's not large numbers But the other side of that coin for acuity is that is taking more resources outside of respiratory therapy, whether it's medications ancillary testing nursing coverage To to address the needs of those patients, but it is decompressing Dartmouth to a degree Which I think is good for all of us having patients in those cost-effective clinically-appropriate setting is always where we should be going And it's also provided some resources for some of the other regional hospitals Group purchasing again, you've probably heard this in nauseam over the last several years. So we are I mean every Month with leadership and materials management at Dartmouth We have weekly meetings and my staff participating with the Dartmouth staff and we leverage standardization of product group purchasing for capital and Utilized they actually have Boyars now that we can use within that department To better negotiate our contracts and make sure we're protected in any new decisions that we make And so that's gone very well. I mean we've we've done we do a really good job beating down pricing with some of the vendors and we just had a purchase we did two weeks ago that we beat them down from 350 to 290 and Considered that a huge win because it was below market and Dartmouth stepped in the last step and take a look at the contract and By the time they were done it was down to 250. So we've definitely received benefit of that and we're pretty good about Leveraging that relationship and their relationship with the vendors. So that's been a positive for really all the number of hospitals in the system System integration laboratory radiology benefit platform all these things we've talked about in the past and they're all still true last year we adopted the Biomed services from Dartmouth and that's been great the individual that we We have on site is there more often than our prior vendor and Actually considered part of our team And then as Joe referenced we still have shared staff management providers that We do with Dartmouth. The captive insurance and shadow captive stop loss So we are in the off-shore captive for liability through the Dartmouth-Hitchcock health system and Additionally, we've set up a program two years ago, which we're in our 30s actually now The shadow captive stop loss so we're able to raise our attachment point and Reduce our risk on our health insurance benefits across the system that's been very good for us as an institution and We have not only saved some money In fact, we just did a rebate check two weeks ago But we've also been able to avoid some of the market pressures of hardening markets And then we've lowered premium and been able to raise our attachment point That's all been positive the reconciliation for FY 19 going budget to projected some of the Key changes Counting for the change from what was approved to where we're coming in We've had an increase in gross revenue We can talk about that later slide, but we've had an increase in deductions from revenue Which is really driven by payor mix and the shadow payments in the ACO program That is offset by FPP fixed perspective payments that are Bulked in other operating revenue but for purposes of remount care board reporting are moved up Into into the deductions in that revenue area Health reform payments so that we get from one care that we utilize for care management of patients with a primary care Bad debt free care actually Went down From budget to projected We picked up about $40,000 in the final dish calculation, which wasn't available at the time of our submission of budget last year And then we've just got some little stuff and surrounding So that gets us from a budget to projected on that patient service revenue and on the other operating revenue side Really, we've got a great deal of grant income which Joe has Reference we've we're pretty aggressive especially when those funds are Speak to what we're trying to do with one care and medical home projects and whatnot So we've been a little more aggressive with that this year. We've seen a return on that and really we've had a big increase in three four and B and That's that's something again. It's good news for all of us As far as containing cost of reducing price increase, but it's a little bit scary They were becoming more and more dependent on Something that's not our core business Expenses we have a large week-class adaptive Historically Purchase labor just as a reminder one of the questions from staff, which was a new question was well if your staffing vacancy is getting lower And you're becoming more of a employer of choice Why was your purchase labor up and what we do every year? We say how many travelers do we have for nurses and whatever department and we estimate their workload in terms of But we take that differential between what it would cost to have as an employee and the cost of having this traveler And we put that amount in purchase labor. And so what happens earlier in this year? We did have some vacancies back in late fall early winter. And so we ran over that amount But we as this year has gone on we've we've trimmed that down and as Joe referenced earlier We have trimmed that down, but not I'm not only that we've been historically low Vacancy rate for our employees We've had an increase in salaries and fringe benefits Some of those salaries are people that we brought in at higher rates Then we would typically have had them in because of the market pressures that we're Experiencing some of those are expansion of services the biggest chunk out of that 500,000 is moving to three shifts in respiratory therapy and doing the radiology weekend coverage Fringe benefits are out. That's kind of actually been better the last few months since we submitted our budget and And So really that's about the only notable things there and then below the line This is where we're having the donations and Investments in the sale that are up. This is our historical net operating income budget actual chart and So you can see that we're looking to do a 1% in 2020 And we are projecting a loss For this year. Hopefully we'll be able to mitigate that over the next 30 days with some clarity on some reserve issues This is our cumulative. So, you know, how are we doing over time? Oh, we've kind of flat one. We went down with a huge trend of losses from 2007 through Really 2012 and then we kind of stay flat Since then with some very small margins This is kind of interesting last year we came in one of our key points was how much our New Hampshire business had grown from the prior year and and part of that was our swing bed utilization and being a major referral recipient from Dartmouth for sub-acute patients on both sides of the river And and and there was some other issues going on with some providers in New Hampshire We absorb that business so what we did this year was we looked at the same numbers compared to last year and Again, we've seen almost a 4% growth rate in New Hampshire Business Most notably more notably we looked at two quarters last last year to this year comparison and This we had a 25% increase in patient patient revenue from the Service area spring through the hospital and a 13% increase In the new Hampshire business. So that's pretty significant and really that's not because we have a super aggressive marketing program In fact, I'm one of the only CFOs who think we should actually spend more money in that area Seems I can't go up and down the highway for my job every day about here. There's about three other hospitals But so we're not really aggressively marketing. This is just what's happening organically within the region based on the having flow of available services Capital budget. So I'll use the word I use every year. We have the least sexy capital budget ever And so we do about four point five million dollar capital next year. There are no CONs for 2020 we should have already filed for that if we do But I will give it to the board a heads up that we are Trying to figure out a date to convert to the Dartmouth EMR and they're related supporting systems And so that will be coming up and that will be the CON level discussion We're still working through the details of how that would be rolled out and when but just so you know that that's hanging out there Historically we have been underfunded by capital. We have made great efforts over the last four or five years to Get to a normal rate of replacement to maintain our age of plant We're really just doing routine replacement. There's really what not anything that I would consider a strategic project Coming we are always energy efficient as Joe referenced earlier with any new technology that comes in we're always looking to leverage latest opportunity with energy star and Our biggest issue internally is bandwidth issues and that is do we have enough people to actually get the capital in place and So every year we fall short of our capital spend and An amount of money has to roll over into the next year and then we roll that into the Certain out into the following year, but that really is our biggest issue right now is getting the The time and effort Available with our main staff to implement new technology or upgrades This is our capital spending by department You can see that we're really focused as we are every year 1.2 million dollars in facilities Trying to get that easy facility up to speed And diagnostic imaging we have to make ongoing investments in that to stay current In information technology those are really our big three departments and again, we're talking about routine replacement for most of this Key capital items the biography unit a new generator for the main building and Replacing our telemetry unit, which we actually started this year, but it will not be in service until the next fiscal year roof talk replacements super exciting stuff and But you know you if the OR is running too humid or too hot. That's a problem So we've done a great. We've got a long-term project. It's probably gonna run out five more years to update and upgrade all of those more energy efficient and more effective Mechanical Long range finish a lot of looking plans continue to deepen our integration within DHH we're Starting next Tuesday the day after Labor Day We will be an integral part of the Dartmouth Hitchcock Health Transfer Center, so we'll be able to redirect Patients that are being referred into Dartmouth Hitchcock when they're at capacity We can bring in our docs and referrals office in real time to help these docs from other hospitals that either Can't care for a patient or the family's request to get closer to home or whatever the issue is Instead of just having Dartmouth Hitchcock and Cheshire Medical Center be the two main hospitals on transfer center calls will be In there as well, and it's a obviously a smaller slice of acuity that we can manage Because we don't have an ICU, but We've got a great hospitals program there. They want sicker more complex patients as do our nurses So there'll be more efforts around system capacity like that And of course regional service line planning. How do we you know, write size and coordinate care better in our three hospital? In our three hospitals of Southern Windsor County and Southern County, New Hampshire We'll continue to run lean and manage expenses As I was on a conference call yesterday was with The Dartmouth Hitchcock Health COO. I said, you know, we're still counting papercliffs and looking under couch cushions So we need this formulary plan and PBM plan to start Bearing some fruit for us We'll continue when able to push our Our wages and benefits to market levels at some point Sooner rather than later, we will move to the Dartmouth Hitchcock Health platform in HR and in benefits I was in a question I think that was asked last year about our self-insured program and not being in one care and that that continues to be the reason why We're not there. We're we're on the glide path. It's a shallow one right now, but it is coming and we'll continue to Improve our recruitment and retention, although we again as our three hospitals work closer together we're gonna have to be more More broadly focused for recruitment and retention for our region as opposed just to Moscow hospital And again, we will reduce pricing of services to better rely with market where we are outliers a real benefit of our one-care engagement as we get HSA evaluation reports and I review them in detail with the folks at one care To make sure that we're not falling outside of predictability What I can't say through the first three to four months in 19 the Windsor HSA is the lowest cost I have the lowest Costs for our attributed lives in both Medicaid and Medicare on the total cost of care Windsor HSA we're staying below our historical 3.5 percent target However our limited experience in 2019 and the lack of claims data has really made it Difficult to not impossible to know where we are financially right now Dave has not had the ability to run an interim cost report because we don't have cleaned out And that I know is Horrible for Dave and the rest of our finance team to be this late in the year and You know planning a soft close in a month and a half and not knowing where we are because of Double payments from Medicare Uncertainty around the cost report it is not a place that we like to be in a really different spot than we've been the last few years But some of our strategies to control the cost of care again continue around care coordination We've hired another social worker Into our clinic to help with complex care management We've been working closely with one care so that we Not I wouldn't say provide incentives to use care navigator But to make the use of care navigator easier easier for our providers and our nurses I'm acutely sensitive to the need for providers and nurses to leave our Comprehensive EMR and go into another EMR to document the work that we're doing There's just not enough bandwidth and the claim to do that that said Like Dave we are throwing a little bit of money at this problem We're going to hire a community health worker whose job may honestly just be transcription of care planning from our EMR Over to care navigator, but that's that's what we need to do especially with new payment models In one care starting in 2020 and as I mentioned before we're adding three docs in primary care I believe that in care management We will lower costs in the long term with better primary care and keeping folks out of EDs and ICUs And this slide That's it we have Bonus slides if needed, but we'll leave it at that one Super thank you. We're going to start the questioning with board member Holtz Thank you So first of all So actually I want to start I want to understand a little bit better the relationship actually between Dartmouth Hitchcock and What we've seen over the my time at the board even the last couple weeks of hearings is that The hospitals that have some affiliation have some ability to share services breadfix costs are doing better And it sounds like a lot that you describe the integration Affiliation has been successful on many levels and there's continued work to be done with moving HR or those things but let me just ask you I noted in the narrative the Emphasis by Dartmouth Hitchcock to help you the importance that you reach a 1% margin and I want to understand better How Dartmouth Hitchcock is helping you do that besides some of the cost savings? So for example, you talked about 1415 post-acute You know referrals from Dartmouth and the 5100 referrals from Dartmouth overall Can you tell me if those referrals are high-margin referrals low-margin referrals? I mean of those at these referrals actually helping your bottom line keeping it the same So Dave and I will tag team on this one. It's a it's a mix our acute rehabilitation referrals are higher-margin referrals for us Swing not so much We and we also have a third track and these are the folks that are languishing in DH without a payer without a disposition plan That we agree to take down to free up a tertiary care bed in Lebanon and Davis worked on a daily rate that we then just build our Directly for the system directly for Tremorses for that care and that is a rate, you know between swing and Medicaid reimbursement I would say but David give it probably a sharper answer there Yeah, so the rate is between a nursing home rate and a sniff rate and I Wanted to be overly detailed with Dartmouth and build them according to the level of care that the Patient was receiving and they said no, just take the two blend them together We're gonna pay so a few years ago we came here and this was kind of kind of evolving and So we had talked about a system allocation payment of approximately one two million dollars It went below the line as we again, we're trying to figure out where services were going to go with it not only the system but the region and so we we signed up for that and And so the first year was kind of like okay this we're gonna pay you and it's gonna cover these patients And we'll figure it out. But what's happened is we've gotten pretty good at what we call outstationing or in people coverage Whether it's through the Medicaid program or the exchange or whatnot. And so we've been able to get people covered And so anybody who's not covered and comes from Dartmouth We still bill them for that rate that has your reference And so now we're seeing a little bit of a change in Mix of patients we're getting because we're actually getting some cute to cute transfers from Dartmouth now Which you know, again, we're very high Medicare and And it's a financial Medicaid. So let's just say 60% of our business is paid at below cost And so, you know, I don't know we have a lot of margin business period We have a very slow or so we're not getting a lot of that. So, you know, we're really looking, you know, I don't think That a 1% expectation from Dartmouth is unreasonable on Operations, I think that somewhere is the vicinity of two two and a half is what a CAA should be able to pull off But again, we're still working through these allocations of services within the region And I think we've gotten better and we're not receiving that subsidy anymore. We've learned to kind of make things work And so we were hopeful that I will continue Thank you. That's helpful. As a follow-up to that, you mentioned in the narrative and briefly here that you've beat the financial targets for domestic care Care, we've had your hospital, but where you owed money was in the non-domestic care And I'm imagining a lot of that non-domestic care is actually occurring in Dartmouth HCAP But maybe not all of it, but you specifically reference the Family practice that's sending a lot of their patients to Dartmouth HCAP and that was Potentially problematic for you. So I guess I'm also wondering what that backstop looks like if you're doing well managing the care that you can control But some of the care is going throughout the HCAP and you're still trying to make the bottom line Can you help me figure that out? Well, if I could, I probably would be here I'd be on the road consulting somewhere or teaching But that's I think you know we had a reference in the slides about you know I call threading the needle of getting 1% for Dartmouth staying within the growth rates of the Green Mountain Care Board Putting up a margin for our board expects us to be able to stand on our own and to Build our balance sheet and then looking at the one care and so That's it's really difficult. It's it's nearly impossible. I think we came pretty close this year I think we did a pretty good job on that, but to your point Once somebody leaves the friendly confines of Mount of Scotney whether especially to Medicare or Medicaid ACO patient tribute in life. I mean we really the patient that Joe referenced is down in Boston for 10 days To some degree that's truly non-domestic care I look at care at Dartmouth Hitchcock coming out of a Mount of Scotney hospital is Not quite non-domestic care to the extent that you're affiliated with Dartmouth Hitchcock So I I don't know how that all works with the facts happening. I get the Boston patient completely out of your control Well, you're going to replace that. This is this is their rate structure. This is their their tertiary care You know protocol that this is what that patient needs it and so we really there's really not much even Dartmouth can do They can just render the care So maybe I'll try answering this way so essentially the system all-member hospitals You know we have a consolidated balance sheet. We have a functionally consolidated P&L everything's Consolidated by definition. We're back stops We no longer need our own credit rating up that small hospitals necessarily have one But we're not reviewed in the credit market our lending is done As part of Dartmouth's financing planning and so You know we have the cash at the end of the day that we would have for a margin because there was actually that asset Transfer then Then that's that's what we have we have a position the financial position to still invest in capital and do the things we need to do Regardless of how the P&L works Thank you I was encouraged to see that slide 16 that had the regional planning with the three critical access hospitals because we recognize there's three critical access hospitals within 20 minutes of each other and so I'm very encouraged to hear that The three present CEOs or leaders of that those organizations are getting together to figure out care delivery optimization in our region and I'm hoping that Duplicate of services will be reduced and living I'm going to talk a little bit about how optimistic you are that this is actually going to materialize in the next 12 to 18 months Some sort of regionalization of service delivery. Sure I don't I don't think we have 12 to 18 months. I think that's that's too long of a timeline So so there's there's there's time pressure to get something moving. You know, we also have two of the three hospitals have CEOs that are either interim or or higher management firm I'm sure I'm looking for significantly extended time in those roles in fact the Valley Regional interim CEO is one of our board members, so and So I Am cautiously optimistic Dave is on the working group as well to Provide a financial voice. We are getting outside health as well. There are fish cut health is Also at the table and helping us work through this because this is a this is a tough problem And eventually we will get to the difficult decisions of who does what and where and that's that's any system coming together I've counseled folks the same way that We've shepherded ourselves through the darn fish cock affiliation as you each institution has to look inward and and then and to determine who they think they are and then Then we kind of all have to agree that coming together. This is who we think we're going to be really be the one issue that is You know the sacred is every every community must have robust and vibrant primary care And good local options for primary care, but beyond that frankly, I think everything should should be on on the table We have limited resources or a limited number of surgeons and specialists who provide the care now if that means we have to Come up with significant transportation solutions to help people move into communities It's not like we are dealing with communities of Weston Wellesley and you know some other I mean we're our folks have a heavy pair mix of Medicare and Medicaid and we need to make sure we serve them in Transportation between communities can be owners for them. So we have to we've got a lot of irons in the fire We have commitment from all three organizations to make this work. I wish we had 12 to 18 months But we don't Have Yeah, I'm comfortable saying that we have been working closely with Valley Region for at least the last Year plus in fact even a few years ago looked at bringing our organizations closer together. Just didn't make sense at the time But Springfield issues, you know jump to the head of line sometimes I think One of the things I've experienced over 30 years in health care is we have a lot of these discussions Oh, you know that they kind of cycle through and Nobody's willing to give up anything at the end of the day And nobody's willing to take the leap this situation is a little bit different because we have two hospitals that are not in a good place and So I think the dynamics of this discussion are a little bit more reasonable I know Joe's very reasonable believe it or not I'm actually very reasonable and we are looking at shuffling things to the best possible place regardless of Because we're looking at it as total expense total cost total margin We're looking at it from that perspective What what let's make sure care doesn't leave the region just it just might be in a different building And I think the other nuance that I think is helpful in the situation is that Dartmouth is actually looking at What things they could solve with their operations by utilizing the capacity in these three smaller places appropriately And and so that's a dynamic That I don't think typically happens in these regional discussions where somebody else is saying hey We actually may be able to push some other services out. They're currently we keep inside of work We're compressed. So it's a win-win and I think that's one of the nuances. It's going to Hopefully make this thing work So let me can we talk about your PR so the MPR Request at seven point four percent budget to budget Six point five percent over projected. So whenever things are six point five percent over We worry about aspirational budget And then the expenses being As more angle probably talk about I don't want too much time to tell you what Maureen's gonna go through But I want to ask you about if you can give us a little bit more breakdown of where this is coming from So I recognize some of it may be coming from Springfield So this is NPR that exists already in the system that's basically being transferred if you could help us carve out a little bit I saw the 25% I think was that right in the slide, but Some of it may be coming from New Hampshire. It sounds like These new patients in the other hospitals have given us new patient Data to show that actually new volume coming in new patients coming in Is it coming from the three providers of primary care providers that you've added and help us to understand a little bit about where This volume is coming from because I get pieces of the story, but I'm not really getting the full story here And it's a big leap especially since it's a big leap over where you are even projected to be in 19 understood so this Chart that we actually provided it last year after our hearing because we had a similar but smaller discussion And this seemed to be well accepted. So we went back to this When we submitted our budget to see okay, this is past the straight face test for us and so Looking at the change from budget to budget. That's what we're talking about here. We have patient service revenue increase of 3.8 million year to year and So that's a 7.4 percent increase year a year and so 3.5 percent is what we were allowed. So if you take that off, we get down to 2 million out of that remaining 2 million 525,000 Was is the hand is associated with folks coming from New Hampshire now whether that's a referral from Dartmouth? because it's the services aren't available or Something going on our Valley Regional. I mean Joe can speak to those service lines Better than I can But that's the increase that we're seeing based on current Trend and then other out of state is kind of negligible. It's leaf deepers, right? So and Skeers and then we we've got 282,000 at the time of budget that we That we had seen moving from the Springfield HSI to ours and so that brings us down to about 1.2 million dollar growth and really the other 1.2 million dollars is what we're Essentially using you know to guard against these some of these ACO issues were still working through and Joe and I talked I mean we talked in nauseam about this, I mean it's we talk about this literally every other day and in one of the things that we decided on when we submitted our budget, so July 1st was if we're able to Clean up some of these things with the ACO and get to clean numbers where we can really understand where we are and We can alleviate the cost report pressure that we're feeling currently we would be happy to revise our price increase and the gross net revenue and deductions to to remove That million dollars, which is really the boat you were looking at and if you look at the 1.2 million dollars Yeah, we're going that patient service revenue net patient service 600,000 is our 1% margin right so So we're really at the end of the day looking at $500,000 That we're associating with the ACO risk at this point based on our current understanding and resources So If you go back to the slide that Showed the Q3 to Q3 Q3 quarter three comparison. Yes. Sorry. I'm losing my voice But it in your answer to Jess she was basically pinpointing the fact that what your projections are for the end of this year and I'm assuming that this Q3 Shift the 25% of Springfield 13% from the Hampshire is Already being seen in the projections So I'm curious obviously you might not have seen much Earlier in this budget year from Springfield But what has been the shift from the Hampshire in the initial quarters of the existing year? Q1 and Q2 from the Hampshire and what makes you think it's going to shift even more? Because it's really a three-year trend for the New Hampshire the Springfields a new issue, right? But the steady trend that the steady growth. Yes That's what we spent time on last year as well Is that New Hampshire when we ran all our data was what's going on here? And then we decided to do a study by zip code patient had your zip code and that's where we found that New Hampshire was burgeoning in our shop and so we did this as part up front. We actually ran this Early in the budget process to make sure that we could see what was going on and how that was changing from year to year And what you can see from this slide is Going year to year the change is 13% positive for the Hampshire in other words We have 13% more New Hampshire business Measured in that quarter versus the prior quarter, which is what we used to submit our budget last year. Does that make sense? Yeah, so I'm assuming that most of that is probably in the rehab, right? No, it's it's perfect. It's primary care. It's swing bed. It's rehab It's it's we don't have a lot of surgical business by some of our surgical practices. We're seeing it And some of our ancillary services And is there sufficient capacity left to meet a continued turn like that? Yeah, actually there is and we looked at that when we develop our FTE model for the upcoming year Looking at what we're running at now. So one of the discussions we had I don't know if it was last year's budget hearing or maybe the reimbursement Presentation that Joe and I did we talked about the percentage of fixed costs that a critical access hospital has which is arguably 75 80% You know, you have to have somebody in that seat 24 hours a day whether anybody comes in or not You can't have less than one person and so there are a number of departments that in taking this business in We're just filling up. What's the existing capacity better? Okay Okay That's basically everything that is not above and what we needed to put a 1% margin down We needed that much in that patient service revenue growth To get to the 1% margin Well It's tied to so when we budget we say, okay, what do we need to do for a budget? Dartmouth says we'd like to have 1% our board says 2% you guys say you're limited with net patient service revenue growth You know, and we got one care cost goals. So We say, okay, we're gonna try to get to the 1% that's our goal. And so we figure out how busy we're gonna be we take The necessary expenses FTEs paperclips whatever and we determine how much it costs in Stuff and people to deliver that volume and then we look at our contractual rates our reimbursement rates historically and We back into the necessary price increase to get us to that 1% margin with the infrastructure that we need to deliver And so that's that's that's how we That's how that's how we're doing it. So in order to cover The risk that we perceive in the ACO and put 1% margin. That's kind of what we're talking about for 1.2 million But we always start with the end in mind and work backwards and the last thing we put into our model is The price increase which does have an effect on that patient service So I would add just as quickly so again three new primary care dogs We're I'd say it's in the 1.2 I mean, these are these are folks whom are gonna we're gonna build their practice over the next year. No, no new doc comes on And sees 15 16 patients in a day. We're all Walk orienting them slowly into our clinics. There are ongoing discussions at the system level or out other service lines That began are driven by community need and also capacity needs and You know, they're they're operating rooms are burgeoning for example, do they need to set Surgeon cases so that they can serve their their patients better. We have capacity in our OR So I think that there's the potential For revenue growth there by the discussions are truly embryonic at this point So not anything that we're comfortable budgeting for this time Sometimes we receive new services and providers from DH very quickly other times it can take the year or so to arrange for a day a week of a specialist You know, I said as I mentioned earlier that we have at least a thousand maybe 1500 patients that we need to bring Back into our system that they have been kind of waiting In the weeds until we had new primary care dogs so that that infusion I think will help us Next year when you're presenting it helps us I think to think about where is the growth coming from and if you can partition it from volume Separating it from price and recognize the price increase is going to have a contribution to the PR Where is the volume coming from it sounds like some of this spring field Or some of it may be coming from patients that have not been Seeing a primary provider now will that would be a helpful way for us to think about it I don't want to be the force on that But more you might go I I Couple one well actually a quick question. There's a big jump in Medicaid in particular Projections can you just talk a little bit about that it was as part of a big shift Now patient revenue So, you know, there's a little bit in there, you know, a couple tens of thousands that are associated with Medicare increase We were forwarded July 1st and and then there also was some increase in the patient population I think part of the other thing is we're trying to get to these chronic care patients and Some of these folks in the ACO and trying to get them in and we're seeing the effect of that in our project this year We expect that to continue and possibly grow more preventative care versus episodic Be happy to look at that On this I Will add that one of my goals in 20 is to deepen the relationship between My spending hospital in the health center and what we were filming practice since all those contributed Medicare and Medicaid lives So weird word for the for the downside risk there so a lot of our Our current Medicaid attributed lives are coming from them So we need to find a way to better serve them and that maybe work around the ancillaries and such I don't think it's enough to double what we expect. So we need to do a deeper dive on that Narrative there was reference to a cost report uncertainty Million dollars do not count in the tribute of lives that you then have to recognize the 2020 budget Can you speak to this because I thought my understanding was that Cost report now there's more understanding about how to do the medical cost reports With how we kind of should be lives. I'm not an expert on this But you speak to that a little bit and how I think that some of that information has come out recently before your budget Well, it's after your budget was submitted how that impacts your budget so a couple things so Way back early this spring We went we went over a visit with Porter and talk because they were in the process of settling out 2018 for Medicare and Jen Bertrand and her folks great people we went through what do you mean and In the discussion there. She says well, how do you think this should be filed and I said based on my understanding of regs That these attributed lives Should be handled in the cost report like a Medicare Part C patient Where they're considered in the calculation of cost per day or cost per charge ratio for outpatient services but they are not included in the settlement process and And so she she that that's what we've been so I say great great minds, you know And so when they filed their cost report Very done their their firm that they use Agreed with that and so they filed it that way And then when we started doing it as part of our budget process There were two aspects of it one there was no clear Reg that spoke to this and the only example that we could compare it to would be part C people so I went out and talked to our firm as well as two national firms who've seen stuff all over the country and The consensus was they should be carved out So, you know and these were questions that we've I've been asking for four years like this. They're clear. We can get some position on this So as I tell as I told our board members we will be labored through this discussion I can file my taxes at the end of the year and tell the IRS I'm entitled to a million dollars But that doesn't mean I filed my taxes correctly or that they're grant actually paid me a million So as we we try to pull this together as part of our normal budget process to an interim cost report We realized that the PSNR Which is basically a reimbursement report with Medicare shows they paid on what patient for what service during a given period There was the shadow payments were not reflected For the first quarter We found out that they were paying us fee for service When they should we should have been getting that in the fixed payments or we're getting it in both So we really couldn't even estimate Medicare side of the settlement process so we went back into the cost for what started talking to everybody and Determined again that there is there's no clear direction On how to file this now everybody wants us to be able to include that cost in the settlement We do one care does see in the mind. Thanks. It should be included The there was an email that came out approximately a month ago. I believe they said yeah You should be able to do that basically I'm paraphrasing and and so I went back to great Show me where that is because the only thing that matters to me is regs You know because that thing is not going to be audited for three years And so I need to be able to go back and say I was directed that this is how this is to be filed and To date CMS says yes, you should be able to but I still don't have a document and the People who I really trust the industry are saying no so I I'm I have an aspiration That this will all be resolved and we will get a clean PSNR and be able to generate a cost report with reds That support our action and that million-dollar issue which again is an estimate We don't even we really couldn't even get to a really solid number like we usually can I can get to the penny on this thing Normally, but I can't you know, well, this is our best guess Does that help? Well as I referenced earlier I would that million dollars or most of it would go by that discussion and that would that would come with me going all the way back to the rate increase and reducing that so Reducing what we would be leveraging the commercial payers for generally right and so we would Make most of that go away and we've been talking about we're totally open to doing that But based on everything that we have for documentation, I would never get to want it Taking a different position Thank you helpful. I guess my last question that I've asked every hospital, but I think I have the answer to you for you is Yeah, the HDA question was the ratio of commercial to Medicare you reported that it was 1.3 So can I assume that on average Medicare pays a hundred dollars for a service your commercials payers on average $130 Thank you First great question is just a bunch of those that were similar I do want to spend a bit of time on the net patient revenue and Really kind of going back From the past three years and just kind of understanding some of the one-time things that go out in person I say I totally appreciate that there's a lot of new things happening You know with the ACO and with double payments and things like that. And so, you know, I think it's very challenging So I'm trying to just for myself really go back through and understand which years were impacted Any changes would be so I know I think the first one was 2018 which If you go back to one slide to your budget compliance slide Actually on your NPR you were quite quite high you came in at 4.4 percent above right for NPR, so But part of that year you talked about double payments At the time and just want to understand did those double payments from Medicare get Registered and then later on you're giving them back. I mean I understand it's kind of a year over a year piece But this is the first question is this in 2018. Do you think there are any one-time things that may be artificially? Inflated your NPR, which we're then adjusting for in 19 or 20 off the top of my head I would say no, we didn't have double payments in 18. We've had that 2019 Program for the ACO, but off the I mean I'm looking at Theresa. I don't remember any Any one one get wonder from 2018 But I'm happy to go back and take a look at it And then the other thing you did talk about is the swing bed piece which I think you said record was Reconciling like for three years like 1718 and 19 and were there any one-time impacts of that in 19? adjusting for the prior years then There's been incremental we did figure out a way to mitigate the effect of that and the net hit that we're taking is built into the 2020 budget and We're accruing for it as this year goes along So why would the net hit be 2020 instead of 2019 if we know about it now? Yeah, we're we're accruing for it this year as we go along So it's in both We haven't realized the full amount And then going to your reconciliation had for The NPR justification So the challenge there is you also provided a bridge which we don't have up here Which I understand here you're saying okay We get the three and a half percent and then we have this extra number down here and when you did your bridge chart for For this you took the 51195 which was your starting point for 19 and you went to the 55 and you actually have the commercial rate is 1376 So that's pretty clear. That's part of it. That would be The utilization was 4.8 million which is up 9% and then some of the offsets to that are Other a co-reserves which is about two million dollars one hundred seventy five, which is four percent. So the challenge here is really Understanding what that nine percent utilization changes you're you're showing about the eight twenty eight You know million dollars of it, but the change you put here is four point eight million And so there's an additional four million So just the fact of saying I get to go to three and a half percent as a target and then I have these other issues I think you know There's still a struggle to get to what's building up that you additional utilization What's building up that four point eight and I also will say that's against Budget and against projection it could be different, but your budget and projection are pretty close In this case, you know, you're coming in Pretty close to your budget for the year So it may have to be a follow-up But can you or can you talk to what that nine percent utilization changes from budget? Well, I think a lot of it is in the volume numbers that you did for projected 2019 you can see where or some of that is and That that's part of that jump The other part of it is some of these things that we're experiencing right now during 2019 the growth from the Springfield service area the growth from the answer service area The growth of acuity within our organization and I'm happy to be honest with you We really struggle with the bridges the bridges presentation We don't think like that That's not how we we cut And divide up business and so I know we struggled with it last year It was less of a struggle this year And but I'm happy to go back and do whatever is needed on there to make it more clear because this Slide this up on the screen now clearly doesn't cut the way the bridge cuts. No And I think even if you take it projection your projection is 51 639 and you're going to 55007 In both of those years you have a reserve for the ACO so the net change of those is about a 700,000 increase year-over-year, so I mean that that to me is an additional NPR before you get to the reserves because You you very well could hit the numbers exactly dead-on right and then you're projecting In 2020 about a two million dollar reserve for the ACL for a hundred percent of the downside risk But could go the other way right you could get two million favorable and separate to that I always have had a little bit of an issue of this affecting NPR because your underlying gross business is going up higher and then this this change for the reserve is Has nothing to do with Utilization right now It just has to do really what you'll have to pay for those patients who might be receiving their care Outside of your area and the rest so you absolutely have the rest But you actually have a higher Year-over-year change in NPR when you adjust for just the impact of the reserves Yeah, and you know one of the things that you know can Jonah talk to Don's even out is We're taking the most To go to kind of go over these reserves because in theory I Would agree that we're over-reserving The key standard is is it probable and is it estimateable and right now for us neither of those can be accomplished And so again as some of these issues are cleaned up then I'm happy to go back and revisit and I think that We'd like to all separate that risk from you know Then that patient growth discussion, but you can't they're they're they're they're dovetail and so And it was very it was very hard to us to to go through this process and come up with what we thought we could stand on and You know, I'm happy if we have to revise it will not happy But I'm feeling I'm willing to do the additional budget work Even if it were, you know, in the middle of October if we're still languishing some of these issues I'm happy to do that Joe knows this and folks have been here a while. I don't come in with made-up numbers This is as close to made-up numbers as I've ever presented anything here ever all the way back to Bishka days You know because we're so uncertain. We can't even our own internal modeling We can't get to the number. This is the first time in literally 20 years That at this point of the year. I have no idea how I'm going to really finish You know you're highlighting, you know, one of the big challenges with the reserves and I know we're all learning in this and it's interesting because you know the Hospitals are running the spectrum on how they're accounting for that I would say you're on the most conservative side Which is budgeting a hundred percent each year because the chance of a risk of losing all three payers a hundred percent You know to the downside two years in a row It's probably fairly significant and I understand what you're saying with probable and estimatable But when you're given the estimate from the ACL if you believe there's a fifty percent You could be down and a fifty percent you could be up and the probable Estimatable year over year is not the downside a hundred percent and what we're seeing with some of the hospitals now is You booked the hundred percent the first year because who the heck knows what's gonna happen and then when you get to the second year They're adjusting to kind of say okay. I'm gonna book Some said seventy five percent of the total some said fifty five percent fifty percent of the total some have said, you know None because they're gonna backstop and and you know, you guys did talk a little bit about a backstop from Dartmouth Which you know many of the other hospitals don't have but if there's such a backstop then you know and as we learn Sometime in 2020 we'll have a resolution for what happened in 19 You know at least directionally what's going on with 19 and then 20 will still be out there, so I Don't know what the right answer is for sure And I understand what you're saying your auditors are saying I've also dealt with a lot of auditors and you can talk to them about things and say look We did a hundred percent this year. We're not going to do a hundred percent second year So and I agree. I don't disagree with anything you just said at all but We had we did not even have 2019 budget Well, we came here last year for and we kind of we signed up in good faith, right? And so we're we don't have a history our history started January 1st and our history started with double payments right and and so It is literally impossible for us to parse this data out To open in a way that we feel comfortable for you about the auditors And so we're we have no history We've spent so much time working on this that we really haven't had a chance to go back and look at the baseline data For the model that estimated the risk from one care Vermont It's fine as far as I know But I don't know if that was people were just healthy that year or those three thousand attributed life were healthy in the Days here compared to normal years. I have no idea So we have taken a very conservative position I would be happy to back off that position and for the good of everybody But we just really didn't feel like we could do that But you know, we did this our budget had to be done for us by June 5th in order to meet the Dartmouth guidelines Submission guidelines so we can get their approval to send the budget here July 1st and in doing so You know, we really only had three months of data And we had you experience the full lag of the Medicare and Medicaid claims coming through the one care system Yeah, which is nobody's fault. That's just the timing of the data So I mean we really went into this thing fairly blind And the magnitude for your hospital is so significant that that won not the two million dollars that you're reserving for the ACL risk in 2020 is about three and a half percent And so therefore when you're targeting a one percent operating margin and a half in that and then there's another million potentially within You know the issue you may resolve with with Well, I mean it's pretty big spring swing items and then looking at it's not obviously a one-for-one But looking at your commercial rate ask of you know 1.3 million in total 1.4 You know, that's if some of these other things were dropping to the bottom line Absolutely, you'd be able to decide which lever do you pull and that may be the lever you don't need to pull So it's it's a challenge for us as well as the other piece of it is are you even going to get to this NPR to begin with and You know, I mean really a nine percent utilization change once you adjust for all these one-time things that are It's pretty significant. And if you don't hit that then you're not going to hit your bottom line either. So I mean It's a struggle we're going through as well And I don't know what the answer, but I do think there will be some follow-ups about you know, how do we look at it? Yeah, and I want to reiterate that we are fully committed to as much revision as necessary Certainly, there'll be downward pressure on NPS As we answer these questions as we get more firm answers around Again, the cost report and I remain optimistic that's going to be sorted out and as we put more Put a little more thought to what are being in a larger health system means around Downside risk you know, I Don't know how any critical access hospital could go into the Medicare program if they weren't part of a larger health system with deeper pockets I really think it's a struggle when you just you look at your budget and you say Yeah, it's unlikely that we're gonna Max out our downside risk, but if we went halfway there 1.1 million That's you know, that's the margin And our board really struggled With that we still do have an independent board with that has some DH appointees on it But even the DH appointees we're very concerned about their responsibilities you know, I think we've We've leveraged as much as we can at CMS, CMI, pre-month care board, one care They're going to try to help leadership to To convince both our senior leadership team in our board that this is the right thing to do and as a physician again You know an internist this is the right model is the right thing to do But if booking downside risk compares our ability to give a market raise to our housekeepers That that's a real balancing act that's that's kind of the the boots on the ground What does this mean to the to the institution? What's a rounding error for a larger place is you know, it is Unfortunately, you know This year, I don't know how I'll handle this, you know, but next year You'll know what's going on and you know if all this were to ride through this year, for example We just said, okay, let's let's let it roll. Let's see what happens the next year You know, should there be an understanding of a settlement for 19 and and not needing them to book it You know the expectation would be you know, how can we potentially give some of that back? Yeah, I think as we grow our experience at this time next year I know that I'm hoping that that the Greenmont care board gives Reserve guidance risk reserve guidance in the same sense that we get our NPSR growth guidance Well, we'll have the experience to actually make now the problem is we'll have the experience of only a couple Real critical a couple of critical access hospitals that are part of a larger system So it's going to be easier for us to go. Oh, yeah, sure. We can do that I think it's still going to be a struggle for the smaller hospitals to jump in and you know to be honest It's it's it's hard for each hospital to do it individually and you know for us to try to give that reserve guidance On top of what your auditors are going to also be telling you and instructing you to do is a challenge I think I think we need to just find a band of reasonableness when the dust settles That we can all live with and I think that's really really where we need to go But at the end of the day or for this health care reform Program to work it needs to be doable for every hospital on its own And really the system discussion while we support that You know at the end of the day You know any hospital participating they should have a fair reasonable chance to at least break even on this thing, right? so You know the system allocation payments and things like that to me Fly a little bit in the face of this should just be a good program and should work clinically and financially and otherwise That's what we should all be shooting and again, we're all figuring out as we go along There's really the experience for critical access hospitals in Springfield. We had a difficult year regardless of the last year And Porter who's had filed one thing but they now refiling their cost report because of these issues and us and we've You know we've been at six minutes, so It's it's a really awkward It's like I'm 13 again I think that we are all learning I think the hospitals are learning I think the ACO is learning I think the board is learning how we deal with all this and I think that there's even some Reimagining happening at the ACO level of how do you portion that risk? And so I think we're gonna learn a lot more and so we all need to be patient with each other I'm upset. Thanks. Jeff. Well, though just covered by other questions about Swing beds and Thank you. Good Tom members that were thinking alike that Probably could have designated one of us to ask these questions. I to look forward to clarification I can look at This document that's that's on the screen and see that you know that the two line items allowed 3.5% NPSR growth and the other NPSR growth and up to 2.98 million, which is 78% of the Delta in between the year But it's really not an expressive that well specified. So when I go to bridges to see how things move, you know, I can see the kind of That we're all kind of struggling through in terms of movements from reimbursement to other ACO reserves to other FFP so you know, I kind of went to the Kind of the major columns and I look at the chart you have there and see that Medicaid out of state moved from 345,000 to 835,000 which is a 41% increase then thinking okay, well, maybe that's New Hampshire You're coming over and then looking at the Vermont Medicaid number going from 1.5 Million to 3.2 million. That's a 115% increase, which is a big number and and then looking over at commercial going down from 20 million to 19.7 million and I think cost shift, you know, you're you've got an increase in Medicaid and a decrease in commercial And so how does that relate to the cost shift? I think this horse has been beaten enough and And I'll move on. I do kind of want to get maybe your insight into How you feel the transition so under the all-pair model Might affect the cost shift one way or another Well, I think if the experience is unfavorable after all Which is not what 2018 came out to be as I understand it from the folks who participated At least two of the programs in 2018 if that experience is unfavorable it grows the cross the cost Cautious is a seesaw You you you can't push down on one side without the other side going up. It's it's inherent so You know, I think, you know, if we do well in this program by containing costs to render care and And we do well against the medical expense targets for the system and we're rewarded for that And that takes pressure off the cost your provider tax increase going from 1.7 million in 2018 to 2020 which is a 14% increase over the two-year period is Is that what's the basis for that calculation? It's the basis that they use to calculate the provider tax So we finish our budget we look at the net revenues that are included in that tax multiply by the 6% max So Just pull off a second Tom, could you repeat the question? I'm just wondering if My understanding is that some hospitals have received a number based on prior your Audit Financial States as to what what to expect for a provider tax number So but this is you're just applying the 6% rate Yeah, we're using the same methodology that Diva would use and we've just applied it to our budget projection I've wondered as I listen to these hearings people talk about the Thinking about just this question in terms of if a Medicare payment was a hundred dollars What would the commercial payment be and what would the Medicaid payment be and so it's from my ages people Portion of folks will be moving out of Medicare as their primary source of insurance Into out of Medicaid as their primary source of insurance and into Medicare and is that is that a? Substantial migration in terms of pay or mix So you're correct that if folks left the Medicaid program and went into the Medicare program Our reimbursement as a percentage of charge would improve and for a critical access hospital That would probably be diminished by cost per unit going down So the answer would be somewhere between where we are and where we would be that makes sense And just a side note that's a depressing future if we have a Substantial amount of remoders who transition their primary payer from Medicaid to Medicare I think that's a that's a larger statewide non-healthcare issue that we need to we need to address that That's not a sustainable model for statehood. I would say if everyone's un-medicated waiting to get to Medicare One thing I noticed in your bad debt presentation in the appendix that You sent in 2018 1.5 million to a collections And a recovery of four hundred ninety six thousand dollars And I know that the appendix was not you know subject to great artists But those were the numbers that that you sent us which is a very very high collection rate among the other relative to the other Submissions and I'm just wondering In your awareness of your bad debt Financial aid program and other hospitals whether or not you do things that are different than your peers well, we all think we're special and We we have When I got down the amount of scouting I had a lot of preconceived Concepts of how financial counseling free care and that debt should be administered and I actually they had a very very Program, so I really did next to nothing We have an excellent financial counseling program Whatever we call outstationing in people on Medicaid exchange Our days they are fairly low compared to industry average and I actually came out of the collection agency industry 30 years ago don't hold that against me One of the the metrics we used to use back then is you lose 10% of recovery every month on Southpay dollars and so if you wait 30 days to bill you just watch 10% doing nothing and so Because we tend to operate gross days around 36 38 39 rain that range there I think part of the benefits we're seeing that That we're getting to that that person a little bit earlier and reducing that erosion as one thing The second thing is once you have a consistent process in place and you stick with it quite frankly folks are Trained sounds like a horrible word, but they understand that's the process and they work with it and the last thing is you know, I had a similar experience at Gifford for for many years and Folks around here pay your bills and so I can't talk about what's going on in Newport or St. John's barrier or wherever, but we keep our Southpay and financial counseling people busy taking phone calls and working through issues So I think we've got I like I don't even mess with it anymore I just left the thing run because I'm just gonna mess it up. It works really well right now We have payment arrangements that we extend the people. I don't know if that's any better or worse than any other organization, but We've provided some different ways to encourage people to pay and make it easy for them to pay So I'll take credit for that one, too I think that's it for me okay Robin clarifying questions I Was I just wanted to clarify one of your answers to the questions about the 1% change in charge and so you indicated The that your calculation and our staff calculation was about the same at 430 but the value of the charge increase was 202,000 and then is that because about 12% of your reimbursement is charge-based is that the difference between that gross number and the value number that you included the only question that I can think of from from the materials was what was What's your calculation of a 1% the net value of a 1% increase versus three mount care boards And the answer that I recall on my head was that the difference was the consideration for a dish Is that the question you're referring to yes Increase in charge request is equal to two hundred and two k. Yes So that would be the net value of 1% Because 12% of your reimbursement is charges as opposed to other fee schedules and stuff like that I'm just trying to get it to live We get charges on next to nothing every day we get a reduction on all of our all of our buildings. So But yeah, that's what's left over. Yeah, okay, but I just want to make sure I was understanding the how the math works I was also noticing in The one care reports about the total cost of care that well as you said your Overall total cost of care is quite low that you were on the higher side for advanced imaging And I was curious if that was really you or that was really more driven by DH or It's both The most prolific Order of advanced imaging in our HSA is one of our internists He's also the only 1.0 FTE internist with the largest patient panel. So some of it does track But the the docs at white group family practice are contributing to that as well I had a long discussion about the utilization disparities with Megan Johnson from one care 101 walking through the data and It's still at the end of the day talking about there's small numbers The hand the end is pretty small of the actual number. It's like talking about their relative risk reduction versus the absolute risk reduction And so it's I think it's under double digits Difference that said it is something to stay on the radar screen. I will admit to having Increased anxiety as I looked at the outliers until I saw what our net overall cost was as well nobody's perfect, but Doing well so far, but again three months of data could swing wildly in the next night I Wanted to just return to the discussion that just had with you around the regional planning and I'm also excited to hear about How that's going is you know, I'm Charing the rural health services task force and I and we're charged with looking at hospital sustainability As well as other healthcare systems sustainability in Vermont And so I'll be very interested to hear more about how that's going I was curious to know whether at some point you were thinking about including brought a borrower and Cheshire As well in that discussion because at least for the springfield population, they're kind of in between Where you guys are and Claremont's pretty close. Yeah, it's a 18-minute drive from us to Claremont and As I'm doing it frequently now, you know, it's 22 minutes down the springfield We're still those three hospitals are still far closer. They're they're really more nuclear than the further field Hospitals of Brattleboro and Cheshire. I think it's natural that Brattleboro and Cheshire Move closer together. I think the interesting work being done between DHH and Granite one Will help guide that as well as the Nadnok hospital is a member of Granite one and that's just on the same axis Well, you know the same latitude basically of Brattleboro Cheshire and the Nadnok, too I think they'll be closer work around them You know Springfield patients that get redirected to Brattleboro I think we might try to get redirected to Manuskatni or to stay in Springfield. It's that much closer our zip codes overlap Substantially in our service areas, so I'm not envisioning a drive south further than Springfield At this point, I think we've got our hands full with the three close-in And then I'm wondering also as the three of you discuss that are you also kind of looking at what's going on at Alice Peck Day Because that's of course in Lebanon, so very close as well. Yeah, I mean my perspective on Alice Peck Day is You know, they're two and a half three miles away from from DHH. It's an easy it's easy to move services and physicians Across the town of Lebanon And really they're in a unique situation. I almost look at them as a department of DHH or DH Lebanon as opposed to someone that would join in on this, you know, southern Windsor County Sullivan County Group that we're trying to pull together APD is an unique spot as is new London Hospital the other critical access hospital in the system They're in the the what I've called the DMZ between Darryl Fishcock and Lebanon and Concord and the competing health system is there All the you know, we're all All the critical access hospitals have their own market pressures and in geographic location that that kind of Guide where they're headed This is great work and I'll be very interested to see where you land because I do think one of the challenges with that whole quarter Is there's a lot of capacity in that in that quarter compared at least relatively speaking compared to other areas in Vermont Yeah, there's you know, there's 75 inpatient beds and a 10 bed rehab for you know 35 to 40,000 patients in total That's a lot of capacity. It's probably too much inpatient capacity Where we run pretty full Values from fielder are not at this point So there's there's there's room to move people around and there's there's capacity to keep people in our communities As opposed to sending off the DH the DHS full we send them to Cheshire And if they're too sick they go to Bay State where they get the UVM and then I have a call from an irritated Cmo UVM saying why why can't you handle these people in your in your backyard? Thank you And my last question is whether there has been any discussions with DH about Considering to participate in the one-tier network for the Vermont folks because I know it that wasn't really possible when they were part of The pioneer ICO, but they're no longer part of that medicare ACO. So yeah Yeah, I don't want to speak for Strategic DHH, but I know there's a concerted effort underway now to Better educate. I think the rest of the DHH senior leadership about what You know what DH is footprint in these in the alternative alternative payment models or the all-pair model is in Vermont my sense is that there's a Shift in thinking there That you know, we we can't just be the only footprint Vermont as part of the system again It gives us the big part of the system gives us the ability to to go in and take the downside risk, but Yeah, I think it's a it's a complex issue and it's on the radar. That's What I can say at this point Unless Wendy wants to chime in Thank you Robin I'm gonna start with not really a question, but an ask and I I know that I Believe Dartmouth also has a lobbyist in the room and two years ago When UVM was presenting they talked about their captive being in the Caribbean and Dave mentioned offshore captive today and at that time UVM thought that it wouldn't make sense for them to Consider a Vermont captain, but they went out and They did the research and of course I don't get to see the people at DFR like I used to because we've moved our offices but I believe that they switched back to Vermont and it was beneficial for all parties and I was just wondering if you could ask your colleagues at DH DHH to take a look at Vermont because Vermont is a world leader in captive insurance And it'd be nice to see that business here rather than offshore So so I can I'll be happy to pass it on number one But number two I use the term offshore captive that was kind of just like a historical thing that is in my mind together Because I used to be the only option Okay, and but there your liability coverage is actually split in two One one half of it is out of Bermuda and one half of it is is here in Vermont And so we're we're half a half actually a hundred percent Vermont would be better Thank you Okay You went into great detail about how you calculated both your NPSR and your charges and really you backed into that based on the margin that you were looking to get I'm curious on The charge that the 3.2 percent if you could talk to us about whether it's across all lines or if it's targeted towards strategically Hitting certain areas and maybe reducing costs and others and so on So I'll do this a little backwards. So pharmacy which covers in patient elevation ER Crosses all lines of business We we have a markup that we use based on cost We have never changed that markup in the six years. I've been there in other words. We have not Guarded any money from that. So whatever we get bill for, you know, we mark it up and that markup is not changed So that's essentially a zero percent increase for Physicians and middle-level providers in our clinics and in hospital settings. It's a free percent increase to those charges that they generate and then for Inpatient in patient rehab swing bed in outpatient is four percent blended a weighted blend Would be the three point two percent We try to shoehorn A smaller rate increase for outpatient I think our inpatient charges are kind of okay, but our outpatient have issue and we talked about this This is some prior hearings where you know, we're trying to bend that down and get outpatient more in line with average market And we really that was kind of our last fall-back position We can't we can't do it two and a half in our patient We've got a we've got to move to at least three and a half So and again, I would if I if we were able to solve some of these other issues and I can make that million dollars go away I'm really going to try to push that towards the outpatient because that's where we have our biggest crisis issue Okay, great At this time, I'm going to turn it over to the office of the health care advocate Eric So because of the time first start with I Think it's wonderful. How do you expand your MAP program? and to the ER and I think at some point it would be useful to Hospitals get together and try to come up with best practices to deal with Substance use disorder and also mental health and which is a serious problem in the state And I mean I think objectively the population you serve It's a specific challenge Also, I'm betting a full-time psychiatrist in primary care So thinking changing topics a little You know your 2018 community health needs assessment, which is quite an interesting read actually and I For my opinion, it's a substantial job and you did a wonderful survey with a very large end The majority of community survey respondents identified access to affordable health insurance health care services and prescription drugs as the overwhelming issue In recognizing that that's a substantial substantially difficult issue to address I've heard in other presentations hospital budget decision this tension between Access to care or the level of care that can be provided and cost so you can decrease costs But then you decrease the services provided from a consumer perspective If costs remain high you can't afford to use costs. It also impacts accessibility so I was wondering if you could talk a little bit about this tension between Cost and access from the consumer perspective short on the I'll start with access We've as Dave has already mentioned we've invested pretty heavily and having navigators for folks To get them onto the exchange to get them on to Medicaid We've tightened up that process Substantially and we have a fair number of folks every month that are on our rehab units who we Do all of the transition work to get them on to Medicaid no granted that benefits us as well But that's a complex long journey for patients and we've invested in helping them get there. We actually One of our really one of our finest employees is one of those Navigators and as and Dave and I have talked about expanding her role You know regionally to not just help folks lucky enough to be at Windsor Woodstock with those closer to Springfield and those over in Sullivan County We've committed to adding FTE and primary care as I said We're not positive it is substantially with three new nearly full-time primary care providers we've had to adjust our clinic staffing to accommodate for Parktime providers of which we have a lot of and a lot of primary care clinics do have these as an article in the In the times very recently about how primary care jobs For women have actually offered the most flexibility to have work-life balance and we've recognized that So we have providers that work a couple days a week that that creates a strain on everybody else Because when providers aren't there someone else has to pick up the slack But you know, I think we've invested in both now on the cost side You know echo what what Dave said, I think there is We're hoping to have more room to move to push that increase down In our outpatient services, which is that is I think we're Responding to the community health needs assessment We do a lot of physical therapy occupational therapy specialty work there. That's that's kind of what we do as a rehab hospital And and that that is not cheating. I think that's when people feel like they see their primary care doc But may have to pay out of pocket for their PT work. So that's where they feel it and I wish I had a better answer on prescription drug costs as Dave said we really try to hold the line there So just quickly I want to commend you guys on Looking at your drug formula, and I think it has real potential and I think speaking with it It's worthwhile and I think overall looking across regulatory processes PBM part of the black box in the system right now we hear from one side that it's a net saving to the system we fear from another side that it's a substantial cost driver and My guess is the answer is somewhere in between the two But we'll never know that answer unless we're able to try to peel back or Look into that black box. So I would hope that in the future In the hospital insurance rate review process that those two questions are allowed So this is a Question to try to understand it and not a criticism So I would have expected with its consumer issues with affordability Bad debt and free care to both increase. So that's what we see from budget 19 to budget 20 but if you look at budget 19 to Projections for 19 you see a substantial increase in bad debt Roughly 26 percent in a reduction of roughly five percent in free care And that's one of you could talk about what's driving that I think a number of Drivers really What we have seen even with our Navigator work is She's moving most of the people that can get onto the they're willing to go on the exchanges onto the exchanges And getting the folks that are willing to Go through the the complex journey get on to Medicaid to do that I think that population is is is shrinking or they get into the folks that Want to be on neither? I think that's one of the Probably one of the drivers I don't I don't have a great answer unless you have a thought on others And again, you know, I think we're still doing with a small and and you know a couple Inpatient surgeries a couple skews the number of great but we've kind of stated in this band of reasonableness and I meet with the financial counselors every week I meet with the care management staff every week to go over uninsured poorly insured cases that we're seeing in whatever setting and You know, but it did it were so small the other flow is really tough to predict or manage But if you look over maybe five or six years We're kind of in a band of reasonableness and some, you know, if you I think we had to submit I don't know if it was in your letter or You know the number of denials as a percentage and all of that and that's and you can see there's It's a fair variation in the years because we're talking about a few hundred people receiving benefit or not receiving And Triggered a memory not a great one. We had a visitor Who was severely injured visitor from Central America that had an extended stay in our acute rehab? and No way to pay for that car accident multiple multi-trauma Month plus stay that you know probably accounts for big chunk of the free carry Actually that case by itself was well into six figures and The problem with this gentleman was he was not from this country But he had three payment sources potential payment sources between the United States and his home country and So we ended up having to we we worked with them all while he was there Being his wife great people want to do the right thing, but the insurance companies were all pointing fingers to each other as being responsible There was a worker's cop carrier It was Medicare and it was an out-of-country commercial all of all and nobody wanted to take responsibility So what we ended up having to do is we wrote that off to bad debt within 30 days of discharge And sent to an attorney to work on his behalf For our benefit to get all the stuff resolved and that's still that's still a process So I've talked with David about my concerns with the booking of the reserves and that's been talked to death And I just want to echo Statements that this is a very difficult phase with no historical data And I think reasonable minds can disagree about what constitutes objective data under gap principles and I Hope there is guidance. I think The range idea is interesting. I think whatever the guidance is has to Account for the substantial variation between Vermont hospitals and particularly critical access hospitals I agree And I think there's going to be real work done at the ACO and CMI level to look at what asymmetric Risk looks like if we want to get small where my ACO If we want to get small hospitals into the programs comfortably, I think most would say I don't need any upside benefit I just need my downside risk vantage better And I think again these asymmetric risk orders are going to be what we move to but we got to we got to get there We got to get through you know our first year in Medicare It's just an ox leg You've talked your substantial patient volumes from out of state and that's played out also From your data and also in from the bloods data looking back three years What's the thing that's for that population relative to the Vermont payers Populations are sorry. So yeah, we actually did look we do look at that So it is actually beneficial for us to have any extra patients and Medicare is a percentage point higher as a percent of business from New Hampshire versus Vermont so but statistically insignificant the difference but Medicaid is half as a percentage of people coming in so So it's about four percent of the New Hampshire folks have come in and ten percent of the Vermont Ten eleven percent of the Vermont people coming in and then the balance moves to commercial Definition so we actually have more commercial covered patients coming in from the answer as a percentage Thank you so much. That's all our questions. Thank you, Eric Is there any member of the public who wishes to offer comment on the model scutney budget? Dale What Yes, actually looked like I Realize what's happening with Springfield and therefore on the Vermont side. I'd be very curious to know If there's something like new housing developments going in near them on the new Hampshire side I just know that the population ship and very They can ship very quickly and it's very small moves to make a big difference down there In terms of people can decide why I want to live here this year or I want to live there and It can be like do I want to live in Etna, New Hampshire or do I want to live in line, New Hampshire? And I would imagine that would affect Who they see As a patient from New Hampshire That's a good question Dale our communities Windsor greater Windsor Springfield Claremont are constantly single and It's demographics that said there is more business investment in Claremont going on There are companies there that are trying to attract a younger workforce and Red River being one of Services computer and IT services firm that we work with they are grooming local high school students and local college students to come into their workforce and Have built it really a remarkable space in an old factory old mill building in Claremont So there is I think more business development on the New Hampshire side attract more of the workforce and that I think explains what Dave Just mentioned around the the higher true commercial pair mix that we see In New Hampshire, I think again Springfield and Windsor are very similar very similar pair mix and demographic A little bit more change on the Claremont and Sullivan County side in New Hampshire Okay, sir any other public comment seeing none. I wish to thank you for your excellent presentation And I see it's 1120. We are going to Take a bio break and resume at 1130 with Grace Cottage. Thank you. Thank you