 Well, I'll call to order the Green Mountain Care Boards hearing of August 14th, 2023. Today, we have Grace Cottage and Northwestern in the morning. And then this afternoon, we will have Rutland. And so I think Matt Sutter will be doing the Grace Cottage and Northwestern walkthrough. And then Director Sarah Lindberg will be doing Rutland this afternoon. So I'll turn it over to Russ McCracken to swear in the witnesses and then Mr. Sutter can take it over from there. Thank you, Chair Foster, for the Grace Cottage team, who will be presenting and answering questions today. Doug's on mute, so I'll speak for him. Doug DeVillo, CEO and myself, Stephen Brown, CFO. Great. If you could both raise your right hands, I'll throw you in. Do you solemnly swear that the evidence you shall give relative to the cause no under consideration shall be the whole truth and nothing but the truth, so help you, God. I do. Thanks very much. And I believe the floor is yours. Great. Well, good morning and thank you for having us today. We were very pleased to be able to meet with you to present our budget and answer questions about it. We put a lot of work into refining our budget for 2024, although I will say, you know, we do continuous new budget development all year long at Grace Cottage. We review the budget every month and make adjustments as we go in terms of our operating strategies and our our fiscal determination. So, you know, doing the budget every year is a pretty simple process for us because the 2024 budget is really just a continuation of our 2023 activity and performance, which we think has been quite exemplary, given given the challenges and the struggles. And, you know, the difficulties in running healthcare organizations these days. So, hopefully, we'll be able to answer your questions and make it very clear what we want to do in 2024 as far as our financial strategies are concerned. For those who don't know Grace Cottage all that well, there may be a couple of you, two or three of you. I just want to say a couple of things about the organization. You know, we're an independent, you know, for profit healthcare facility, we're located in rural southeastern Vermont, about 19 miles north of Brata borough. Our multi facility campus of about 10 and a half acres includes a 19 bed critical access hospital where we provide skilled rehabilitation, we provide acute care we provide palliative care and of course 24 seven emergency care. In fact, we just recently completed a renovation of our ED to add an additional 17 by 42 foot extension to better serve our community and to better increase our productivity and our accessibility to patients and very proud of that that renovation. We also have a full service laboratory here in the hospital. We have a diagnostic imaging suite, which includes a recently updated CT scanner. One of the things we're really proud of here at Grace Cottage is our rural health clinic. It's kind of the crown jewel of our organization. Where 13 healthcare facility health care health care providers provide over 31,000 patients visits, both primary and mental health visits every year within the clinic. So it's quite a large operating unit for Grace Cottage. We also have a very rapidly growing outpatient rehabilitation department where we provide physical and occupational therapy. We have a full service of pharmacy, low retail pharmacy located across the street from the hospital. Messenger Valley and we also have a community wellness center where we offer wellness programs for the local and surrounding communities. As I said, we're dedicated to providing primary care. We don't do anything in the way of invasive procedures here. We don't have an operating room. We really focus on emergency medicine, acute and skilled and rehabilitation services within our facility and obviously our large rural health clinic where we provide 10s of thousands of visits to patients where we focus on wellness and keeping people out of the hospital and keeping people on a track to taking care of themselves. And that's really what we're known for or what we're quite proud of. And as you'll see in the budget when you review the numbers, you'll see that we've had a pretty substantial growth in our volumes year over year. And that's really helped us to weather some of the challenges that a lot of hospitals are facing on the tail end of this terrible pandemic we've had to deal with. So with those opening comments, I'll ask Steve, if he wants to add anything to any of the things that I've had to say, and if not, we'll answer questions. No, I think you gave a good quick overview and happy to try and answer any questions you might have about what we submitted that we haven't already responded to. Thank you very much for lunch. So when's unmuted. I'm getting a little feedback there. I believe I muted that. Are you sorry. Yes, thank you. No worries. All right, so in our efforts at continuous improvement. We just wanted to make sure before we dive in that we that we Sorry, I don't know why. Okay, am I not one presenting. Okay, I'll try and share another way sorry but we wanted to just make sure that our conversation today is focused so you can see that the topics in the Grace Cottage budget that we wanted to make sure to hit. We're just making sure we understood some of the variation in the cost inflation assumptions. Understanding the amount of the charge increased likely to are expected to be realized from commercial insurers making sure we're all clear on that. Just covering a question that was already asked about the Medicaid price increases on and covering some ACO participation. Some of the referral and follow up responses as well as the lag and visit information. So with that, I'm going to turn it over to Matt. Butter to go over the budget so I will be driving for him. Go ahead Matt. Thanks Sarah. Can you all hear me. Great. Yes. Okay, so looking at the overview. If we just restrict this to critical access hospitals and kind of get a better feel for Grace Cottage's position here. Consider NPR growth was just over 16% so above the benchmark below the growth in operating expenses of about 14%. Not really. However, if you see those, their charge master and commercial price increases there for in 2% respectively. So growing more for utilization suggests if we go to the FY 24 tab. Thanks. It was a little small. So going down the list, as we just mentioned, NPR and operating expenses exceeded the benchmark. NPR exceeded the benchmark. We didn't have an explicit benchmark for operating expenses. But for labor, it's grown within the benchmark. And if we switch real quick to the labor tab, I think we can see that it's grown. Yeah. Thank you. You can see kind of it's more it's kind of kept in line with the ECI benchmark starting in 2017. And then sorry, coming back to the FY 24 budget. I was I wanted to pause real quick and make sure I didn't think we had any questions about their labor estimates or utilization on the staff level but I wanted to pause. No quick make sure there's no no questions from the board. Matt, I had one on commercial price. I'll wait if that's a different. Yeah. Just on the overview, it said 2% and here it's 9.3. Is that just because the time periods different here than in the overview page? That's correct. So this is for 24 over 23 is 9.3. And on the overview, it's 22 actual to 24 budget. No, this is 23. Yeah. And I'd say that. I don't want to speak for Mr. Brown, but I'd say that that exhibit was a real bear, especially for some of the smaller hospitals. So this 9.3 might be. Not the most relevant indicator for how. Is it also including volume increase in that period? Not just that we increased. I think the 2% is we got an additional 2% reimbursement on anything that we build to commercial versus the total commercial that we got went up by 9.3 based on the fact that the volumes are up. Yeah, that's designed to try to. Yeah, it was designed to try to just get the effect of price over the 2 years in that exhibit 10. And it's, it's not a trivial thing to pull out price and utilization and often. No. Yeah, yeah. I can assure you our commercial increases have not gone up any part of 9.3%. What would you say it has gone up. You know, and very certainly by payer, but the majority of our commercial payments are based on fee schedules. Everything in the rural health clinic is based on fee schedules defined by the commercial insurers. And, you know, at best they go up a minimal inflation factor each year they set those we don't have any control over those. It's not really relevant even what we build a commercial insurers for anything that's paid on a fee schedule. So for anything in the rural health clinic. The majority of our excuse me our outpatient work for commercial is also paid on fee schedule. For instance, everything Blue Cross pays us as one of our biggest payers for both diagnostic imaging and lab is all a fee schedule that they determine again. It's increased annually based on a very minimal inflation factor. So I think the 2% is probably an average overall of what we got additionally for any particular item that we build one year over the next. Thank you very much. I do have a question about utilization if we're ready for it. Sure. So, I noted I did notice in your submission that and as you just spoke to your utilization is based on current levels of volume for the first 7 months of fiscal year 23. Could you give us a little bit of color commentary on what areas that utilization seems to be most prominent is it across the board, mostly in the rural health clinic. The biggest area is in the emergency department. I mean, mind you, our average number of encounters in the emergency department is. General was generally in the single digit. So we're not talking huge volume. But thus far this year, the emergency department has been up like 40 plus percent over budgeted number of encounters. Which only gets you from say 8 to 12 a day. But the outpatient rehab is physical therapy and occupational therapy is. Way over budget. And continues to be we she's got a stack of referrals for outpatient work. People are pre booking for post surgery, you know, through like visits in December. And it's just, I don't know if it's people are finally getting work done that they put off throughout the pandemic or. More and more people are just needing to get work done probably based on the health of. The general population that's part of it. But they've been extremely busy just, you know, people walking in the door. So. The rural health clinic has been a little busier. The providers are seeing a few more patients. But it's mostly those 2 areas. And then of course, as the emergency department's busier. Some of the diagnostic imaging. Particularly CT is also over budget on the outpatient side, mostly related to. Emergency department visits as well as some lab. We haven't changed any service lines. It's just more people coming in to use those. Thank you. I just a quick follow up question about. I'm wondering with the increases in volume and ed visits. How many beds are you currently staffing? I know you have a 19. Bed critical access hospital, but we have we have 19 beds set up. Or license for and set up are available. We generally have a staffing level for an average daily census of 12. To 13 and that's. Pretty much where we've been running most times. I think our current average for the year is. For total acute and swing is like 10.8 or something like that. But, you know, that's usually fluctuating between. An average are a daily census of. 12 to 13 down to 8 or 9, you know, going up and down depending on when the emissions come and go, but it's on average. There's around 10 to 11 people in the building at any 1 time. Thank you. If there are no other questions about utilization, I think we can move to pharmaceutical costs and cost inflation. Okay. I was just wondering. So your, your pharmaceutical expenses increased about in line with our. What we've seen across other hospitals and the cost inflation also met the benchmark. I was just wondering if you could maybe speak. Provide more detail. For context for what you guys are seeing for cost inflation across. Over services or different supplies, pharmaceuticals, just kind of. Speak to what you guys are seeing this year, you know, our pharmaceutical costs as you'll see. Excuse me, compared with other facilities is relatively small number. You know, in great part, because we do not do any. Surgeries or and or. Cancer type drug treatment. So the majority of what we have from a pharmaceutical standpoint are in general, relatively. Lower cost items and not huge volumes. It's mostly. Small amounts for outpatient visits and. Whatever our inpatients, which are primarily swing bed. So you, you know, by the time they get to our facility. They're not usually on. You know, some of the net drugs necessarily than an acute high level. Acute patient would be getting. And it stays pretty consistent. But as with anything else, some drugs go up a lot. Some go up a little bit. It's really hard predicting inflation. I mean, looking at the numbers that we quoted in our narrative overall for various areas. You know, those are best guess as trying to base it on what it has been over the past year, what you think it might be. A few of the things, you know, you might have. Predicted growths coming from our group purchasing saying saying we might see this going up. But sometimes, you know, I'm sitting here, I'll sit here and look at accounts payable bills and see that. You know, a food item went up 10% from one week to the next. It's just. Still so fluctuate so much on things that you have no control over. So, are there any other staff questions on the cost inflation? I think I'm good for anything from you. No, thank you. Were there any board questions. On a pharmaceutical expenses or cost inflation. Any questions from the health care advocate on any of the topics we've covered so far. Forgive me. I completely forgot to ask that. That's a good. Good morning. This is Sam from the health care advocate. Nothing from us on this. Thank you. Matt, would you like to walk through this or would you prefer I do it? I think you can probably I can do it, but it will be a little waste a little bit. Thank you. So, we know cost reports are in, you know, measuring 1 thing. And what stands out to me is even among critical access hospitals, grease cottage is extremely small. So, right at that bottom end of the distribution here. So as a reminder, this mark in the middle would be the median. So half of the values are below it and half of the values are above it. Down to the 25th percentile so and up to the 75th percentile. So we have our middle 50% of the data and then we have one and a half times the distance in that box pod and we see that grace cottage is very, very tiny. Yeah, I didn't interrupt you, Sarah, but just, you know, comparing us with the other seven critical access hospitals, you know, as is as you well know, is the best comparison you can have. But in reality, we don't even compare with them because we do not do two things that make up the majority of the business in both, which is operating room surgical suites and delivering babies, which are both, you know, high volume and cost services that we don't have. So that's what really what makes us stand out so much from everybody else. You're right. Yeah, totally. And you see that in the, you know, very relatively low acuity. So just over one. And then we see, oh, so this is kind of the inverse of that small issue where the ratio of admin to clinical is quite high. And I believe that would be due to relative to these other ones at 36%. We certainly see those numbers for some other hospitals for different reasons. So I'm assuming this has to do with some fixed costs, but I'm curious how you interpret that. Exactly. I mean, you know, we're spreading, say, human resources director over a smaller number of employees. You know, you everybody has one human resources director when you're dividing it by 19 the employees for a 19 bed hospital versus the employees for a 25 bed hospital. And pretty much that applies to a lot of positions throughout the facility, a lot of fixed costs in it, particularly a small facility like this. Yeah, and I was just curious, you know, back to the envelope of your, you know, operating expenses, how many of those are related to the fixed costs associated with labor. I mean, and again, it's also hard, you know, when you look at a lot of those kind of positions where they're, you know, they fall under, say, administrative costs, but they're a lot of what they do on a day to day basis is job responsibilities that might otherwise be on somebody else's budget be not showing up at administrative costs because you've got a whole separate position doing that and it's classified as something different. So that also makes a huge difference here. Certainly not that we're paying all those people far more than they're getting at any of the other eight facilities or seven facilities. Right. Right. And then just, I don't even think you're. Yeah, so cash available to operations obviously not surprising to see that on the smaller side as well. And then for a bit are, I'm sorry, a bit are per adjusted discharge we see, I think that you were just here near the, there we are. I have to keep working on that. So a little bit profitable certainly still 22 nowhere near where anyone expected to be. And as far as the cost per adjusted discharge we've got, I think you're right in this clump at 14,000. So again, and thanks to those who have given this some diligence, more accurately saying that this is the average cost per Medicare discharge, which is adjusted for that acuity. So, I think some bunch in there for that. So any board or questions related to the cost report results here. Nothing from us, Sarah, we wanted to ask about the admin in general salary or issue, but you asked that. So thank you. Quick on the admin. What are which hospitals in these others do you think are most comparable to grace cottage and size. And where are they on admin. So the closest one for size would be my own escutney. I'm sorry, I won't steal your thunder. No, I was just they, I think from from an actual bed size we are the only one we are 19 everybody else is 25 correct. I'm pretty sure. But again, everybody else when you're taking that as a percentage of say total operating expenses. We don't have the operating expenses such as running surgical suites and things that are a huge, huge additional amount with the next what's the next closest expense overall expense level compared to us is probably significantly higher. Yeah, and I think the other thing we always think about with any percentage is low numbers. Low denominators just add a lot of volatility to this. So, yeah, so I think that's another important point. And then for cost coverage. So again, this is re pricing cleans based on the Medicare allowable cost. And looking at how that cost coverage is over time. So we see some, you know, relative improvements in the commercial cost coverage for outpatient. And it looks like a bump up in inpatient after quite a bit of stagnation, but still not up to 100% Medicare, you know, fixed at that kind of cost based reimbursement. We see quite low relative cost coverage for Medicaid outpatient, a little relative improvement that seems to have been lost over time for Medicaid. And we see that actually a relatively lower cost overall in delivering those services for commercial residents. Or I'm sorry, recipients of care with cost coverage, about 148% of that Medicare allowable cost. But seeing again, only half the cost coverage for Medicaid so almost kind of a push I'd say between those two bucket buckets. And any questions on this set of data before we. Okay. So, this one. Remember, we've lumped things together for several years here. And it can be difficult to actually see these guys pop so apologies as I hunt around a little bit, but I think that might be You're too small to be in this data set, of course, that's why there's no grace to highlight so it and so there's a need to be a certain number of discharges to be included in the Ram study and even if you lump three years together. They don't qualify for a public data file so just always helpful to remind ourselves how relatively small grace cottage is compared to other hospitals. So, I think that that is the data portion so I'll turn it back over to Matt to kind of help facilitate any other discussion. Thanks. We had a question about ACL participation I was wondering if you could speak to that any plans for the coming year. We don't have any specific plans for the coming year we've had discussions with the ACO over the last couple of years and you know the biggest problem for grace cottage is number one we have such a We really don't have a significant opportunity to really impact overall cost of care across the entire state of Vermont. We look at the cost of participation in terms of the dues that we would have to pay as well as the potential risk that would that would be exposed to if in fact prices were to go up across the ACO and we would have to We would be really in a position where we wouldn't be able to afford to to handle any type of risk on that side so we've had discussions with them about the ways that we can participate, you know without being treated like a full service. PPS hospital but you know those discussions really haven't come to fruition. And you know so so really from the standpoint of cost and the standpoint of risk, given the our size and given you know how little cash we have at any given time we just we just can't justify you know putting our organization at that level of risk. You know nor do we see any real significant benefit that the ACO could could provide a grace cottage to offset those those risks so that's kind of where our discussions have been. And, you know, we're certainly, you know, open to further conversations with the ACO but we really haven't, you know, been successful and coming up with a model that would make it. You know, make sense for us from the standpoint of our responsibility for keeping our organization out of a risky, you know, endeavor. Thank you. I think that's what I had for staff questions so looking to the board for any additional questions. I'm wondering if you could speak a little bit to the Medicaid redetermination effort and how that might or might not be factored into your budget. We did not factor anything specific in truthfully having zero idea how much it might affect depending on how many people either lost their coverage or additional people got it but we have been working very proactive we have a very top notch resource advocate in this facility that works closely with all of our patients, particularly with Medicaid patients and will do anything she possibly can to get help them fill all of their paperwork out. And, you know, are very hopeful that anybody that simply isn't getting their Medicaid because of not completing the paperwork that shouldn't be an issue. Now granted, there will certainly be some people that may lose it once they submit it because they're no longer eligible, but we did not factor any specific amount in for that. No. Thanks. And if I'm remembering correctly, she helps folks sign up for the exchange plans. Yeah, she will help them for anything exchange. She goes beyond above and beyond helps them sign up for fuel assistance anything any types of resources but her primary job function is yes, signing up for either the exchange or doing Medicaid paperwork. And truthfully, as Sarah just pointed out. If somebody loses their Medicaid chances are they're probably going to be eligible for 100% reduced fee still anyway. Or close so as she pointed out, we are reimbursement on Medicaid patients is so low. What we're really going to do is it won't have a huge impact on the bottom line. It'll just transfer it from a Medicaid contractual allowance. I mean a Medicaid contractual allowance to a free care line. So just a different kind of deduction. I had one question and I'm not intimately familiar with the program, but have you considered the rural emergency hospital designation and as curious if there's any opportunity there if that's something that would ever be pursued in the future. I mean, we looked at it briefly when it came out. I mean, it certainly could maybe be a possibility for this facility. At some point down the road, although I don't. You know, it would mean us getting rid of our inpatient beds all together and at this point, you know, there's a shortage of skilled nursing beds in the facility, which the majority of our inpatient as you can tell looking. At any statistics if we submit them. Which we don't do that kind of level of detail in the last couple of years, but the majority of our inpatient business is swing bed. So, you know, the average of 1, say a acute patient we have a year could certainly maybe be taking care of somewhere else, but I'm not sure where those other 10 or 11 patients every day for skilled nursing would go. But it would also make a whole lot of other changes. The facility in that, you know, part of what. For instance, pace for all of our diagnostic imaging equipment is the fact and lab equipment is the fact that you need that for the inpatient services as well. So they're helping. Spread that cost out over those things, whereas if you no longer had the inpatient business. You'd be trying to have all of those services available with only your primarily emergency department revenue and whatever the primary care patients needed. So it's a lot of factors that. You know, it's not just the inpatient beds you're talking about. It's how that volume of business affects your overall organization. And then you'd, you know, you'd still need a CEO, you'd still need a CFO. And now you're dividing that over an even smaller number of service lines and or. Total business. Increasing that administrative expenses. So expense. If it's follow up question to that, actually, chair Foster. Please. Yeah. I mean, we have been hearing from other hospitals about the difficulty in placement of their acute, you know, their sub acute patients to skilled nursing facilities in the state. And so I'm just wondering, given that you have, you know. 19 bed capacity. But you're averaging 10 beds on an average day. I mean, has there been thought to increasing scale and so that you could spread some of those fixed costs and provide more skilled SNF, you know, skilled nurse nursing facility beds for the state. We would actually be more than happy to take additional and keep our average daily census at 1617. I'll be completely honest with you. And. As many of your as some of your questions certainly. A loot know about base that you asked on all hospitals is. Skilled patients and one of the reasons they're getting hard to replace no matter where they're going is. That. Skilled patients are getting increasingly. More complex. They all have comorbidities. Back a long gone are the days where the majority of our swing bed patients. I mean, I can remember. Not that many years ago where almost every swing bed patient we had was probably somebody who had a hip or knee replacement. They were just here getting PT or OT for a couple of weeks. And they went home relatively simple to take care of. Now. The majority or of our inpatient swing beds patients. Although they may still be getting PT and OT, a lot of them are here for. IV treatments or all kinds of other things. They're just here because they are sick in so many ways. But that. That we have to be careful to make sure they're paid full that we can take care of, but what's become more of an issue. Is. Not wanting to get stuck with those patients once they're done being a skilled patient. And they need to go to a long term care facility. And there are not enough long term care facilities, meaning. That patient is not going to end up going back home. They have to go to a nursing home. And then we end up with a. Bunch of long term care patients waiting to go to a nursing home where we're either not getting paid really anything for them. To be here like 100 or $200 a day. Or. As we actually quoted in our narrative response, we've had a couple of different ones over the last. Year where we've had a patient, one of those patients here for 3 months where we were taking care of that patient for 3 months. Waiting for Medicaid to process the patient's paperwork so that they would be able to be transferred to a long term care facility. We had the beds available, but the long term care facilities won't take them without their paperwork done. So, you know, that's. Not anything we can change. But we have that's part of, you know, there's a lot of patients that we don't take for that very reason, because we know that after the end of a week or 2 weeks of being a skilled patient. They're just going to be occupying 1 of our beds. And. You get 2 or 3 of them here and then you're no longer able to take the ones that. The acute facilities are trying to get rid of for us to take care of that we should be taking care of. So it's. Another drawback of. Both the shortage of long term care beds in this area, particularly, as well as. Most of the people in this area are. Relying Medicaid. So what percentage of patients do you turn away because you know that there will not be a. Eventual long term care placement. I don't know. I have an exact number. I mean, it's also hard to tell because we don't always know. For instance, when Dartmouth wants to send as patient to a skilled facility, they send a mass thing out to all the skilled facilities. That could take that patient everybody around them versus and even down to here if it's somebody who's from this area and. They might get acceptance for that patient to go somewhere else before we have a chance to get back to them. The process of us accepting a patient when that happens is we get a referral from Dartmouth saying we have a patient that's going to be ready for skilled. That tomorrow say. It gets reviewed that medical documentation gets reviewed by our hospitalist by our pharmacy department to make sure we've got to whatever is available for them by our rehab department to make sure. All 3 of those departments have to make sure that they can. Take care of that patient before we accept them. The other thing that's becoming a huge problem is with so many Medicare patients switching to. Medicare Advantage plans and getting authorization for skilled. Stays from those sometimes takes 2, 3. Days or up to a week to get a authorization and they will sometime we've run into a lot lately where. We just had one a couple of weeks ago where the person literally lives 3 doors down from my office here in town. Wanted to come from Dartmouth. The insurance company was insisting that they go to. A facility nearby Dartmouth they wanted to get 6 denials from facilities within a 30 mile radius of Dartmouth first before they would consider authorizing them to come here. I mean why I don't know my presumption is they didn't want to pay the ambulance ride any further than 30 miles. I don't know. But you know there's just so much of that happening lately that. It's. And that's partly why they get stuck in places like Dartmouth it's it's waiting for us. Even if we're going to take that patient to get that prior authorization from the commercial insurance companies. Thank you very much. Are any other board questions. Seeing none. I'll ask the healthcare advocate if they have any additional questions. Nothing out from us. Thank you. Seeing none. I believe we'll. We do. I'm sorry public questions. I think it's the next. And chair foster. I don't know that I can see if there's any questions. Oh. I don't see any at this time. Can I just ask a quick question. Which is. Out of a total revenue. Standpoint Dave Merman. Sorry I don't think we've met before. We have nice to meet you both but out of a total revenue standpoint. What's the breakdown of inpatient to outpatient for your organization. 20 20 80 or. My from. The. Out of the. So our gross patient revenue that we submitted in the budgets $44 million. Strictly outpatient of that is about 27 million. So. Our outpatient business is a little over half of the total revenue submitted. Inpatient if you combine inpatient and swings together. Is about 11 million so about 25% of our total. Revenue and then the remainder is the primary care practice which is. Just under 8 million of that 44 million. I'm sorry so it's impatient the. 11 11 million or the 27 million. 11. Okay. That's in gross. In gross. Yes. So roughly a quarter quarter inpatient to. 75% outpatient is where the breakdown is. Just just just more curiosity than anything. Yeah. Yeah. Great. Thank you. Seeing no public comment or questions I will turn it back to chair Foster. I think that's great for Susan. I don't know. Please correct me if that's. Correct. Yeah. No worries. So seeing no comments from the public we like to have the hospital get one more chance to kind of leave us with your parting thoughts and so we welcome to hear anything you want to leave us with today. No, I would just say, you know, we appreciate the opportunity to participate in this process. And I think we're really proud of the of our performance year over year, as well as the budget we submitted for your consideration. We really believe that it accurately reflects. You know what we need to continue to carry out our mission of taking care of our communities. And our patients and we believe that it's prudent. It's efficient. And I think it really reflects the local needs of the health care of this region and we are happy to answer any questions that come up after this morning and hopefully you'll give our budget. Thank you for your fair and considerate review. Thank you very much. And I think I might add not that it necessarily is specific to this budget but in Doug's initial comments for those of you that aren't really familiar with where Grace cottage is or how we're located in comparison with other hospitals. It's true that we're 19 miles north of Brato bro and a little over that. Southwest of Springfield, but if you ever looked at a map of southeastern Vermont and where we sit on that map compared to the next closest hospitals in the north of us. We're about an hour south of Rutland and it's an hour of the other direction. So it's it's the people that live in our the north service area in the north and west of us that. Because the question has come up many times over the years. Well, what do we need grace college for your only 19 miles from BMH? Well, a lot of the patients have already traveled to 45 minutes or more or an hour over back mountainous roads to get here. And if we weren't here, they got to drive the other half hour to get to Brato bro. So, you know, it's a it's a crucial spot in this service area to have this hospital centrally located the way it is. And with the rest of them so far away from a lot of those people, I drove an ambulance for when we owned one years ago for six years and let me tell you it's a long trip to get here from some of those locations, especially in bad weather. And when you're taking a patient from here to Brato bro in bad weather at 2am. All right. Well, thank you. I think at this point, we can adjourn until our next date, which will start promptly at 10. I don't know if we need to formally adjourn chair or how that part works. Yeah, we can all during the meeting until 10am and they'll be with Northwestern at 10.