 And whenever you're ready, Dan. Okay, so good afternoon. My name is Dan Bennett. I'm the CEO at Gifford Medical Center. This is our agenda for the day, which is familiar probably for everybody who's been in any of these hearings this year. It's standard format. This is our team here at the table and at the table behind. Again, I'm Dan Bennett. To my right is Jeff Hebert. Jeff is our CFO. Rebecca O'Berry to my left is our Vice President of Operations. Dr. Josh White is our Chief Medical Officer and Katrina Lumbre is our controller. So I'll start out. This is our org chart. Those of you on the Green Man Care Board have seen this before. Gifford does have a somewhat unique structure in that our parent organization is a federally qualified health center. One of three organizations in the country that have that structure. Under the FQHC we have Gifford Medical Center, which is, as you know, a critical access hospital and that is the entity we'll be discussing today in this budget hearing. We have a third organization in our structure called Gifford Retirement Community, which consists of a nursing home, an independent living community and two adult day programs. We have in the slides we provided some overview of the organizations that are within the Gifford umbrella. We have a number of locations from White River Junction to Berlin and points in between. We are centered in Randolph and offer services to communities throughout our area. What is not reflected in our organizational chart is what we do to complete our mission. And Gifford is a community health organization. We are a community hospital and as such, you're gonna hear the word community come out of my mouth quite a few times here today. We are an organization that is focused on our community and we're an organization that enjoys the support and participation of our community. What I have here up on the screen right now is a listing of a number of activities that we've undertaken in the past year focused around community health and community outreach. This is important because it speaks to the investments that Gifford makes on a daily basis and on an ongoing basis to community health based on the needs that are in our community and with many partners within our community. Those partners include our school systems. They include our food banks, both our local food bank and statewide food bank as well. Law enforcement entities, senior centers, our designated agency, a local nonprofit that does mobile health services including mobile dental services that we work with them on. Our local recreation program. And this year also with Rise Vermont through OneCare Vermont, we started a partnership with them. That has been a good marriage because it brings to, it brings to our disposal their resources and their assistance to continue the good work that we've been doing for years and the relationships that we've built within our community. In short, Gifford is making a lot of investments in our community focused on primary care in conjunction with our FQHC, focused on population health through our work in OneCare Vermont, through our community health and outreach programs. And as I noted, our community turns out around and supports Gifford as well. And that was never as apparent as it was this past weekend when we hosted our annual Last Mile Ride event which is an event where we work with our community members to raise money to assist individuals and their families at the end of life. We had a total of 497 people who participated. Next year that number will be over 500, I'm quite certain. We had 54 business sponsors who participated and we raised over $120,000 again to assist individuals and families at the end of life. Over the 14 years that we have held this event, we've raised $876,000 towards end of life care and that is all money that goes back to benefit our community members. That, if nothing else, I want people to understand what it means to be a community health organization. It's understanding what the needs are in your community and it's mobilizing your efforts to meet those needs, working with your other partner organization. Gifford does that very well and we look forward to continuing that in the future. I also want to just say thank you to the Green Mountain Care Board. At the end of May, you came out to Gifford and held one of your public meetings. You also took the time to go with our staff and see some of the programs, see some of these collaborations that we have underway. That is incredibly important, I believe, for you as well as you're doing your work to understand what is happening in the communities, what it means to be a community hospital and I thank you for taking the time and effort to come out to Gifford and to our communities and see what's going on on the ground. The other investment that Gifford has made and we've made for the past several years but really has started to show itself in the financial statements that you see on a regular basis is the investment we've made in mobilizing expense reduction efforts throughout our organization. Those efforts have been very successful. They've involved people throughout our organization and it is reflected in the financial results that you see as well as in our budget moving forward. So on that note, we are here to talk about our budget and our finances so I'm gonna turn it over to Jeff to take that next step. All right, starting with our revenue. We did include the appendix that we're in our narrative but specifically looking at our gross revenue and looking at the revenue streams, our inpatient revenue. We have this year experienced lower patient days however our discharges are at expectations and so because of that we are budgeting our FY19 projections for our FY20 budgets. In regards to outpatient, again we are using the 2019 projections to predict our 2020 budgets and with our clinic revenue streams we are increasing them slightly. In 2018, we instituted a new EMR. Our providers took basically 18 and 19 to get up to speed and because of that they're getting more efficient so we have put some slight increases in revenue due to that. Looking at net revenue specifically at our payers, when we looked at our expense increases as compared to the inflationary increases that Medicare expects, we see that our inflationary increases on expenses overall are about three to four percent so we are expecting due to our cost-based reimbursement to see that net revenue or that increase with our rate increase with Medicare. With Medicaid we did not budget any increase due to the rate increase with the commercial. We do have that built in. The other thing that we saw this year from 2019 to 2020 we did see as our community ages that we experienced a movement from our commercial payers to Medicare so that's built into our budget as well. For DISH we did have a slight decrease and that is reflected in the budget. Looking at our five year net patient revenue, we have and we did wanna put this slide in to communicate that in FY 14 you see that it was at 58 million and then it dropped in 15 and what we wanted to communicate is in FY 14 Dan reviewed that organizational structure for Gifford. Prior to FY 14 our organizational structure was GMC. GMC included our nursing home. GMC included our FQHC or our primary care practices. In 14 we saw that we had revenues for GHC which is the FQHC of 2.5 million and then the nursing home of 3 million and so we actually in 15 that became its own separate corporation so that revenue now was not in our budget submission and then in 16 we were able to move our nursing home. It was a hospital based nursing home. It was a department of the hospital. We moved it about two miles up Route 66 so it became an independent. So that revenue was also removed. So this is just basically restating the numbers. When we do look at the overall numbers the one year that we did experience definitely a shortfall was 18 which we have been getting back on our feet for 19 and into 20. So you've heard us talk about some of the issues we've had around workforce. I can report that we have seen improvements in regard to our physician workforce over the last year. We currently have one position that we have open in radiology which is a significant change from what we've seen in the past years. We do continue to utilize some traveling staff particularly in our operating room. However, we have put in place some longer term solutions there that are going to be favorable moving forward. We continue to have the same issues as everybody else with a tight labor market and that is throughout our organization not just physicians and nurses but also environmental services, nutrition and food services and across our practices as well. One of the issues that we have been working to address is access to capital in order to ensure that we are able to meet our need to invest in equipment and our plant. Our age of plant has been rising. The last couple of years we've depended upon our cash reserves given our financial position to in order to fund our capital expenses. Moving forward we need to be able to return to funding those capital expenses through our operating by generating cash through operations. We also continue to participate in the all payer model. In 2019 we are participating in the Medicaid program. In 2020 we will continue to participate in the Medicaid program and we also are going to be a participant in the SIGNA program as well. As we're looking at our continued, continuing to expand our participation in that the ability to take on risk is a big issue for us and one that we will be continuing to work with one care on as we go forward. So I just talked about a couple of areas of risk in regard to our workforce and also in regard to our access to capital. As I noted earlier and as you've seen in our finances we have done a significant amount of cost reduction work. We've been very successful in doing that. We do feel that there's a limit to how much further we can go with that given what's available to us. So most of the big items that we're able to capture in cost reduction we have done that. We also continue and talked about the difficulty in recruiting staff and a workforce issue. One of the issues that does exist in Vermont in rural areas is the issue of being able to have opportunities for people who come with a spouse or family members. We currently are in the process of losing a pediatrician because her spouse and his needs for work. We also in the last several months had a candidate for a psychiatry position who was interested in coming. But again, in the end chose another position because her spouse could not find a position here. So that is something that continues to be an issue as well. There are a lot of opportunities as well. And I'm gonna turn it over to Rebecca to talk about some of those. It was a thing Rebecca. Hi, thanks for having us here. I get to talk about the opportunities that we have and as Dan said earlier, we have a lot of community outreach going on. This has been a really big focus for us this year as we've been focusing on wellness, preventative healthcare and we've had a lot of focus on the youth in our area and educating them. So we've been really growing our connection with our primary care practices and focusing on care coordination. So working with our community healthcare teams, the discharge planners, whether that's within our own organization or other organizations, we've really tried to grow those relationships so that we are helping the patients to navigate what can be a really confusing period of time in their lives. The outreach that we've been doing focusing on some of the youth in our area, we've partnered with our local police and sheriff's office to bring the LEED program, which is the law enforcement against drugs into schools. We've also had programs on bullying and how to learn some techniques to handle sort of negative peer pressure as kids move from grade to grade to grade. There's a lot of focus on how to handle situations like people who are trying to lure you into vaping, which we have all learned, we don't know anything about and we need to keep our kids safe from that. Dan was mentioning in our community partnerships, those are really important to us and we gain a lot of traction with care coordination and partnering with all of those local entities that we are able to work with in the different communities that we serve. As mentioned up there, we have started our post-acute care clinic, which has been a really great way of keeping our folks after discharge from the hospital, from going back into the hospital prematurely by meeting with them 48 to 72 hours after discharge to go over their medications with them, make sure they understand their treatment plan. Patients wanna go home when they're in the hospital and not all the time do they remember all the things that they need to be focusing on once they get there. We wanna make sure they have all of those pieces in place to surround them. Working with our substance use programs, we have a great team that's providing free Narcan in one of our centers. We've provided a lot of education to our community about that. We have our drug take-back kiosk. I never quite say that right. That's been amazing in our main campus, but in our primary care clinics within our areas, we've got all of our take-back envelopes that I am replenishing pretty much on a weekly basis, 25 to 50 of those envelopes. So that's been really, really a great thing for us. Dan also mentioned that we're partnering with Health Hub. We have this mobile trailer that is providing preventative care to kids and adults. The adults has been something that we've been really focusing on through our primary care clinics is making sure that folks know that you don't have to be a child to get those services and checking on the numbers today because they're moving out Friday. They've been with us most of the summer. We've doubled the number of patients that we've seen from last year to this year with Health Hub, which has been super exciting for us. And the last thing I wanted to touch on was the athletic trainer program, which has been a great way for us to work closer with our schools and getting our students really active and participating in their health and wellness. The thing I wanted to highlight is this summer we had a program with our local high school where we had the athletic trainer volunteer to volunteer to work with kids over a seven week period of time. She had eight to 10 kids each time to work on prevention, injury prevention, endurance training and just making sure that they're going to be healthy in the coming year. Sort of not losing all that time over the summer so that we can really look over the course of the next school year to see how well that's worked. And the last thing that she's doing this week is three different in services on nutrition and how to fuel your body and how that makes such a big difference to them. The response has been really overwhelming and the parents have been just super excited to participate in this with the kids. So we're excited to see how our adolescents fair over this coming year that have gone through this program with us. All right, jumping into our indicators. Looking at basically the indicators that we look at one of the key indicators was our debt service coverage ratio. Again, FY18 for Gifford was a difficult year. This indicator in 18 shows that we were at negative 1.3 but looking at all the cost savings initiatives, getting our P&L back to where it needs to be still has a little ways to go but we've been able to get that turned around and we're at 2.1. Moving over to the long-term debt to capitalization in 2003, we did have a need to also reinvest into the facility and to our infrastructure. And at that time, we did have the opportunity to get a bond for Gifford Medical Center. We took that and we did receive that bond right now. Overall, as of 2019 that bond, we have a payable of about 18 million on it. And because of that, it puts us in a higher bracket or a higher situation ranking with our long-term debt to capitalization. Again, Dan had communicated, one of our major concerns is our age of plant which is in the bottom left-hand corner and we are one of the higher plants as we sit with our plant and we need to start to address that. Our days in net receivable, those for us, we feel are doing very well. Days cash on hand, when we got that bond in 2003, we took the opportunity to start putting money into funded depreciation so that we were able to, if we were put into a situation, draw those funds down. That has been very beneficial to us, especially with our bond covenants. We've had a lot of work with the banks as well as our auditors. And one of the saving indicators that's really been helping us out was our days cash on hand where we were postured. So we did have a poor debt service coverage ratio but then when you put it against the days cash on hand, that helped us out quite a lot. Days payable, look fine. Moving down to the operating margin, again, we ended the year at a negative 10.7% margin. We've got that right now, we are projecting it to be 0.8% and when we take a look at our total margin, we have that in 2018 was at negative 6.2% and right now we have that projecting at 3.7%. We put this graph up to historically show that overall when we take a look at our operating margin, Gifford, we take pride in the, for those 15 years that we were able to meet our budgeted expectations. In 17, as well as 18, that hasn't done the case but we are getting that back in line and we are an organization that once we get back on track, we feel confident that that's where we'll stay. These graphs are more of illustration. We wanted to show a lot of the indicators are repetitive but what we had them in the presentation for was to communicate. This is something that we always every month submit to our board for their review and as well as the annual debt, days cash on hand. In regards to the profit and loss statement, that was requested. If there's any specific questions that can definitely take, we just put the profit and loss, the balance sheet and the cash flow statement. Taking a look at our reconciliation from actual 19 to budget 19. At the beginning of the presentation we communicated that we have seen a shift in our patient days that they're lower. Our discharges are at expectations but that is causing the main reason that our inpatient revenues are below budgeted expectation. Moving down to our outpatient revenue, our ER has been up, it's been down but over the year to date numbers we have been lower than expected so that's contributing to some of our outpatient shortfalls. Last year when we came to this group we were talking about general surgery, getting that program for Gipper back on, it's back up and running to where it needs to be. In the beginning of the fiscal year we actually, our two general surgeons started they're doing very well. What we have seen in 19 however is our other surgery has come down in regards to what we expected it to be. And with our clinics that's also then flowing into our clinic revenue streams as well. Salaries and benefits. When we looked at what's been happening we have reduced our salaries due to our volume expectations. Our provider tax because of our revenue being below expectation we have seen that come in lower. And this one I'm not, our depreciation and we keep looking, we meet on a weekly basis in regards to our expenses. And one of those areas that we've been kind of looking for savings is our depreciation in regards to capital purchases as to what we can and cannot do for this year. So we're seeing the savings there. Interest in long term is up and that's because we had to refinance our bond so we are spreading those expenses. And then other operating we have due to cost savings initiative our supplies are doing well and our insurances are down as well as well as all the other expenses. So in regard to our expense drivers we've talked about our workforce. Our utilization of temporary staff whether that's physicians or nurses as I noted is less than it had been in previous years. So we are seeing some positive moves there in reducing those costs. That being said, we are a small organization and all it takes is one or two people leaving for another leaving their position to drive those costs upwards. So that'll be continuing to be something that there is some risk around for us. I noted the labor market that's not a new story that you've heard that continues to be an issue. I talked a little bit about the age of plant before and our ability to meet our master facility plan which we did complete a new plan this year looking forward for five years. And that is the capital budget that you'll see in a minute is reflective of the planning process that we went through there. We do continue to see an overall inflation in health care costs that outstrips the cost of inflation in other areas of the economy whether that's around wages or whether that's around pharmaceutical costs other supplies we do continue to see pressures in those areas. So we've had a couple of cost saving initiatives this year and one of them was our lighting project that's noted up there which was again another great partnership that we had with Efficiency Vermont. We've worked with Efficiency Vermont with many of our programs over the years with especially when we're renovating we bring them in and have them look at our plans and give us ideas. So this was a really proactive plan that we worked on with them when they came and reviewed the hospital itself to replace all of our old fixtures with LEDs which of course are dimmable. So they've gone through our main campus and provided these lights that are much more user friendly I think and like I said they dim but they also go to sleep so if their room is unoccupied they just sort of dim out and then as you walk by them they light back up but they're preset to actually come on and then come down to a level that you've pre-selected which for staff and patients has been a really great thing to have happen because the light is the way you want it and not feeling so bright and artificial. But again I think that part of the story for me is the community partnership with Efficiency Vermont and those people are pretty amazing and they have a different way of looking at a project so we're hoping to see a lot more benefits from that project that they've just completed. We had a relocation of a service we had a practice in Wilder that's a physical therapy practice that we have been releasing the space for a long time and with a very minimal renovation in our White River Junction practice we were able to move the Wilder practice into that footprint. That practice in White River Junction has needed some work, it needs a facelift, it's needed it for many years. It's been a pretty inefficient footprint to that plant and we were able to with just a little bit of tweaks here and there renovate that space and move that practice of Wilder advanced physical therapy into that building. We have urology and podiatry there now as well so it's a really great marriage between those two those three specialties. Our community investment as far as looking at food insecurity, I mentioned earlier we've been really looking at nutrition and how to help people improve their health and wellbeing through nutrition. We are partnering with the Vermont Food Bank and our area, Randolph area food shelf to do a couple of really nice things this year. We've been trying to get Veggie Van Gogh to our hospital for a few years. They generally partner with hospitals and schools to bring fresh fruits and veggies just they're free come get them to folks who might otherwise not be able to afford to get that kind of nutrition in their food supply. So we've had them here, they come the second Thursday of every month and they're there for about an hour and a half and this last time that they were here it's our fourth month of having them here. We served 341 families and that most of them in the first hour and that was pretty amazing to us. We've seen it grow. It's clearly people who are in need. We've worked with another community partner stagecoach to kind of go around town a little more frequently and stop at Gifford a little more frequently during that span of time every month and it's been pretty amazing. We actually pre-packaged some of those bags and give them to the senior centers for folks who can't actually come out to Gifford and pick up the food during that time. The last thing though I wanna talk about with this is this program that we have and we're calling them the Gifford Green Bags. We have these Gifford Green Bags that are available in all of our primary care practices and also within our community healthcare team that are pre-packaged with basically two days of food, shelf-sable food for families who need immediate access to food. We've heard some pretty amazing stories from our pediatrics department and some of our primary care departments about people who just need food right now. They can't get to the food shelf. They don't have the ability to travel to get this, these services, whatever it is, that we can just hand them a bag of food that has no stigma attached because it's in a Gifford bag. It could be bandages, nobody really knows and have folks leave with the food and inside those bags we have the information of how to access our community healthcare team, the food shelf, veggie van go, et cetera. And we're actually partnering with our EMS teams in our communities to figure out a way to get them to be able to have a few of those bags available as well as they're entering people's homes to provide these house call visits with them. We've also given them to a couple of free clinics and we have given them to our local library. We're trying to identify areas where kids go like after school or people show up because we've noticed that with our families, a lot of times the parents are willing to sort of make that trip into the food shelf or whatever because of their kids. We noticed that a lot of our elderly folks are not willing to do that. So just being able to hand them that food makes us feel like we've made a difference and maybe they'll be a little more open to the idea of letting us help them with that. So moving to our capital. Overall, our capital for this upcoming year is maintenance only capital. It's for items that have come, they're at their end of life. Looking at our buildings and building services, we do have on the, you know, we're planning on doing a pretty expansive OBGYN interior renovation. This is the space that was freed up when we went with our private rooms. We'll be renovating that to accommodate our OB clinic. The other big project for us this upcoming year is our Gamma camera. That is definitely at its end of life and then some. The first part of it, the 335,000 is the actual renovations to get the new unit in place. If we take a look at our major movable, the Gamma camera of 670,000 is the actual camera that we'll put in place. Information systems comes up as the number two major movable type of item. There are a bunch of little projects that just, you know, will equate to a large project. Laptops, licenses in the SOAR. We have a replacement for an X-ray and then our other major movable by service areas are listed. So our financial outlook at Gifford is wrapped around our model of care and that we are an organization that has an integrated model around primary care along with our hospital and with our community health programming and initiatives. We have done a lot of work as we've noted around cost reductions and efficiencies. We've also had some success in rebuilding our staff in areas where that was required. That now puts us in a situation where we are able to better focus on those activities that are in keeping with the goals of the all-payer model, including a focus on reducing the total cost of care for people in our population, in our communities. And I'm gonna ask Dr. White to talk about some of the work we're doing to that end. Good afternoon and thank you. Addressing total cost of care has largely fallen into two realms for us to begin with. There are the standard quality initiatives, a couple of which I will highlight. Within the last couple of years we have in partnership with DHMC employed an orthopedist who has fellowship training in joint replacement. His specialization in techniques has resulted in a decrease in our average length of stay between fourth quarter of 17 and fourth quarter of 18 from six days in the hospital to 2.9 days. Our antibiotic stewardship team has done extensive work with antibiotic utilization. On February of 2018, we were utilizing 531 days of antibiotics per thousand patient days. This has been reduced to 213 days as of April 19th, a 60% reduction that comes with obvious direct costs as well as reduction in length of stay and reduction in the complications associated with antibiotic utilization. As mentioned previously, we have been focusing on our post-acute care clinic. This allows the opportunity to address patient understanding and compliance of the plan in their care as well as medications. It allows us the opportunity to identify problems and failures in the plan of care early as the patient follows up. As was previously mentioned, it's not unusual for our patients to be somewhat confused with their disease process at the time of hospitalization and simultaneously in a hurry to get home such that this addresses an additional touch point to make sure that things are getting done correctly. Ultimately, the goal here is to reduce unnecessary ED visits and readmissions. We have had the opportunity to start to utilize the OneCare Vermont dataset with Workbench, which is highly advantageous in addressing specific problems as it allows us the opportunity to drill down to specific provider and patient costs such that we can identify exactly where problems are and ultimately this is even more useful as the data is quite timely, only being a couple of months old. In our recent data received from them, imaging has been identified as a target and we have initiated studies in terms of is it specific provider, specific departments or system-wide image utilization that needs to be addressed and we have already initiated projects given quality projects a target from that dataset. That is the ideal one as there are numerous pre-existing strategies to address this issue. The second aspect of reduction in total cost of care focuses on social determinants of need. Ultimately, a number of failures in the medical plan are not a product of the medical plan but a product of the patient's inability or misunderstanding of that plan such that they cannot comply. When patients are faced with questions like am I going to buy food this week or am I going to purchase my medications? We have a versioning addiction medicine service which has included in it a NARCAN distribution, the take-back kiosk as mentioned, specialist and then we have recently introduced a rapid access to medication program through our emergency department such that opiate dependent individuals can start treatment at the time of arrival to the emergency department even if their chief complaint does not specifically relate to substance abuse. The PACC also addresses the opportunity for social determinants of need. A recent study we ran in May looking at the 30-day readmissions to the hospital identified that none of those patients had made their follow-up appointment. Subsequently, we have started a study into exactly why and the suspicion is a lot of that has to do with transportation which brings about the need to offer services at Gifford that patients otherwise may not be able to achieve and do what we can to reach patients at their homes such that they don't have to travel. This brings me to the rural paramedicine program. We have a small EMS service which is engaged in at-home visits such that we can do social and observational interaction with these patients and identify things that may not otherwise be apparent in a clinic visit. Do you have opportunity to make your next visit? Do you understand your medications that you're supposed to be taking? Do you even have those medications? Is the heat on? We've applied through OneCare of Vermont for an innovation grant to expand this to all of the EMS services in district eight and the idea of being identify issues early, issues that the patient might not otherwise share and again reduce readmissions as well as unnecessary ED visits. So overall the long-range financial outlook. Gifford has been using a tool for many years. It's a five-year planning tool that will be every year goes to our board for review. Looking at it this year, one of the key areas that came up on the radar was our average age of plant and the need to address that age of plant. Overall, we as an organization look to try to aspire to a triple B setting and we are, you know, as we work on trying to get our age of plant back where we need to be in 2024, we still feel that we need to continue to work on that. The other indicators that will come out from that five-year planning tool are of, you know, we look at current ratio, days cash on hand, days in AR, cash to debt to capitalization and the debt service coverage ratio. Again, this slide does represent Gifford as a whole. Gifford as a whole is Gifford Medical Center, Gifford Healthcare and Gifford Retirement Community. In review of the historical compliance, the first is our net patient revenue. Again, wanted to point out and that's where GHC and GRC have arrows. That's when we actually excluded those revenue streams from that. And also to point out that unfortunately for FY 18, we did see a dramatic reduction, but we're getting back to where we hope and need to be. And then looking at operating margins, this is a graph that you've already seen. Again, it shows that 17, 18, but we're back moving back in the right direction to get it to where it needs to be. And that is the presentation. We welcome your questions. Super, thank you. I'm going to have Maria lead off this afternoon. Thank you. Clearly, this is one of the hospitals that has been struggling on operating margin for the past few years. And so I want to focus a bit on your profit and loss statement. So maybe, Jeff, if you could pull that up. And one question just to start off. Are there any subsidies or benefits that are running through the P&L for the F2HC or for the nursing home? There is. In 2020, we are budgeting, Jeff's getting the number. All right, just a second. For the nursing home, about 900,000 and 200 for the primary care. And those are expenses, correct? Yes. Just looking through the P&L, when you look at, I guess, what is your opportunity for 340B? I mean, that's what we've seen a lot of hospitals, even this size getting tremendous benefits from 340B and just wanted to find out because you have a pretty small volume there. Our 340B program, again, when Gippert Healthcare was a part of the Gippert Medical Center as a department and stuff, it's our primary care clinics that are qualifying for the 340B revenues. And that is where the revenues are hitting is in Gippert Healthcare, not Gippert Medical Center. So that's why you're not seeing it reflected in our popular law statement. Okay. And just looking at your 2019 projection, one of the things we looked at this year and I think you got from the staff analysis is kind of a quarterly breakout of where you're trending for the year. And your fourth quarter is looking to have a 27% increase, or 27% of your net patient revenue for the year. And it has been going up month, quarter by quarter. So we've seen that trend, but just wanted to ask you with a little more time has passed and you submitted the budget, how are you feeling about the NPR forecast you have in there? So overall, we just gave to the Green Mountain Care Board our July actual data. We are expecting that our projections are coming into where we expected them to come in. And so we feel confident in what was presented in the project numbers for this budget. Okay. And then just sticking with NPR, and I'm not suggesting you change it, but I do want to applaud that you seem to be having this year a conservative forecast in there for your growth. I mean, obviously you're missing the budget for 2019. And that was a pretty significant increase over 2018. I mean, here if we look at the change, which is just a little bit over a million dollars, your rate increases for commercial and the Medicare is like 2.2 million. So that's showing really that utilization is going down or mix is going down. And that change of only a million dollars is pretty small compared to what it was even for this year. So just wanted to talk about if you think there's conservatism in the NPR, we hope you're right, under promise over deliver, right? Exactly. Yes, we definitely feel that it's realistic. It's conservative. And I don't think we'll see that sort of spread between budget and actual coming forward. So we definitely think it's attainable. Good, no, I think I do as well. Like last year, I think one of the challenges was it was a pretty big increase on your budget over. You know, we know you kind of had been on the progression of a higher NPR than you had the big drop in 2018. And I think it was a little hopeful in 2019 what the budget was. I think given our experience between 2017 and 2018, it was a difficult projection to make in the last budget year. And I think we have more information to go on this year. And again, I think it's attainable and I think it's conservative. Okay. And then can you talk about your achievement of cost savings? Because I know you do have a bunch of cost savings that you were rolling through. And just wanted to talk about are they on the other operating expense line? And are you getting everything you expected in 2019? And can you talk a little bit about 20? So if you'll bear with me a second, I just want to go a little further back and talk a little bit about process. One of the things that there's always been a good culture of being responsible stewards of money at Gifford. One of the things given the situations that we experienced and the difficulties we experienced was that we had to ramp that up even more. So from a process standpoint, Jeff noted just a couple of minutes ago about a weekly meeting that we have with a number of people throughout leadership to look at where we are in our process, where we are in our cycle, what we need to do to continue to save money, what our volumes are looking like, matching the volumes up with our expenses and our expected expenses. We also are meeting on a daily basis with our entire leadership team. We're looking at what volumes we have in that current day, what we've had in the last week. Looking forward, Rebecca will bring in what we're expecting for providers in terms of vacations, et cetera, so that we then can say, okay, we need to, from a staffing standpoint, we need to staff down in particular areas because we know we're gonna have people out. So we're matching those expenses with our expected revenues and with our actual revenues. That has had a great impact in our cost savings, both in terms of being able to have people take vacations at the right time so that we're not over staffed at times when we shouldn't be. We also have been able to utilize low census policies that we have in place more effectively and over the past couple of years, we have reduced the number of FTEs because of attrition. So that's been areas where we've seen the biggest impact. We've talked about some of the items that were in the narrative that we put forward. Rebecca talked about a couple of items that we've done as well. But the other part of the process is that cost reductions and stewardship of our resources goes throughout our organization so that it's not just a leadership team, it's people throughout Gifford that are thinking of ways that they can save money. We have our materials manager and my assistant who work together and have put a program in place where we're now looking at our thrift store that our auxiliary operates for office supplies to see what's there. So instead of paying a buck and a half for a pad of paper, they'll pay 25 cents there. So there's things that like that that we've saved about $1,000 on this year up to a much larger item. So it goes throughout our organization, it's a part of the culture and it's something that will continue moving forward. And we do feel that the initiatives that we've put in place, some of the cost savings that you've seen in our financials this year were things that we put in place last year. Some of the things that we're planning on impacting in the coming budget are things we're putting in place now. So that lag will continue to, the lag in time from implementing and seeing those savings will continue to move forward as we go into 2020. And I am confident we'll be able to continue those efforts going forward. So do you see any risk then in what you've put in for cost savings for 19 as well as 20? Or do you think you're... I feel very confident in what we have in there. And then just on the non-operating revenue because that's really what's helped you make you're having a margin at all. And I know for 19 in the projection, I think you wrote about getting some revenue, grant revenue of about 850,000 or money that you've achieved through the community. And then the rest is that really the change in your investments. And can you talk a little bit of the difference between the 19 projection to the 20 budget? Yeah, so it is what you just communicated. It's that, you know, the projection and versus what we put in the budget, we're very conservative what we put in the budget for non-operating revenue. So the difference is how the market's doing currently to what we actually built into our budget. So the two point, the difference there, the extra two million is really pretty much the market performance. And then obviously for 20, don't really budget that, but it could happen if not. Okay, and one other area, just on your ACO reserves, what you have in for 19 and what you're proposing for 20, can you talk to that a little bit? Yeah, so unfortunately, we did receive our updated numbers in July after we had submitted the budget. We did for 19 have a risk reserve of 238,000 that was built into our budget. We did find out that that should have been probably closer to 330,000. But in the 2020 budget, we have 238,000. So are you gonna be provided for 100% of 19 and 100% of 20 as far as the maximum reserve? Yes, that's what our auditors are requiring at this time due to we don't have the history that we can, and so that's what they require us to do. And hopefully that's gonna be conservative too when we go through it. We hope we don't hit the max on everything, right? That's all I have, thank you. Tom. Well, I remember a while back you were here, we were before at a meeting and you presented this list of cost savings and I remember they even had $100 items on it and so I applaud you for your diligence. It's resulted in the fact that over the last, since 2017 that you've kept your operating expenses at a negative 3.6% growth rate and let's hope that 2020 is when the corner is fully turned and better days are ahead because you've certainly earned them. First question I have again is just looking at your relationship between bad debt and free care is that bad debt has actually declined from 2.9 million down to 2.3 over the last few years and your free care has increased from 383,000 to 438 and I'm just always curious as to whether that is happenstance or is that a planned effort to move people from bad debt into free care and recapture some revenue out of your bad debt portfolio? So I'd like to say that I feel that Gifford is always looking before anything goes to bad debt to make sure that we're working with the patients out front, trying to get them on to payment plans so that they don't get to that level where they have to go to that debt. Overall, I feel that the decrease, unfortunately in bad debt is a reflection in the decrease in our revenue from 2017, 2018 and that's what we're seeing. Our bad debt overall has been holding true to historical trends that we haven't seen an increase or decrease. So one, and just another short one on bad debt, one that stood out was the appendix where you kind of profiled bad debt moving from 2018 to 2019 and the amount that went to collections and what you recovered from collections and you get the gold star of that 52%, according to the data you sent, 52% of what you sent to collections you got, you was recovered. Those numbers are, it's a big number that you recover from collections, 1.7 million out of 3.22 million that you sent. But I'm just wondering that because this is not a rigorously monitored form that we ask you to fill out whether or not that truly reflects your experience that you, from your collection agencies, you get a plus or minus 50% return on what you send to them. I would like to take the opportunity to just schedule this bad debt that you're talking about, the appendix seven. Yes. I'd like to make sure that all of us as organizations are reporting it the same. We did have questions on what is the appropriate way to fill it out, 52%. I clearly thought there was a high probability of that, but the number stood out so much that I had to ask the question. Thank you. I'm looking at your bridges document, you know, where you profile from the rate increase, a 1.3, 1.34 million dollar increase in commercial revenue from the rate increase. But then you have a 3.4 million dollar reduction due to utilization and another 1.8 million dollar reduction due to reimbursement, they are mixed. So that, you know, on a net basis, there is no gain. And I'm just wondering if those shifts in utilization and payor mix are things that you're worried about going forward. I mean, these are, you know, to have your rate go up and have some return from that, but have that offset by some underlying factors. Is that, how serious an area of concern is that for you? Well, our utilization has definitely been our primary concern, you know, in AT, we did see that our net patient revenue did take a serious, you know, a dip. So that is the highest concern. As we communicated, one thing that we have seen is our payment shift. We're seeing that the Randolph is aging and we're seeing that it's moving out of our commercial into the Medicare. And so, you know, that's something I think last year when we came to this group, it was, we were seeing a shift from the Medicaid population actually into Medicare. This year, it was a shift from our commercial payers into Medicare. But again, and again, in the Bridges document, you know, for fiscal 19 approved budget, you're at 19.7 million. And for the 20 budget, you're at 19, just a little over 19 million. And again, there is an up because of the commercial rate, but a down because of utilization. So there seems to be a little bit of a war going on there that I'm just thinking about what does 21 look like and 22 look like if that continues on. So I'd refer back to the previous conversation that with Maureen Youssefer, that's budget to budget. So our actual performance in 2019, our actual volumes in 2019 were much different than what was in the budget. So that's not a real dip in utilization. That's a budget to budget. So, you know, actual to actual would not be as profound a change as that. And, you know, we are seeing some shift as Jeff indicated from an aging population, but it's not as big as it would be indicated in this because this is budget to budget. Can I just, I'll just follow up on what Tom's asking there. What would be helpful is if you could give us a projection, you know, do that bridge chart from projection because you are a hospital that's missing significantly. So I totally understand what you're saying, Dan, because it's going from 55.9 million approved budget to 49.6 for the 2020 budget. But when you actually run the numbers on where you're trending to the new number, it would be an increase. So, you know, what you're showing is a decrease because of the budget to budget, but I think it would be important to have the chart from projection. So to rework the chart, but instead of using the 55, use the projected and then show what it's going to the budget 20 times. Yes. Yeah, that would be good. Again, I'm Bridges and I fully appreciate this conversation about budget to budget. Under Medicaid, you have a changes in accounting of $2 million and what is that? That is our ACO, so this is our purge here. That's what I thought, but I wasn't sure. And I guess my last question is, and it's a common refrain is that when it comes to Medicaid, you assume no increase in Medicaid. Why is that an assumption when Medicaid is a large part of the population that all hospitals serves? Well, that would come down to Medicaid increasing what they pay for reimbursement. So, unless there is a known increase through legislation or other, you know, whatever the processes are, we can't assume that. So, you know, if you're suggesting whether we would support some increase in Medicaid, I can say yes. I'm more than suggesting it. Well, we agree with you. My personal observation as I get deeper and deeper in this, I do worry that the cost shift is an existential threat to all that we're trying to do. And so I raise this issue with most hospitals because I think it's fundamental and structural and something that with the advocacy and the bottom-up can be redirected to some degree. Can I pile on, Tom? Pardon me? Can I pile on? Yes. So, what's been troubling to me, and I made a statement at the end of the day on Monday, is just imagine if the Green Bound Care Board said no to all the charge increases that were asked for by the hospitals, there would be outrage. And yet there doesn't seem to be outrage by the hospitals about government continuing to underfund and ship costs onto a certain part of the population. So, just piling on. So, maybe I should just go on to the next question. Thank you. Thank you. I mean, I'm so serious about this in a way that I looked on the legislative website to see, to make sure I knew who your Senator was, which is Mark McDonald, but I wasn't sure. And I just, you know, having been a dentist in up the state house one time and having served on House Appropriations and having worked with Governor Dean to start a VHAP, I know these things can change, but they can only change if there is a united voice, an illogical voice and a reasonable voice. And all the hospitals have legislators that are their constituents. And if they're not, if they're giving the message that we're just assuming that no increase in Medicaid's gonna occur, then no increase in Medicaid's gonna occur. But I think Kevin's on the right track is that this has to be discussed because those bills still get paid and they result in 10 and 12% increases in Blue Cross, Blue Shield and MVP. And the whole system gets kind of in an unbalanced direction that I think is problematic. So, despite my previous comment, I will jump in a little bit. So we do meet with our legislators regularly and we do advocate for increases in Medicaid revenue. We actually hosted at Gifford, the Senate Health and Welfare Committee this year and we talked about these issues. We hold legislative forums where we talk about these issues and we get back and forth in some of those and some of our suggestions and comments are not, it's not all jovial. Some of them are tough conversations. That's called not being well received. That's called not being well received. And so we do advocate for that. As does Vaz, we also, now we are a member of One Care Vermont participating in the Medicaid program. We are active with that organization as well and do advocate through that means also to ensure that the Medicaid revenues are keeping up. It's, as you know very well and Kevin Mullen knows very well from his time in the legislature, it's not an easy thing, but we do advocate for that and we will continue to advocate for that. And we'll make sure that we follow up if you let you know what we're doing. Thanks. The squeaky wheel gets the grease. Very good. Medicaid, I didn't want to mention that we had heard from Copley that they had received notice in late July that there was going to be a Medicaid rate increase for outpatient services from 10% to 113% of the Medicare APC rates. Did you get a similar notification from Diva yet? Yeah, we did. Do you think that would impact any of your budget submissions in terms of your assumptions? I'd have to go back and look, but I don't think by much. Okay, yeah, it doesn't seem like a huge rate, but Copley did have a number associated so that would be helpful. So thank you for that. I wanted to talk a little bit more about some of the utilization changes, the ER volumes being reducing, sounds like it could be directly related to some of your work with your critical care team and making sure people understand what's going on. So that's actually great news even though I know financially it's not great news, but I think certainly where we want to see care going. I wondered if you could just give us a little more color commentary about if you know what kinds of group causes might be reducing some of the surgical services. And if you don't, that's fine. If you've had any ideas about why that utilization was changing, whether it was related to something you were doing or out migration of people or less need, I don't know. Well, I don't know all the factors and we don't have data to understand all the factors. I do know that as we've covered with you in a couple of, well probably many different conversations that we've had some staffing issues in relation to providers over the last several years. And we have begun to build those back. What is common in my experience in working other places as well, when you don't have someone to provide the service, service goes elsewhere, it doesn't immediately come back. As Jeff had indicated in some earlier comments, we did build back our general surgery volume and we have seen our general surgery program and we have seen that volume return. Dr. White in particular has been doing a lot of work with our medical staff as we have new people coming in to make sure that our primary care providers are aware of what services they offer, that they develop the trust and reliability with those people. And we've also, one of the things we've done is we haven't tried to employ all those positions. We've worked with other parties. I saw the slide that North Country put up before about the different areas where they have physicians coming in from other hospitals into their hospital and where they have physicians from their hospital going outside. We also utilized that type of relationship so that we're not duplicating. Our orthopedic surgery, Dr. White talked about the surgeon that we have that we're working with in orthopedics with Dartmouth-Hitchcock. Again, we're not duplicating, we're utilizing the existing person who is down there to provide a service closer to where people are. So we're doing all of those things, but in some, for most part our issues there were because we lost folks and we're building it back. Thanks. Can you tell a medicine in any way? You didn't really talk too much about telemedicine today and I wondered if you could just highlight what you're thinking around that type of service. We do have telemedicine, telepsychiatry that we utilize. Oh right, no, actually I do remember. I did actually have a question specific to your, thank you. The telepsych in terms of, I hadn't heard of the provider, Altime Health, so I wanted to get a little more information about that. So that is a service that was a program that was started by a physician named Mark McGee, Dr. Mark McGee, formerly of Brattle Row Retreat. So he is known and we've actually had already some good success in utilizing him in what has been a pretty difficult situation. And he is offering, he offers that service to emergency department, our inpatient, and to our practices as well, although we do, we haven't utilized it as far as I know for our practices, but we have for the other two centers. Successful. Dr. White and I attended a presentation at Bi-State Primary Care just in the last month around utilization of telehealth services in different areas. So we are investigating what we might be able to do. We have had discussions with some organizations that provide those services as well. So as of yet, we haven't signed anything to increase that, but we are actively investigating what our options are and how that might benefit our service array and our patients. Great, thank you. Okay, Jess. I guess I'm actually gonna dump a little bit on that the last question that Robin asked in the sense that I know cost reductions are really hard and I've pledged a lot of the efforts that you already have made on that. And I think to some degree going it alone is getting harder and harder, right? I mean, we've got fixed cost rising because medical technology is becoming more costly with that population declining. So you're spreading those fixed costs over fewer and fewer people. And what we've been hearing from some of the hospitals that are really getting themselves out of financial crises is these collaborations, whether it's telemedicine or whether it's sharing services as it sounds like you're doing with ortho with Dartmouth-Hitchcock, but... So I'm wondering if you can speak a little bit too. Do you see more? I mean, you said you're exploring telemedicine right now. It sounds like there's a lot to be learned from some of the other hospitals that have done this successfully. But how about any other kinds of collaborations that would allow increased access to your community, maintaining quality, and perhaps reducing some costs? So we, you know, I gave the example of the orthopedics with Dartmouth-Hitchcock. That's one of probably six or seven or eight areas where we do those types of collaborations with whether it's with Dartmouth-Hitchcock or whether it's with UVM or whether it's with Central Vermont. So we have a number of those collaborations. We also are collaborating within our local communities. Rebecca mentioned Health Hub. That is a mobile dental service. That is a much more efficient way of our offering those services within our community than it would be for us to create our own service. We, you know, we work with a number of different entities to provide services in a more efficient manner. Is there any more opportunities? I mean, can you see any future? You've made more progress on that front. We've talked with, I think, every hospital within whatever the radius is, 50 miles, about sharing services, about sharing medical services, about whether that's our having two days a week of a particular service, they're having three days, rice versa. The big obstacle right now is where are we gonna find the people to fill those positions where we both have needs? We have a process, again, similar to what Brian was talking about with North Country and looking at the service line planning around what services should be provided in our community and what we're looking at are what are we referring out to other areas? What are the areas where there's a highest number of referrals going out to those areas? And then taking a step back and saying, okay, is it appropriate for those services to go elsewhere? Or is it would be more economical and better for the patients if they were provided in the local community? And then if that ladder is the answer, then how do we provide that? Is that something that there's enough volume, enough need, and it's efficient enough for us to hire that service, bring in that service? Do we do it that way? Or do we partner with another organization? So we also have that process where we are embarking on that. And again, we've talked with pretty much every hospital within 50 miles about where we can do that. Everybody is on board with doing that. It's a matter of figuring out where we find the human resources to to have success with that. And when you just mentioned, do we have enough volume? So you heard my earlier questions around the relationship between volume and quality. So how do you figure out what enough volume is to maintain a certain level of quality, knowing there is a correlation, at least on some procedures and surgeries that you need to have a certain amount of volume to achieve a high quality outcome? How do you figure out what that number is? Because I have not been able to find in the literature some of these, I mean, there are some minimum volume standards for some procedures that I'm seeing some hospitals adopt. But again, there's a lot of procedures where there don't seem to be this. How are you figuring it out? Well, we don't have that hard and fast metric either that you've found so elusive in the literature. We have implemented when we have new providers coming in, in our credentialing process, we are asking for information to indicate either through training, if it's someone who is new into practice or through their past experience that they exhibit a expertise in that area, that a proficiency in an area if they're doing a particular procedure that they're asking to do it differently. So we do ask for that information. Our medical staff, the credentialing committee then looks at all that information and determines whether they think it's appropriate for that service to happen at Gifford. We're also taking into consideration what are the other supports that are needed in order for us to provide a particular service? Do we need a higher level of nursing expertise or do we need particular other ancillary services around that and whether that's economical for us to do that? If it's not, we don't do it. So there's a lot that goes into it and there's no easy playbook to say, okay, you check X, Y and Z and then you can provide it. But we put as many safeguards in place to ensure that we're gonna be able to do something safely and appropriately and at a cost of care that's going to be appropriate for the patient and for the healthcare community. Are you, I couldn't remember this and I should have looked quickly but I'm sure you can answer this quickly. Are you part of a purchasing group? We are, yeah. So drug costs and supply costs you've been able to? It's called health trust. Health trust, okay, thank you. So speaking of the total cost of care, you knew I was gonna ask, right? So everybody was prepared for this. But we put in the budget guidance, a table that was provided by the Green Mountain Care Board, not risk adjusted, not limited to care at Gifford. It's the residents in your community. I think we've seen that chart now twice this morning because the other hospitals have put up some data. So total cost of care for capita in Randolph is the highest in the state and the growth rate is 5.7 compared to 3.9 for the rest of the state. I understand that's not risk adjusted. So when you look at the blueprint profiles, that's also suggesting that the Randolph area has high total cost of care. And Dr. Wainer really appreciated, sounds like you all have been doing some deep diving into understanding that data and the one care data is starting to help you to figure out where there are variations in cost relative to other parts of the state. So it sounds like you're really starting to dig into this. And I think, I speak for myself, I appreciate that because we do have some commitments to the federal government in terms of meeting a 3.5% growth in total cost of care. So understanding the areas where that might be growing faster or the absolute levels are higher is really important for us to understand. The blueprint data is risk adjusted. And so to some degree that levels off a little bit of the playing field, it's always not risk adjustments are never perfect. But it's still pretty high. And so it's still high even with that risk adjustment. And when you look at it, the resource use is high, inpatient discharges are high, imaging rates were high on that metric as well, particularly for low back pain that tends to be an indicator of over utilization, right, if it's imaging for low back pain. And the preventable hospitalizations were high and flu shots were low. So I guess my question, when I look at that and I don't have a full understanding of the full story and you all have been digging into it, I wonder, is there enough primary care delivery in your area in the sense of if flu shot rates are low and ambulatory care sensitive hospitalizations are high and you're starting, so I would ask you, what do you think about that? Could that possibly be an issue around primary care, utilization, access? Is that something that could be driving some of that? I think that that could be a factor that plays into it. I, one of the reasons that we're utilizing the one care data for us to tackle these issues and we are actively tackling all those issues and trying to understand all those factors and devise actions that will be effective. But the reason that we're utilizing the one care data for that is that it gives us the opportunity with patients who are actively engaged, at Gifford currently, for us to make that impact. What we can't do is go back and look at data that's further back and we don't want to do that because it doesn't, again, doesn't allow us to necessarily work with patients who are coming into our practices now. We've talked about in our previous time sitting in these chairs, our struggles with bringing in primary care in the last several years. We've seen over the last two years, our visits in primary care increase significantly. So we think that we are making up some ground there and our expectation is that over time, having better access to care and primary care, having significant initiatives that we have in place based on data that indicates where we have, where we need to put attention, we think those two things are going to begin to have positive impact. But it also doesn't, that kind of change does not occur overnight. So we're hoping we get back here next year. We'll see some incremental change there that we can point to, but we are, I can assure you that we are actively engaged in that work and very serious about changing that. Well, I believe you and I really appreciate that, yeah. Two quick questions then. What is your average daily census, sort of the min and the max? We've been hearing from some hospitals how they swing. So I'm just curious to you, you've got your 25 beds, but what would be a min and a max over a month, say? We are seeing fluctuations from 18 all the way up, I mean from, excuse me, eight all the way to 23. So how do you staff when you have a day with eight and a day with 23? Very carefully. I mean, is that part of your cost issue of those swings, right? I mean, how do you staff with that? It is. As I noted before, I probably wasn't quite as specific, but those are some of the things we're looking at if we have our daily huddle at 7.45 in the morning or seeing that our census is quite low. We are doing low census staffing, whether that's in our nursing area. It also might impact our nutrition and food services because we don't have as many meals to serve that day. Maybe our environmental services, we don't have as many rooms to turn over that day, et cetera, et cetera. So we do that to the best of our ability. You do have to have a minimum level of staffing available and then who knows? There might be, you know, we may have a surge in the emergency department and we go from a census of eight to a census of 17 or 18 within a five hour period and we have to bring some of those people back. So it's not easy to do. It also impacts your staff who are being called off and put on low census a call. So that's difficult, but we do manage it very quickly. Does that hurt recruitment? It can, you know, I can't point to it right now and I think we've had better luck in the last year in regard to our staffing in those areas, but it definitely does have an impact. As Jeff noted in going through some of the stats, we've had as many, we've hit our targets in terms of our budget in terms of the number of patients we've had in the hospital. Our discharges are on par with our budget. It's the length of stay that has changed. That's a good thing. You know, that means that we're reducing our length of stay for orthopedic procedures. It indicates that some of those quality projects that Dr. White talked about, they're having an impact that lowers the total cost of care. So those are good things. But there's a lot of work that has to go into it, a lot of management that has to go into it to ensure that we still have highly qualified, engaged people caring for those patients day to day and year to year. Thank you. All right, so my final question is this is really just trying to get a sense of relative pricing. So if on average Medicare reimbursed $100, what would the commercial average reimbursement be? Did that calculation about $166? Thank you, appreciate it. That's it for me. Thanks. Dan, if miraculously we could convince the state colleges to start a PA program, would Gifford be willing to step up to the plate to create some clinical placements for students? For a PA program? Yes. We would. We already do that. Yes. But I think you're doing it with an out-of-state institution, right? Yeah, we do that with a number of institutions. From a PA perspective, we work with Franklin Pierce. We also work with a number of nursing schools, including places like Norwich and VTC. There has been discussion about including residency experiences for general surgery as well. Perfect. When you, could you actually describe what your process is, what your methodology, what your calculations were to determine that 5% was the appropriate change in charge to ask for? So again, and I think we're going to be resonating with the other organizations that have communicated, it's our budget process to begin with. We go down to the departmental level. We ask them for the key, what is their volumes? What are their expenses? That's step one. We make sure we ensure that the expense, we run it through multiple passes to make sure that we have our true expenses. We figure out what our net revenues would be without the rate increase. And then we look at basically what we need our operating margin to be. And then I'll account for what the rate increases from that point. And it looked like from your submission that your 5% seemed to be across the board. You didn't selectively target areas, correct? Our net, when we actually institute a rate increase at Gifford, the first step that we do is we look at all our supplies, our pharmaceuticals as well as our menstrual supplies. We then go through and we make sure that they, we raise those according to what they're costing. Then we'll take a look at what our overall rate increase, what that has consumed. And then we'll spread the rest based on SO that we do come in at the average. So we do have, it's not an across the board. We'll actually make sure that our supplies are priced appropriately, that our pharmaceuticals are priced appropriately. And then whatever they consume, whatever's left, we then apply it to the rest of the charges. Okay.