 Okay, it looks like everybody is here who needs to be here, so I'm going to kick us off. Good morning, everybody. My name is Jessica Holmes, and I'm currently serving as the interim chair of the Green Mountain Chair Board. Today is our sixth and actual final day of our hospital budget hearing process. So we'll be hearing from both Copley and Northeastern today. Just as a quick reminder, I've been saying this at the opening of every meeting, but to arrive at our decisions for each hospital, we're going to be looking at our statute and our hospital budget rule for the guiding principles. We'll have to balance competing factors. On the one hand, we need to think about the growth in health care expenditures and efforts to slow those down. But on the other hand, we need to ensure that our hospitals have the resources they need to recruit and retain health care workers and provide the high quality care that we've come to expect in our communities. So as we attempt to balance cost containment and access and quality and ensure that our health system is sustainable, we should be mindful of this year's incredible headwinds. We've seen historically high inflation rates. We're seeing workforce shortages. We're seeing workplace violence. We're seeing provider burnout. And we're still experiencing the impacts of the pandemic. So both nationally and in Vermont, hospitals are facing unprecedented financial challenges as our businesses and families and individuals. So over the next couple of weeks, and at the end of today's meeting, I'll give a timeline about our deliberation and voting process. But over the next couple of weeks, we're going to be approving the hospital budgets for our 14 community hospitals. But in the meantime, I want to remind everybody that the board is working very, very closely with the Agency of Human Services to begin the work that was outlined in Act 167, which aims to move us closer to a more sustainable hospital system that ensures that homeowners have access to high quality, affordable care. That work is going to involve a lot of data analysis and real hospital and community engagement. And the hope is that the result will be a more sustainable path forward. So I'm going to turn us back to the hearing today. And as I do that, I want to extend a thank you to both the COPLI and the Northeastern teams for the time and effort that you've taken to prepare and submit the documents for our review. And a few housekeeping notes about the hearings today. The presentation is a public meeting. It's being reported and transcribed. So there will be a publicly available record. If at any point during the presentation or during the questions and answers, the hospital's leadership team feels that there's some confidential information that the board should consider, please just alert us before responding. If needed, we can go into an executive session and review confidential information from hospitals. Executive sessions will be limited and spoke just to that, which will be provided by the open meeting law, limited information such as contracts and information that would be deemed confidential under the Public Records Act. So if one of these potentially confidential issues arises, I can call on our legal counsel to determine the scope of what could be discussed in that executive session. And if deemed appropriate and at the appropriate time, ask the board member for a motion to go into executive session. It's 1.30 on my computer's clock, so that means we can start. So good afternoon to the Northeastern team. It's great to have you all here. And I just want to actually take a minute, Bob, it's nice to see you. And I want to take this opportunity to thank you for all your decades of service to the people in your community. I see there's a transition happening there. And I know you've been a very responsible steward of the financial resources of your community. And so I've always appreciated your hard work and your candor and clarity while I've been at the board listening to your hearings. And I just want to wish you luck on the next chapter of your life. And I'm glad you're here today. I suspect the last official time we will see you before the board. So thank you, Jessica. Very thank you very much. Appreciate it. Yeah, this is my 24th and final. And as I said, I'll say it again. I mean, this is the highlight of every year presentation. This is what I'm going to miss most about not being a CFO in VRH. Well, Bob, we can make that happen for you. I can get you a special invitation every conference. I mean, we can deliver that VIP kind of thing. And you can come anytime you want. We did try to talk him into going for one of the open seats. But he prefers retirement. Well, you mean people don't want this job? Are you kidding? Well, I wouldn't do as good a job as you guys do. All right, well, I think we are ready to transition over to your presentation. Before we do begin, we need to swear in anybody that's planning to present or answer any questions today. So I'm going to turn it over to Russ McCracken, our legal counsel, who can take care of the swearing in for us. Great. Thank you, Chair Holmes. This is Russ McCracken, attorney for the board. Who from the NRNVRH team do you think is going to be speaking and presenting today? We probably all might, except Dr. Ruth, who's on the list, but he's not here today. So everybody else will probably have something to say. All right, sounds good. I will go ahead and swear you in if you could raise your right hand. Do you solemnly swear that the evidence you shall give or relative amount of under consideration shall be the whole truth and nothing but the truth. So help you, God. I do. Great, thank you. You're sworn in. And one other favor to ask. It's really helpful for the transcription and the court reporter if for the first time you speak, if you could identify yourself by name. And with that, I will turn it back to Chair Holmes. Great. Well, thank you. And I think it sounds like I'm turning it over not only to the Northeastern team, but also to Kara to load up the slides. But you guys can take it away. OK. Thank you. Thank you. So hi, everybody. I'm Sean Tester, CEO of Northeastern Vermont Regional Hospital. Kara, we can move right into the introduction slide. Really pleased to introduce my team who's here today. One more slide. OK, so as Jessica indicated, we are in a bit of a transition here. So I'd like to introduce Andre Bissonnette, who's on my right, your left, now our Chief Financial Officer. He loves this process so much. This is the second time around within the last two weeks. So thank you, Andre. We're pleased to have him here on the team and back in the North country. Behind me, I have Sean Burrows, our Chief Information Officer, who's been with us since 2017. Diana Gibbs, one of the other newer members of our team. This is her second round. Joining us last year, she weighs 50. Betty Ann Glockin, our Chief HR Officer, here since 1999. Laura Newell, our VP of Operations and Medical Practices, here since 2013, almost coming up on a decade. Who is not present is our Chief Medical Officer, Dr. Michael Ruse, who is on a much well-earned vacation. And we also have Julie Schneckenberger, Chief Nursing Officer, member of the team since 2013. And she's over here behind me as well. Our special consultant, longtime member of the team, Bob Hersey, in his farewell event. So thank you. I want to just go to the next slide and just give a quick overview of NVRH. As a reminder, and for those of you who are new members, joining us, we're an independent, non-for-profit, 25-bed critical access hospital, serving the half of Essex County and all of Caledonia counties of Vermont, a population of about 30,000 people. Our emergency room visits run about 12,500 annually, given there has been some fluctuation with the pandemic over the last couple of years. We have 15 medical practices, 11 specialty practices, and four rural health clinics. And we have about 711 employees. Our mission is to be a leader in improving the health and health of our community. Next slide, please. Oh yeah, you want to do this, right, Bob? I can, sure. Bob Hersey, the staff person, former CFO. So I'm just going to highlight a few things about a 2023 budget. I think I just start by saying that 2023 will be a transition year for NVRH. For several years in a row, we were able to generate a positive operating margin, typically between one and a half and 2% of our operating revenues, until we hit fiscal 2022. And we're going to have a loss, as you've probably seen, of about $1.9 million. So 23 is transitioning us back from a negative operating margin to a positive, modest positive operating margin of about 0.4%. And that's part of our strategy to get back to where we had been, someone that one and a half to 2% operating margin range. Part of that transition will require us to have a 10 and 3.25% average rate increase for our services. Another part, and you've heard us, I think, every year, practically say we expand and add services as needed to meet community needs. And fiscal 23 is no different. We're doing the same thing again in fiscal 23. We continue to focus on reducing our affordable ED visits. ED visits, you'll hear more about that. I do want to highlight that although you will see trends is up a little bit in ED visits, it is then about 15% from pre-COVID time. So we're still again tracking and doing well in the avoidable visits and reducing overall ED visits. And we are expanding our participation in value-based payment programs to include Medicare. We will be part of the Medicare risk program. We worked with One Care Vermont to come up with a risk strategy that we thought would be compatible, palatable, and appropriate for a critical access hospital. So we're very happy to be able to expand our participation in value-based programs. Next slide, please, Karen. So if you'll indulge me, I did prepare some opening remarks that really speak to what you're seeing on this slide here. And I'd like to open with those. First off, I want to give a big shout out to the entire staff and clinicians that make up the NVRH family. After two-plus years of the pandemic, it's really their hard work and the commitment to our patients that's helping to ensure the health and well-being of the communities that we serve. While we present our budget today, I just want to remind everybody that this is not about a budget. It's really about providing care to our patients who are also our friends, our family members, and our neighbors. We are passionate about our mission and that is what has sustained us through these very challenging years. Over the last two years, I've said a number of times that while I was confident we could successfully manage patient care during the pandemic, it was what I call the long tail of COVID that I was most worried about. What you've been hearing over the last two weeks from all the hospitals is just that the long-term fallout of a global pandemic whose impacts will be felt for years to come. These impacts include significant and growing workforce challenges, a stress system facing severe capacity issues, long-term underinvestment in facilities and infrastructure, and unprecedented inflation. Regarding workforce, I really think it's important to note and recognize that our staff are stretched in. These heroes, our nurses, LNAs, techs, clinicians, and support staff are frankly exhausted. While workforce shortages predate the pandemic, they're much worse today. NVRH currently has over 50 unfilled positions despite our best recruiting efforts and I think we're in better shape than many Vermont hospitals. We've been gap filling critical nursing shortages with traveler staff at a significant cost to our budget and that challenge will continue. Despite that, we've made long-term investments in workforce development, including partnering with the Vermont State College System to expand nursing programs on our Linden campus, supporting LNA programs that are local high schools and adult education programs and enhancing internal education programs to help grow our staff. Unfortunately, these years are gonna, these investments are going to take years to bear fruit. I also should note that on top of the workforce shortages, we have a regional housing crisis and that is compounding our challenge around recruiting professionals to this area. Meanwhile, the entire healthcare system is at or over capacity. We're seeing a continued rise in mental health borders in our ED and with that, we've seen a rise in workplace violence which is contributing to our own workforce challenges. This is also compounded by the fact that our local law enforcement agencies are understaffed and they are strained to respond when there's an event here at the hospital. We struggle to place post-acute patients in acute care facilities and as you know, the region's SNFs have their own problems. And finally, our tertiary care facilities are operating at or near 100% capacity, meaning that our smaller hospitals are keeping sicker patients longer or sending them farther and farther away to receive appropriate care, which is really hard on the families and caregivers who support those patients. Years of frugal budgets have also meant delayed investments in our infrastructure and now construction inflation is making long delayed projects even more expensive than they were before the pandemic. For example, our emergency department, which was built 50 years ago, that's five zero years ago, cannot cope with the volume and complexity of today's patient population and is in dire need of expansion. Twice this week, we had medical surges where capacity in our emergency department was 200% of capacity. Now, in the coming slides in this presentation today, you're gonna hear us expound in more detail on these issues and more. We are committed to serving our community and we're gonna be here for our patients and this budget cycle represents a defining moment for Vermont's healthcare system. After years of limited investment, we'll take the steps necessary to capitalize, to stabilize the system and we need your help in support by proving the budget that you see presented here today. Thank you. Next slide. So this is a snapshot of our income statement. On this slide, I just wanna highlight the projection for 2022. As I mentioned, it's a loss of about 1.9 million. I also wanna point out that this is higher than the budget, the loss we projected when we submitted the 23 budget back in early July. We've had some significant downturn in some, upturn I should say in some of our expenses that's created an even more significant loss than we had expected. And you can see that again in 2023, we're planning to get back and have a positive upward march and again. Next slide, please. So our budget to budget NPR growth is about 13%. These are the components of that. It's a rate increase, as I said, it's about 10.75%. And you can see it only affects the commercial and self-paid population, raising our rates does not affect reimbursement for either Medicare or Medicaid. But we're looking about a 4% utilization, overall utilization increase. And you can see that that's distributed amongst all the major pay groups. Our fixed perspective payments are going up about 731,000. And part of this, if you look at a couple lines down, you'll see a drop in the Medicaid pair mix. And what I think we're seeing is an increasing shift from the FIFA service Medicaid to the fixed perspective payments Medicaid. We did have one provider acquisition that is included in the 23 budget. That's a podiatry practice. And we'll talk a little bit more about that. Looking down under the Medicare reimbursement pair mix, some of that is a little bit of an increased Medicare pair mix. But a lot of that has to do with our cost report impact. Medicare's reimbursement goes up as our expenses go up. That result of our being a critical access hospital. So although rates don't affect our Medicare reimbursement, our increased costs do. And that's what we're seeing in that line item. The thing I just want to highlight here is we used to have Medicare replacement as part of commercial. Really wasn't correct. And what we're seeing is more and more of the Medicare population opting for the replacement Medicare products as opposed to the traditional Medicare. So we want to make sure we corrected that as part of this year's reporting process. Next slide, please. Thank you. That's again requesting a 10.75% increase, assuming it's approved. Our five year average rate increase will be 4.7%. I had been about three and a half to three and three quarter percent and again, we're asking for a more significant increase this year. Each 1% of a rate increase yields about 436,000. Again, that's from the commercial and self-paid population and how we're going to achieve that rate increase is increased hospital service charges by about 12%, a little bit, 12%. And we will not increase the provider service fees at all. Last year we had a charge description master analysis done. It took a look at us compared to some of the peer hospitals and we're going to use that as a guideline as to how we're going to increase our rates. The MPI increased utilization and services growth. You see the list here. There are a couple that I didn't put on the list that I should have highlighted at this point. And those include laboratory and infusion drugs. Our lab services have increased significantly. A lot of that is to do with referrals from the Norris Cotton Cancer Center, which is down the hill from the hospital. They're seeing an increase in population, particularly from out of our service area. And those patients are coming up here for labs. So that's part of what's driving it in addition to some of the COVID testing. And our infusion drug program is very busy and as you may have heard from others, those infusion drugs are incredibly expensive. So as our volume goes up, the cost of those drugs goes up and that's part of our utilization increase. We continue to be a more of a regional provider every year. Services like pulmonology, podiatry now, neurology and a lot of major joint replacements that are now patients are coming from outside of our service area for those services. We continue to use telehealth. We're appropriate, you know, it's often a great resource and a great tool to connect with patients. So in our primary care practices, we're doing about 10 telehealth visits a week. And just a small note that the NPR increase from the depediating transition is worth about a half a percent of our NPR growth. Next slide, please. So I am going to stop for a minute and turn it over to Laura to highlight this slide for us. Good afternoon, everyone. I'm Laura Noel, the vice president of operations and medical practices here at NVH. A little bit of historical knowledge on the slide. NVH began working on reducing our avoidable ED visits about four years ago at the 2019, I believe, Green Not Care Board hearing. We've committed to the board that we would continue to present this data to the board each year at our hearings. As you can see on the top portion of the slide, we've reduced, we've continually reduced our avoidable ED visits by quite a big percentage. We've done that by, we started a campaign back in 2018 called Call Your PCP First. We collaborated with our local group of federally qualified health centers and started sending out postcards, doing different media pushes to encourage patients to call their primary care providers first prior to going to the emergency department. The following year and 20, well, actually through the following year, we began a partnership again with our federally qualified health centers to develop a model called Northern Express Care. Northern Express Care opened its first location at Corner Medical in Lindenville in early 2020 and we opened another location for, excuse me, our partner Northern County has opened a second location standalone in St. John'sbury in late 2020. Northern Express Care provides walk-in primary care services to our community. When you look at the section below the line graph, you'll see the top yellow graph represents our ED visits and the bottom, the orange line and the blue line represent our Northern Express Care visits. The gray line is a combination of all Express Care visits. What I really like to highlight in this graph particularly is the pattern. You'll see that when ED visits are up, Express Care visits are up and what that tells me is that we're doing the right thing. One is not replacing the other. So visits are going up and they're going down in the same pattern. So that shows that Express Care is really a benefit to our community and really helping to drive these lower avoidable percentages that we're seeing. Thank you. Next slide, please, Karen. So this just shows in a graph form the trend of our rate increase requests going back to fiscal 2019. From 19 to 22, the average is about 3.5%. When you factor in, what we're hoping will be approved for fiscal 23, it brings a five-year average up to 4.7%, that is 4.7% average of the five years. Next slide, please, Karen. In this slide, I've tried to illustrate the components of our 10.8% and 3.25% rate increase. It does require a little explanation. So if you'll bear with me, I'll dig into the details a little bit to explain it. So if you look at our inflation increase, it was about six and a half million dollars. Some of that is gonna get reimbursed by Medicare, right? Because again, our cost-based critical access reimbursement will have some of those inflationary costs covered by Medicare through the cost report process. What's left is about 4.1 million dollars. And if you think again, each one of our rate increase represents about 436,000, that's a 9.3% increase, right? So the 4.1 million divided by the 436,000 is about 9.3%. And so that's how that formula works for each of these categories related to costs. So again, the other salary increase, same kind of thing. What's left is, it requires after medical, what's left of the increase after Medicare reimbursement is about a 2.1% rate increase. Again, same with the cost of the travelers. The provided tax increase. The cost shift increase is just, what that increase is, Medicare is not participating in that. They're part of the reason for the cost shift increase. So we need about a 3.2% rate increase to cover that. Some more for our uncompensated care increase, Medicare is not participating in that. But then those increases are offset by volume. So a volume increase, again, using that 436,000 as a denominator, allows us 6.2% less of a rate increase. The cost savings we've achieved, about $1.7 million. After the last reimbursement, in this case, from Medicare, that reduces our rate increase request for by about 2.4%. So hopefully you add all those together about 10 and 3.25% and that's how we get to our rate increase and the components of it. Next slide, please. And some of our payer assumptions for the year, no major changes with our commercial payers contracts have been included in the budget. We do not anticipate any changes to Medicare critical access payment rules during fiscal 23. Nothing has come across my desk, at least. I wrote, there's a slight decrease in Medicaid fee schedule, but that's really minimal. It's so insignificant, I probably should not have put it on there. So just disregard that, pretend you don't see it. We, as I mentioned, are going to participate in the Medicare risk program. We're not in the AIPBP model, the all-inclusive population-based payment model. Again, we worked out an arrangement with OneCare that minimizes our risk. It does not affect our Medicare cost report reimbursement, which it was a big change as well as to reduce risk. So that allowed us to participate in the Medicare risk program. That'll be starting in calendar 2023, right? Because OneCare programs start on a calendar year basis, not a fiscal year basis. We don't expect any significant changes in our uncompensated care trend. We're not changing our policies at this point. We, there was a little bit of an increase in uncompensated care as a percent related to, frankly, like the rate increases we're expecting. Our rates are going up, other hospitals we have seen are gonna have rate increases as well. And what we're anticipating is that may result in more healthcare costs being passed on to employees, which may bump up our uncompensated care a bit. So that was factored into our fiscal 23 budget. Next slide, please. So our one adjustment was the podiatry clinic. We had a long time podiatrists, I think the only podiatrists in the Northeast kingdom retired before doing so. They tried to bring on a partner to take over the practice, but was not able to do so. And again, this is an example of Andrea R.H. needing to help meet a community need. So we agreed to take over and set up our own podiatry clinic, but started actually this week. And so you can see in fiscal 23, we anticipate about $490,000 of new net patient revenue associated with that clinic. Again, it's incredibly needed in this community and we're fortunate that we were able to step in and again, meet that community need. There are no other county changes adopted in 22 or 23 that affect our income statement or balance sheet. Oh, cash flow. Next slide, please. This iChart tester is our other operating and non-operating revenue. A couple of things to highlight here. Our 340B program is dropped and continues to drop. You know, the big pharma continues to exclude drugs being eligible for that 340B program. And what we're also seeing, at least in this community is the impact of Walgreens not being able to provide full service pharmacy, retail pharmacy to the community. And we've seen a fairly significant drop in Walgreens revenue that has not been picked up by others at this point. So we're doing a little bit of research to find out what's going on there. But we see this is an increasing risk in our 23 budget. You know, we budgeted a little bit of a pickup. We are working and doing what we can, working with our providers to find alternatives that would, drugs that would be 340B eligible. But I am concerned that we may not see that growth in a 22 budget, 22 projected to the 23 budget. Again, that's a risk at this point. The reference lab work is that we do a lot of reference labs for our QHC partners and that's what that is. We do not anticipate any more PRF funds. We got 2.4 million dollars this year. Fiscal 22 that was not anticipated. We don't foresee that happening again in fiscal 23. Just non-operating revenue is here, primarily gains or losses. We do have a little bit of investment income is non-operating revenue. But the major component of non-operating revenue year to year is gains or losses in our invested funds. And some of you have heard me say for many years, if I could predict what the stock market is going to do, I would not be sitting here today. Next slide, please. So this is taking a look at the expense side of the income statement. You can see we're looking at about a 12.5% increase in expenses, inflationary does an appendix that the detailed a lot of this. I will say that that salary number, a lot of that is also inflationary. It's a combination of some carryover of increases we gave early in fiscal 22 and late in fiscal 21 even in the impact that the salary increases have on our employees of paid time off benefit program. Travelers, if you look again on a budget to budget basis, we're increasing expenses by about 1.8 million. But I need to highlight here that if you look at where we are in fiscal 22 projected, our travel expenses are about 4.4 million dollars. So we've actually reduced travel expenses from 4.4 to about 1. I'm sorry, to about 2.6 million dollars. But that still results in again, about a 1.8 million increase. So we're doing what we can. We've had a lot of success and we'll continue to hope to have a lot of success reducing our reliance on travelers, but that still continues to be a significant cost to us and other hospitals. The drug costs here is, as I mentioned previously, a lot of high costs and huge in drugs for our patients. And that's what we anticipate on a budget to budget basis, the increase in those costs will be. Provider tax is just the function of our net patient revenue going up, right? That's a 6% of our net patient revenue and that's where that calculation comes from. We were able to achieve some significant cost savings. We have a two year, what we call sustainability program at NVRH that incorporates pretty much every employee in the hospital is part of this program to help us identify some opportunities to reduce expenses. Now we have a two year goal to reduce expenses by about three and a half million dollars. The fiscal year plan was about 1.7 million. As you can see, we've achieved most of that goal, actually it's rounding it's, we've achieved all that goal for fiscal 23. A lot of that is efficiencies departmentally and with our providers, we have lost through retirement several providers who won't be replaced, but their patients and their volumes will be picked up by other providers that are here. So we're achieving those savings without really any change in our net patient revenue. We also made a significant change in drug formulary as it relates to surgical patients that will save us about the $400,000. Again, that's part of that cost savings. The next line item, this I mentioned a little bit about orthopedic and major joint patients. The volume continues to increase and this just focuses on most of that 400,000 cost of joint replacement pieces, prosthetics pieces. The physician transfer is again, the podiatry related cost. You saw the revenue going out for that practice and this is the expense side of the equation. The other things that only have any things to highlight major volume to 1.4 is our estimate of what the volume increase does to our expenses for the year on the budget to budget basis. Next slide, please. Our operating margin trends, you know, just what I had said previously, we had pretty consistently had about one and a half to 2% operating margin and then a little bump in the road in 2022. And again, our plan to 23 is to get back to a modest operating margin of about 0.4%. So this just again, illustrates what I had said previously. Next slide, please. So our operating margin and total margin, I feel like I've said this before. The five year average is 0.7%. Returning to a positive margin at 23. Just again, going back to our longer term strategy, we need to get to about a 2% operating margin starting at fiscal 24 and beyond to support all of our operations. But in particular, as we look to our West Wing expansion project with a cost of about $19 million to support that project in addition to all of our other efforts we're gonna need to get back to that 2% operating margin range. Total margin, a total margin is just operating plus gains or losses on investments. As I said, I don't say that. I don't budget those gains or losses on investments. Next slide, please. This, another I-Chart test. What I just wanna highlight here are our cash. You know, our days cash on hand have dropped. We submitted this, there are about 105 days and that's a pretty low level for NBRH. And we wanna be more in the 125 plus range. So you'll see in a couple more slides. We have a strategy to get there, but the balance sheet, the most concerning thing here on the balance sheet is our cash position which we want to improve and have a strategy to do so. Next, please. We were asked to present a cash flow budget summary. So here it is, you know, our plan is to increase cash slightly and by 235,000 heading in the right direction. So the key component of this is to get that gain from operations back into that $2 million range. And obviously that will help us generate more cash. Now here, I just wanna highlight when I say investment in PPE, that's not investment in personal protection. We're not going out and buying $4.5 million of gloves and gowns and stuff. That's property, plant and equipment, PPE in this case. Next slide, please. And here's part of our strategy, you know, to gain, to get those days cash on hand to back up. We turn to the positive operating margin. Fiscal 23 is a first step towards that. Our financial sustainability program I mentioned to gain the goal of about $3.5 million over two years. And we've had to peer back capital spending in 22 and 23 to help preserve cash. On the positive side, looking at our balance sheet, our capital structure ratios are still okay, which is important as we're going to need long-term debt for that West Wing project. So we need to be able to demonstrate the ability to repay and so our debt capacity ratios indicate that we will be able to take on that debt and we'll be able to pay it back. And that's it for me for now. So next slide, please. And we'll turn it over to Diana. Diana. Yeah. Correct. Hello everyone. Diana Gibbs, vice president of marketing and community health improvements here in the back. I just wanted to really illustrate for you the breadth and depth of NDRH's reach in our community and here in the hospital around equity. So starting with community priorities in that community health lens, NDRH really has been a leader in our health service area around community health improvement, addressing gaps in our continuum of care and really looking at opportunities to enhance the efforts that aim to really address our health inequities experience in our population. NDRH has worked really hard to continually monitor the needs of our patients and communities and in turn develop collaborative solutions with our internal and external partners, including the health and human service partners here in the Northeast Kingdom. Over the last 10 years or so NDRH has really been a leader around bringing these critical community partners and organizations together to build the NNK Prosper accountable health community model. NNK Prosper's broad sector representation really allows for this unified response and an aligned vision that allows us to really be responsive to the ongoing and emerging needs in our vulnerable populations here in the community, addressing those root causes and social drive versus poor health. Our shared vision as you can see on the slide here is really to have a community where everyone has the opportunity to be financially secure, mentally healthy, physically healthy, well-nourished, and well-housed. In the last year we've engaged our partners in regional training through the Vermont Community Health Equity Partnership to advance our knowledge and capacity to evolve in shift decision-making to ensure a high level of engagement from our most vulnerable community members. And this is an ongoing effort and we do have the support and partnership of all of our NNK Prosper organizations who are part of this necessary evolution. Kind of bringing that back to our NBRH health care system, we really do have great systems in place, workflows to conduct universal screenings across the social determinants of health to really pair social care and health care for that whole person wellness. We have programs and resources that provide additional support to our providers and our practices through our Community Connections program, staff by trained community health workers who can provide navigation assistance with needed resources, connections to care. They also have some unmet needs funds to help with financial assistance, raised through our philanthropy efforts. We have transportation vouchers for rise to appointments, the wellness appointments, and the support. And we also have navigators to assist with health insurance enrollment and provide health coaching on a non-clinical basis or in product abuse management and tobacco cessation. We also have language-wide resources available on demand to really help meet access needs for anyone who might choose NBRH for their care needs. NBRH also supports some youth substance misuse prevention programing and through their strategic planning process supported by some NNK prevention service funds. They have identified DEI, excuse me, as being at the forefront, looking at our LGBTQIA plus and BIPOC populations as having greater needs for support in our communities and have youth funding and infrastructure and money to really support those efforts in schools and really looking at creating gender and sexuality alliances and schools and supporting a lot of those needs. As we know from youth risk behavior survey data, those populations that I've just identified are about two and a half times higher, are more likely to experience mental illness and or substance use at two and a half times their heterosexual or cisgender peers. And really, really not back into NBRH and our systems internally here. It's, DEI is incredibly important test in terms of workforce and patient care. We as leadership team here have had at-lakes discussions on this topic and have recently identified the needs to understand where we are and where we aspire to be. And we've applied for some funding through the Vermont Community Foundation to help us potentially acquire our consultants who could help us work through the process of really understanding what our baseline is and what those opportunities are for us to continue to work toward a culture of equity. And we do feel that this process will really help us to inform our next strategic planning process, really examining those interpersistent challenges that individuals in our community face. I'm more hopeful that this DEI plan will really be a blueprint for operating parameters, elevating NBRH's programming to be more inclusive and diverse, meaning any unique healthcare needs of our priority population. And at the end of that, we really hope to have a well-informed staff who can make more mindful, culturally and emotionally intelligent decisions, both in terms of clinical and administrative operations that will enhance the work that we're doing already. And at the end of the day, it's our goal to ensure that we have broad engagement across NBRH from the leadership down through to our staff and stakeholders and the community to have a diversity of voices in the efforts to reassign who we are and who we seek to be in this post-pandemic environment. Thank you. Next slide, please, Karen. And I'll turn it back to Laura Newell. Hi, I had provided some more information in the supplemental data, so that will give you some explanations on this, but what I did want to highlight on this slide was kind of right where the mouse is, pulmonology. You'll see the low percentage of 9% under the referral lag percent or appointments scheduled within 72 hours. And I think that this line item just really highlights the stress that we're feeling here at NBRH within our specialties, especially. We've got not only an aging population, but we've got an influx of patients coming from outside our health service areas that are really testing our specialties. We're doing a great job, the offices and staff providers, secretaries are doing a great job in managing all these patients that are coming to us to kind of keep these wait times down as much as possible. They do such an amazing job of triaging each and every individual appointment request and getting those patients in when they need to be seen. So when you see line items like pulmonology where it says patients aren't getting in for six months, that's actually not entirely true. As we get referrals that are more urgent, we're figuring out different ways to shuffle the schedule and move things around and double book patients to get them in when they need to be seen. So I just wanted to highlight that one item. I think the rest is pretty self-explanatory and I'm happy to answer any questions later on this slide. Next slide. I can go to the next one, Kara. Thank you. Yeah, Laura talked about that. Okay, risks. So we're starting with risks and opportunities. I guess I get the risk slide. I'm sure that many of you are probably sick of hearing what the risks are because they're pretty universal. First off is just how tight the labor market is and the impacts that's having on recruitment and retention at all levels of the institution. It's not just, I know like nursing gets top billing, but it's really not just our nursing staff. We're struggling to find people to clean the hospital, people in food services to help support our patients and their dietary needs. It's really at all levels of the institution and that's a problem that we feel is probably gonna persist in the coming year or years. I mentioned in my opening remarks, the housing situation. Like I've never seen anything like this. Who ever imagined that we'd have such a housing crisis here in the Northeast Kingdom? We've lost potential staff who've accepted positions here. We're going to move to the area to take a great job at NBRH. And then they had to back out because they could not find housing that met there or their family's needs. That is a serious problem. It's gonna be one more barrier that we have to address our workforce challenges. 340B program, we have, that program has been under strain the last couple of years. We're seeing continued erosion in that program. That revenue is essential for critical access hospitals and puts us at tremendous risk as we lose that revenue. We have to find other ways to make up for it. Inflationary pressures, it's across the board, cost of labor, pressures in the supply chain, rising prices and supplies, equipment, and of course, construction, especially when we're trying to do major investments in our facilities to maintain the health and quality and up services that we provide to our community. The chronic strain on our mental health system is an ongoing issue. There was a day, I think it was last week, we had seven mental health patients in our nine bed ED. Let me say that again, seven mental health patients, nine bed ED. And the issues around workplace violence are very real and that's hurting our staff and impacting our staff and our ability to staff. People are paying attention to this. And then overall system capacity, availability of tertiary beds, mental health beds and post-acute beds are all impacting us. Next slide, please. Let's see. This just kind of highlights where we are with the mental health beds. Sean Burroughs, I think you were gonna make some comments about the data here. If I can do that, for the scribe, my name is Sean Burroughs. I'm the Chief Information and Security Officer here at MBRH. You can see the data before you. Essentially, it's very clear. We're seeing more patients. We don't have August data in yet, but we're seeing a lot more pediatric patients with no place to place them. They're staying longer. They're more complex. And then the risk section highlighted, we're seeing more response from the public and the community around workplace violence and how they interact with possible staff. About a year ago now, we contracted with Securitas Security Services to cover both the grounds and our off-site practices. And they've reported no less than 68 interactions with advocated patients or visitors. 33 of those escalated into code grade, where we have an all-code response. And two of those are code silvers where someone was branching a weapon, as well as probably incidents. So as you can see, the mental health crisis for the risk that Sean highlighted, as well as their own interaction with patients is just continuing to escalate. It burns out staff. It adds extra costs for security services, cameras, monitoring, controlling. And it's just that it adds to the problem with our budgetary cycle to support these additional needs. Thank you. Next slide. So in our, in our, in his debut as CFO of NVRH, Andre finally gets a chance to speak. And he gets the positive slide. How did that work, Andre? It worked out pretty good. As Andre does in that in the CFO, you know, with the opposite of risk, we also have some opportunities as Bob discussed. We have a financial sustainability program that was developed in the spring. And at the, towards the end of this budget process, that is not a static set of items that we will continue to look for items for efficiencies and cost savings. Leverage one care data, OCD, one care, Vermont, and analytics for the care coordination. They've got a vast amount of data and some really good resources at one care. And we need to continue to tap into that. So you look at the population of our area and leverage that data. Bob and Sean spoke about the risk of the 340B program. There's also opportunities. Continue using it to reduce our in-house drug costs. The 340B program is kind of like what the old generic drug program was. It's kind of a whack-a-mole. So where something may come off the 340B, we got to be judicious in making sure we find other drugs that are on the 340B program. And then continue work with providers to offset loss 340B revenue due to drug manufacturers withdrawal from the program. Next slide, please. The value-based participation, as Bob stated, we have signed up for the Medicare non-AIPBP track with one care for next year. This is a slide that outlines the covered lives, the attributed lives, and the FPP and maximum upside and downside risk for each of those programs. Next slide, please. So this talks about our capital investment plans and our capital replacement cycle involves routine capital replacement, routine facility replacement that operate, technology, and major investments such as a CON project. We've had to peer back spending in the top of those first three categories, the routine equipment and facility replacement and technology because of our losses of fiscal 22. A positive note, we are going to start our mental health support area construction hopefully very soon. That's a function of just supply chain issues for construction materials. If we can get the materials in on time, we hope to get that project started in the next couple of months. This was originally part of our West Wing expansion project, but we have been able, we were able to get it through the CON support, the staff support as a separate project because it meant all the criteria and that enabled us to start this project ahead of the major project. We just talked about the needs of supporting our mental health patients in the ED. We'll be able to do so more quickly now and provide better support with this expansion. So we'll please be able to start it soon. And I do want to highlight the fact that this was completely funded by congressionally directed spending appropriation that Senator Leahy had got for NVRH. So we're thankful for his efforts. Our average age of plant is just about the amount to average at this point, 14 and a half percent. You know, that expansion project, 14 and a half years, I'm sorry, not 14 and a half percent. The expansion project will reduce that once it gets completed. And we do hope to have the West Wing seal and application in. At this point, it's either late fall or even maybe early winter by the time we get it in. But it will be done soon. Again, those of you who've been through this process with us, have heard this, I think, for at least the last six years. It's been on and off a few times. COVID certainly had a significant impact on the project timing, but it is back on track. And by the way, it's not listed here, but we're planning to use USDA low interest loans as funding the significant portion of this project. We do not anticipate filing any other CON applications between 23 and fiscal 26, other than the West Wing project. Next slide, please. So we supplied separately a lot of information, detailed information on the supplemental data monitoring. I can just touch on a couple of things here. But again, there's a lot more details in what was submitted separately to the Green Mountain Care Board and to the staff. You can see the slide here, I want to highlight it. You look at the next slide, please, Kara. What the slide illustrates just briefly is that we continue to see an increasing percentage of our outpatient services provided to non-locals. The trend has gone from like 20% outpatient non-locals to about the most 23, a little of 23 and a half percent. He spoke a little bit earlier about us becoming a sort of a regional provider. I think that illustrates that that is happening. And again, I just ask you to look at the supplemental data that we submitted for additional comments. Next slide, please. This is the reimbursement analysis. This is in our, the materials again, had more detail in the supplemental data we provided. What this illustrates is we're high in a few of the services that we looked at, significantly higher than the range. Most who are right at or close to the range, we did not find any discernible reasons or impact of reimbursement that would have created that variation, continue to look and continue to dig. And if data becomes a more current data becomes available, it'll certainly be more meaningful. I think this data only goes through 2019. Next slide, please. I do want to note that we do serve an older population and with the more disabilities. And that was born out in the data that we looked at as well in this material. And that's actually the next slide I think would show that if you go to the next slide, please it shows that are looking at the disabilities in the age of our population, it's higher than the state average in both categories. Just one more slide, I think. Kara, if you could go to that, please. The impact of COVID, I think at this point, we don't have any material impacts on COVID on access to carer wait times. As mentioned, we continue to use telehealth where it's appropriate. Some of the lessons learned and still maintained the employees working remotely. Our new commitment to focus on our staff well-being, tremendous pressure on staff as you are well aware through the COVID crisis. It's being innovative in the way we deliver care. We stood up some drive-through services as an example of our innovation during COVID. So we continue to find ways to be innovative in how care is delivered. And it's just the importance of negative pressure runs. And particularly as we're building our new ED, it's important to take the lessons learned from COVID into consideration as we construct the restoring an ED expansion. Slide please, which I think is time for questions. Great. Thank you, NVRH team. Really appreciate your presentation. It was really clear. Also, I just take a second to acknowledge the tremendous work that you all have done to reduce those avoidable ED visits. I remember back several years ago, we started discussing your avoidable ED visits here at the board. So I know it's been a sustained effort over the years. It's really impressive. And you're focused on it as a model for other hospitals. So I wanted to quickly acknowledge that because I know where you've come from. So you've come a long way. I appreciate that effort. Yeah, no, you may get some other questions from other board members, but I just wanted to, I've been here long enough to know how much work you've done on that. So it's really appreciated. I think with that, I'm just gonna, we're gonna take a 10 minute recess. This is to help our board members compile their questions and allow everybody just a little stretch break, eye stretch break and all of that. So we'll come back at 2.40 and we'll start with board questions, okay? Okay, sounds good. Thank you. Okay, so with that, I am gonna turn it over to member lunch for questions. Great, thank you. Well, Bob actually anticipated many of the questions that I've been asking others. So I have one comment and one question. The question I would ask about the travelers. So you mentioned that in 22, you had budgeted 0.6 million. That's the reality of this year has been 4.6 million and that for 23, you've reduced that down to 2.3 million. So thank you for that. What I'm wondering is if you could give us a sense of number of humans and the per hour cost that just helps us compare to other hospitals around the state so we can kind of get a sense of how things compare. Yeah, the per hour cost, they know we budgeted $100 an hour. I believe it was a total of a little of a seven FTE equivalence for the number of bodies. We have 15 right now. Yeah, I'm talking, yes, for 15 now. But yeah, in the budget, yeah, down to, I think seven was the number. Right. We'll try and see if I can get it from that. That's great, and you can follow up. You don't, if you don't have it handy, that's totally fine. But that gives us a sense of where you are now versus where you're hoping to be over the budget and. Will, can I just make a comment there, Robin, on travelers? Keep in mind that we put this budget together what, three months ago, really? And we were seeing that collapse in traveler rates. What our internal recruiters telling us right now is the market for travelers is tightening up again. As larger national health systems are anticipating a challenging winter, they're starting to try to grab travelers and that's driving rates back up. So we had budgeted $100 an hour anticipating that the market was easing up. We're starting to see that climb back to $125 an hour. So I hate to be a downer, but that, you know, that's just the reality. Yeah, no, it's helpful to get it from your experience. I will follow up Robin with Sarah and the staff and give them an exact number. But yeah, there's $100 an hour. I know it's what we budgeted for the read. I'll give it a number of FDEs. Thank you. And then my comment was in relationship to your avoidable ED visit slide, which I think is slide 10. Thank you for providing the data, it's super interesting. And I wanna echo Jess's congratulations on all your hard work in terms of reducing avoidable ED usage and really seeing that fall significantly from the 18 and 19 levels. That's really wonderful to see. So congratulations. My comment, my additional comment was just one of the things that we saw in the qualified health plan rate review process was some data related to COVID surges and ED and urgent care uses, which showed that with a COVID surge, ED and urgent care goes down. And I think we can see that same sort of trend in your data here with the ups and downs of the usage. So I just wanted to mention that in case you hadn't heard about that other data because I did find it useful or interesting that it flowed. So with that, that's all I have. Great, thank you. Great. And I will ask, turn it over to board member Pelham. Well, good afternoon. It's, I felt like I was lined up against a football team when I first turned your screen on that there you are in perfect formation and here I am sitting in my lip, my dining room all alone is like, despite that, you know, and nicely, but it's you look organized and you are organized and every time that I've engaged with you you've always been organized. So I don't, I have a few questions, probably easy to answer. But I remember in some of our other conversations in past years, you had developed some relationships with the hospital of Littleton, I think. And, you know, there was some joint staffing, you know, issues and I'm just wondering, you know, has that relationship sustained COVID-19 or are we kind of living in a siloed era? Just wondering how that relationship has unfolded over time. Laura. Yeah, we'll let Laura feel that one. So yes, that was with our ENT services, ENT and Allergy. Last year, last August, we just worked out with Littleton that Dr. Dean Reinke would become our full-time employee because we were needing more ENT services than what we actually had with Littleton's contract. And so Dr. Reinke became our employee and he is here full-time now, he's here four days a week and we actually added a nurse practitioner to his service as well. But we do still contract with Littleton. We have a provider that comes over on Fridays and provides ENT services and then we also utilize them for our allergy services. So that partnership is still alive and kicking. I'll just add that Dr. Reinke was a mutually agreed upon decision to have him become our employee. It's not like we stole him and anything behind the scenes. It was mutually agreed upon to make that transition just in case anybody was wondering. Yes, he lived in St. John'sbury. So, was happy to come here. I think I'd add too, Littleton seems to be more focused on the New Hampshire market and south of them now than Vermont, they're linked to Lincoln and close the Hampshire market area that seems to be where they're focused at this point. And if I could add, since you've given us the opportunity, if you look at some of that growth and strain on some of our specialty care services, we said we were becoming a regional provider. You know, Littleton is a good example. What did they lose? It was, was it pulmonary or was it a pulmonary? Yeah, a neurologist. A neurologist in cardiology. So as they struggled to find specialty care in their market, we're getting more referrals from that market for those specialties. And that's putting more strain on our own staff. We're trying to evaluate how best to meet that outside area of demand. Well, I'm just glad to hear it's an ongoing conversation. I feared that COVID might have just caused walls to go up and some opportunities that were helpful might have been lost. My next question is you and your narrative talked about your financial sustainability project. And it sounded like it's been successful. You had a target 1.7 million and the goal was achieved. And so there's that process and it's ongoing. And then we have the act 167 process, which is beginning to get off the ground as well. And I'm just wondering if you've had any thoughts or conversations or expectations about how those two processes might relate to one another. You know, Tom, I think the act 157, that's still pretty new. And it's not something that as we've been doing our own internal sustainability have really factored into that, we're here, we're interested, we're gonna be partners through this exploratory process. But I don't think one is, we still need to maintain our own discipline and part of our sustainability efforts, which it's hard when you're looking at a slide deck and you see a bullet point, it's a sustainability project. I gotta stress, we've been putting a lot of effort into that, this is really important to us and we see it an important component to addressing our own stability as a system here in the Northeast Kingdom. But I can't say that we've really put any thought into how that might relate to the upcoming work. Well, it'll unfold somehow, so I always, I hope it goes well. And the next, my next question was where you were talking about some of your, let me get here, you said if the same number of FTEs were NVRH employees rather than travelers, the staffing cost would be approximately 1.1 million lower. And I thought to myself when I was reading that, well, there's your margin, you know? And so possibly, you know, and then I had this question, which I don't think I have to ask now, but I was kind of looking at the acceleration of the reduction of the need for travelers as the fiscal 23 unfolds, you know, that this somehow coming out of 22 and into 23, the pace would pick up. But it sounds like you're getting signals that it might go the other direction during 2023. So I don't have to ask that question. I think that answered it. But I did wanna, in looking at the kinds of strategies that you've employed relative to, you know, attracting new folks, most of those seemed financial. And I'm just wondering if you, you know, it's like a carry forward of significant wage increase, a budget of wage increase will help. I'm expanding, you know, clinical education for clinical staff, but I'm just wondering if you've developed relationships with, you know, colleges, you know, schools, other institutions to help build kind of a feeder system into your hospital. You know, this is a great opportunity for Julie to talk about some of the work and investments we're making in that space in the residency program. So please, Julie. Hi, I'm Julie Shantverberger. You know, yes, we have agreements and relationships with the, with VTC. That's been with us for years. We've also been in communication with St. Johnsbury Academy that's working on a adult education program for LNA, an LNA program. So we would be their clinical site and, you know, working with them to start that process for people that want to move into nursing or even stay in that role as an LNA. We have had, just actually signed one today, a contract for a nurse to come from out of state to do her clinical peer. So we do have a lot of those relationships. Linden Institute also has the junior high school, high school students in their medical programs with their, you know, work, we partner with them as well to do that education. And then we started this year with a residency program for new grads that, for RNs and to some degree, LPNs. And we help them gain a good, solid foundation. We have some in the emergency department on, and as well on med surge. So that's a good foundation. We actually had those nurses say that they came here because we had that residency program. We're helping them. They, as you probably all know, during the pandemic, it was very difficult for the students to get real hands on with patients during COVID. So we're pretty excited about that. And we will continue to do that. Well, those pipelines are important. Let's see, what else do I have here? I had one where from, I think from your narrative, or no, from your pair of mixed table, one can see the projected decline in Medicaid revenue since 2021 of 1.25 million through the 2023 budget, comprising a negative annual rate of 3.6%. Conversely, one can also see from the pair of mixed table that commercial revenues increased by 5.5 million at the annual rate of 6.3%. And my thought was, where does this end or where does this lead in the longterm? Because I'm getting a sense as we go through these hearings and reading hospital proposals, that the cost shift has almost become embedded. It's just taken repeatedly hospitals say, well, we're not going to get anything from the rate and our budgeting minuscule amounts, if any, of increased Medicaid funds. But I just wonder, where does that go in the long run? I mean, maybe it's just a shift that we should accept and embrace and, but your pair of mixed table kind of, I think reflected the reality that Medicaid is kind of on a stall at best and commercial is going up quite significantly. And I'm just wondering if you have any kind of long-term thoughts about that or just that's the lay of the land these days and you got to do what you got to do. I think you hit the nail on the head so I'm down. Yeah, that does reflect reality. I think that that's a really tough boulder for us to push up the hill. And I think that's why we're in the situation we're in. I'd love to see that dynamic change. I think we do need to invest more in the Medicaid program that will help us all, whether that's Medicaid rates overall or targeted initiatives to help boost reimbursement, for example, to support our birthing centers. There are many ways to do that. I for one have been advocating with our local legislators to say that this needs to be addressed at the state level legislatively. I did send prior to our presentation today, a few weeks ago, a letter to all our local legislators asking for their support in the budgeting process and indicating that the only way to solve this problem is by investing more dollars in the Medicaid program. Beyond that, I'd love your suggestions if you have any thoughts on how we could better address it. Yeah, well, I do say from time to time that I might be guilty of the cost shift. I can't remember what I did when I was finance commissioner but I know that there was always the back door to the agency of human services where I would call condo and say, God, I need some money and we would figure out how to print it. But that was way back when I'm sure things have changed. Those are my questions and thank you very much and it's good to see you all again. Thank you, Tom. Thank you, Tom. Thanks, Tom. I'm going to peek it over to board member Walsh. Thank you, Jess. And good afternoon, I want to join my fellow board members in congratulating you on the hard work in reducing avoidable ED visits. That was really quite a lot of progress that you've shared and it's impressive to see. On slide 32 of your presentation, you had a graph showing prices that were on some of the lines already exceeding the high end or even the highest end of the range of prices. And so then I'm thinking a double digit request for further increase in prices. That causes me to pause and think about the utilization assumptions of a 4% increase in utilization when there's good evidence that when patients face fire out of pocket expenses, they stop taking their medicine. They stop going to routine appointments. They end up sicker in the long run and end up with avoidable ED admissions. So it could be kind of a circular problem for you down the road and not just for you but for hospitals across the state with the degree of price increase that we're seeing across the state. And when patients forgo their routine visits or stop their elective procedures, oftentimes they end up with unplanned and then unreimbursed care because they're underinsured or not insured because the price of insurance has just gotten too high because the prices that we charge for healthcare are too high. I just want to share that comment that's one of the things that I'm trying to keep in mind in our deliberations as we look at the situation across the state, that the increases that we're asking are commercial payers to bear are substantial and may not be the best for the health of the state. So I want to share that I'll be keeping that in mind as we go forward. And with that, I'll pass it back to you, Jess. Okay, thank you. So I just have a couple of questions. I've been asking every hospital to help us understand what the historical relationship is between change in charge and the effective rate change that the average commercial patient will experience at NVRH. So I know you're asking for a 10.75% overall change in charge, but I also recognize that depending upon your payer contracts, that may not materialize. So would you be able to, and if you can't do it now, you know, follow up with Sarah on what that actually translates into for an effective commercial rate? Yep. I can tell you it's about 10.5%. It's a little bit less than 10.5%. Most of our commercial contracts allow the increase without being capped, but we do have some that do cap it. They're not our major contracts at this point. But, you know, we're somewhere in the 10.4, 10.5% range of the 10 and three quarters. Okay. Thank you. It's about 95%. I'd say 95 to 20%. Okay. Thank you. The other question I had was in the narrative, you referenced some work that you had farmed out to applied management systems. And there was a report that was expected in July where they were going to help you assess efficiencies and productivities. And I'm wondering what did they use to measure productivity and what were some of the key findings for NVRH? I can start. The reality is we just got the report and went through it with them yesterday. And their data benchmarking comes from 50 years of experience, 750 clients and 7,500 studies approximately. All hospitals, yes, I'm sorry, hospitals of all sizes. Yeah. They have expected, I have told this group and they probably heard me say too many times. I actually started working with applied management systems in 1978. So they've been around a long time and so have I, as you can tell. I started in kindergarten as you could probably say. You must have been five when you started. So yeah, they've got a lot of experience. We had a chance to digest and process everything that they included in the report. Yeah, as I said, they just went through with this yesterday afternoon. I would a couple of comments. Number one, the majority of the expense of that consultative engagement was covered through a grant, which is really great. I'm trying to be frugal here. It is pretty dense. There's a lot of data presented, but their methodology is very comprehensive. So it's based on the work they've done with other hospitals and looking at best practices. And then really doing detailed interviews with department managers and staff throughout the, the divisions that we looked at. So I've been really impressed and impressed with the, what they've given us, but we, it's going to probably take us a long time to really dig in, understand the recommendations and evaluate how best to implement many of them here. Andre, I don't know if you have any thoughts. No, I echo what Bob and Sean said. You know, they, and to go to your point, Jessica, the, now they go with department by department for the statistical analysis and benchmarking. So it's not one volume for the whole thing. So it's very specific. It's a deep dive. I've done this before when I was at North Country. We did these premiere for labor and benchmarking and, and implemented it. I think AMS takes a little bit different approach where they actually really come in and understand how each, every, each and every department is, is set up because they're all a little different compared to what you see in other hospitals. And I think that's very important to understand where in one hospital you may have a function in, in one department X. And then our hospital, it may be in Y and understanding that and how that variation is to a benchmark is extremely important and trying to manage any kind of implementation with this. So, you know, we went through the report with them yesterday and I was impressed with, with what they've done. Well, that makes a lot of sense. And I think, you know, we may circle back with you as we're trying to, you know, are we off, welcome your insights in what was the most helpful from that report in terms of measures of productivity. And I recognize that it may be customized to NVRH and, you know, it was very personalized with lots of interviews. But as we're reimagining our hospital budget process, we're trying to at least think about measures of efficiency and productivity. And so, you know, you may have some unique insights having just gone through this process of evaluating your own productivity. So what metrics were the most meaningful to you and also led to the most impactful action steps, I think would be, at least what I'd be curious to learn about as you, as you deep dive into the report. Thank you. So, I just a comment about wait times. I want to thank you for your efforts to track both referral and visit lag. I think not every hospital was able to track the referral lag. So I really appreciated that you made the effort there. And I also, you know, it seemed like from the report that you're moving people through the system better than others in some cases and in most cases and where you're not, it looks like you're looking to hire. I know you mentioned pulmonology. I just wanted to mention one other area that looked a little bit concerning to me and wanted to hear more about if you had plans there, which was cardio. It looked like 85% of people were waiting three months for an EKG and 70% were waiting three months for an appointment, roughly. And so I'm wondering if you have a strategy with cardio, particularly given you, I know you presented some data on the aging of your population in particular. And, you know, you were looking towards pulmonology and podiatry because of the aging population. I would think cardiology would be similar in that area. I also recognize it's really hard to recruit in cardiology. So just wanted to ask some questions about that. Yeah. And so when you look at that snapshot of time, it was July 1st to July 15th. So it was patient, you know, one month from them, one month from that point would be August. And there are a few vacations at that point. And so it actually wasn't three months, but it was two months. It was more like six to eight weeks, rather than the three months period. But those were the data points that we were given. So when it was over a month, we put it into the three month column. So it actually wasn't quite as bad as it looks. There's a little bit more of a story there. So thank you for asking that. So yes, it is. The data is better than it looks here on paper. But we are keeping an eye on cardiology in particular. We were seeing an influx of patients, specifically from North country. When they lost their cardiologist, they I believe hired a cardiologist. And so we're hoping that our volume is kind of weighing back to normal. But Lilton, again, they're struggling with cardiology too. So we're seeing referrals there with respect to cardiology. We have a relationship with Dartmouth who provides our cardiologist. And we have asked for additional capacity there. Actually, contractually, they're obligated to provide it to us. They're unable to recruit. So this gets right at that challenge for a small institution trying to fill the necessary specialty care slots. Even when we're partnering with a much larger academic institution, it doesn't necessarily solve your problem. It's a challenge for them and that trickles down to us. That makes sense. And actually you just raised a really interesting point with respect to people's vacations and the timing of this request. And I'm just wondering if we're to do this again next year in budget guidance. Is there a better two week period that would be more representative of the experience recognizing that people take vacations in the summertime? And so maybe that would not be a representative view of the actual wait times. Is there a better two week window that we should consider? Can I make a suggestion? Especially for small hospitals, we're talking about vacation times for small hospitals where you have one specialist. We also have a lot of, we have a lot of people of child birthing age here. And so there are other dynamics. It's not necessarily just vacation times. What I suggest is maybe pick, I don't want to make more work for us. So forgive me if I say this, I think for us we have the systems to do it, but pick four quadrants out of the year and try to do a sampling throughout the year. Yeah. You know, where it's not just, you know, okay, the holidays, they're rough, vacation time, they're rough, but we may have someone out on maternity leave, you know, and that's going to impact access. Yeah, that makes a lot of sense to me. And when we ask for it, we'll say this was the wonderful suggestion of NBRH. Well, my team will pillory me later. Well, you have to remember where the sources. You can just say it was my idea. I won't be here. I can't believe Bob suggested that. If you say Sean suggested or Bob suggested it gets submitted with our quarterly submission. Done. Done. All right. Well, my, you know, my last is just my standard, which is if anything, you know, asking every hospital to share any known or likely changes to federal and state payments that you're aware of, that maybe you weren't aware of the time of the submission, any increased relief funds or unexpected increases in Medicare and Medicaid. If you could just let Sarah and her team know if something arises in the next week or so, or that you haven't shared with us yet. So that is it for me. Is there, are there any follow up board questions just before I turn it over to her? Nope. I'm seeing shaken heads. Great. So does our hospital finance team have any questions for NBRH? Good afternoon. Sarah Lindberg for finance team. Thank you for your clear submission. No questions. Okay. I just want to thank you. You've been very helpful. I mean, it was a transition for you and your team and a great job. Thank you. Oh yeah. Well, we're learning as we go. You learn quickly for your support. All right. Well, with that, I'm going to turn it over to Sam. I'm all done. Yeah. And I think somebody may not be muted. So if you are not muted, please meet yourselves. And Sam, you're up. Thank you so much. Sam. Thank you. Good to be with all of you. And we're almost at the end. So congrats to everyone for making it there. Just outright. I wanted to appreciate the level of transparency and attention you paid with establishing grievance and complaint process. That was one of our questions. I thought it was very clear and accessible to patients. So I wanted to recognize that quality and the dedication you put there. And also speaking to quality, I want to recognize your community health needs assessment, which I thought was unique in how it established clear outcome areas and worked really hard to establish a study population that was representative of the counties you serve. So I appreciate you for that. First question on slide 12, were you outlined key factors that impacted the development of your charge request? I'm wondering if you could explain a bit more how you arrived at the 3.2% cost shift increase number. So that was an estimate of our cost shifts. Divided by the $336,000 net patient revenue per rate, 1% rate increase. So I think the charge cost shift, I think it was like 1 million, actually have it right here. About a million four divided by the $436,000 is the 3.2%. Okay. Thank you. That's helpful. You noted as a lot of other hospitals have the patients, you're observing that some folks are leaving traditional Medicare enrollment in favor of what you call replacement Medicare, and I think you mean Medicare Advantage. Correct me if I'm wrong on that. I'm wondering, okay. I'm wondering if NVRH does any projections or predictions for churn between MA and traditional Medicare. And if so, how that factors into how you develop your budget. So they've Medicare Advantage or replacement pays the same as the traditional Medicare. We're traditional Medicare. We get a per day and for in patients, a percent of charges for health patients and reimbursement per encounter for our rural health clinics and the replacement slash Advantage products match that. So reimbursement is the same. Okay. That's helpful. And my last question relates to the community health needs assessment that I alluded to earlier. You discussed the work of NEC prosper specifically forming an accountable health community in 2015. I'm wondering if you could speak a little bit more about how that effort is supported by the hospital and if it interacts with one care of Vermont at all and what that looks like. So I can start speaking to that and then Diana can fill in any. I was actually there at his inception. So I've been a long time at the time I was at Northern County's healthcare. You know, it's really central to our work around supporting those social drivers of health within our community. And we meet monthly, we meet regularly, and then we support what are called community collaborative action networks focused on today's five top key areas, which are the, see if I can do this from memory, well-housed, act food access, physical health, mental health and well, finance, financially sustainable. And each of those collaborative action networks are made up of members from different social services or organizations in our community, including members of NVRH staff as well. And they identify opportunities or projects to work collaboratively with our community to address issues in those five areas. So we've continued to do that. We continue to work collaboratively through the pandemic in fact, because we had such a great structure there with our community partners through NAK Prosper, I think it actually really was a signal strength of ours as we address the pandemic in our community. We were able to rapidly ramp up improved access to food and nutrition as the pandemic shut businesses down. That's just one example. We were able to coordinate resources around the homeless population, that type of thing. So we traditionally pay dues into NAK Prosper, and NVRH pays half the dues for that group. It was typically around $15,000 a year. It's kind of a low cost. It's not a big cost center, right? But it gives us some money to invest or support those initiatives. Honestly, through the pandemic, we put a pause on those payments for all participating organizations, but we have a modest bank account with funds in it. It is also kind of a vehicle through which we make investments with money that we set aside through either community benefit or we were one of the institutions, or I don't know, it was the only one, but we set aside 1% of our payments through the fixed perspective payment system to invest back into these community initiatives. And NAK Prosper is the vehicle through which we do that. Thanks so much. That's helpful. Those are all the questions for me. Back to you, Chair Helms. Great. Thank you very much. At this point, I'll open it up to a public comment. If there's anybody from the public that would like to speak, raise your hand. It sounds like we've got Michael Del Treco from Voss. Go ahead, Mike. I think you're on mute. What about now? I thought I was good, but okay, thanks. Good afternoon, Chair Helms, board members, Green Mountain Care Board staff with a big shout out to Sarah, the HCA and members of the public. I know this process can be demanding at times and it's complicated for all involved. So thank you for your commitment to seeing this through. Hospitals have provided you a thorough and candid assessment of where they stand and they've asked you to approve these needs-based stabilization budgets. As you've heard today and throughout the hearings, these budgets are about maintaining care for their patients and communities. I'd like to acknowledge the hospital leadership teams that presented as part of this process and also the doctors, nurses, and support staff that keep these community assets functioning at high levels during such a difficult time. I've worked in healthcare my entire career and I'm truly inspired by the leadership at every level and at every corner in these organizations. Many of you know my wife is a nurse, so I know firsthand that healthcare workers are special. They manage complex care issues and they provide support for families in great times of need. Unfortunately, I also know the mental and physical fatigue that caregivers are enduring. But here's the thing, no matter what the weather, personal issues they might be managing, or in my case, if we have family plans, our Vermont healthcare workers drop everything when they're needed. They're so resilient and they never miss a beat. They are at the ready to lend a hand for their patients, their coworkers, and they support their community in many ways. They deserve us to do the same for them. I often wondered how on earth under these great challenges are our hospitals pulling off the amazing feat to care for their patients and the coworkers and their communities. After hearing hours of testimony, I think we know the answer how and why. It's their smart and innovative plans to manage the challenges of workforce shortages, work place violence that should never happen, workplace pressures, travelers, steep healthcare inflation, supply chain, the list goes on, capacity challenges. So it's been a long couple of weeks and I know that and the 23 budget process is still not over. But as we enter the deliberation phase, I respectfully ask that we remember three things. One, above all else, remember these budgets are about people, patients, their families and communities, the stories you've heard and the experiences are about our neighbors and friends. Our hospitals may present you with charts and graphs, but each figure represents a patient or care they may or may not receive and services a community might not have or may have. Two, these are needs based budgets that represent only what our hospitals need to stabilize. These budgets produce modest but critically important margins. Remember, it's a 2% system-wide margin, very, very modest. And they ensure that these hospitals can make necessary investments in equipment, staff, supplies and technology. I understand the decision rests in your hands. I've listened to every second of every presentation as I know you have and thank you for that. I'm proud of this dedicated group of hermoners and I know our state will be stronger when our hospitals are stable. So for the reasons I've stated through this process and I know that all the hospitals have provided so many details, I again respectfully ask you to approve these budgets as submitted. I thank you for your dedication to the process and I look forward to the next steps and happy Friday. Thank you. Thank you, Mike, for that comment. Is there anybody else that wishes to make a public comment at this time? Just raise your hand using the chat function. Nope, I'm not seeing anybody. Is there anybody on the phone that wishes to make a public comment? If so, you can speak now. Okay, I'm seeing nobody raising a hand and I'm not hearing anybody from the phone. So I want to thank the NVRH team. Really, really appreciate the insights you've given us into your budget this year. Bob, I wish you the best. Andre, good luck in your new transition. Thanks for all the hard work everybody on that, you know, in your team and that room does for your community as well as all your frontline workers who are not here but are really well represented by all of you. This closes our budget hearings for fiscal year 23. So thank you to all of the hospital teams for providing insights into their budgets. We've seen obviously the enormous financial pressures that hospitals are facing, largely driven by inflation, workforce shortages, and the system bottlenecks that we've been hearing about. I think we heard more than one, maybe all of the CEOs saying I've never seen anything like this. I'll just honestly say I haven't either in my short tenure on the board. So let's hope that this year is the worst of it and this time next year the waters are a little less turbulent and the horizon is brighter. To give you a sense of what's next in our process, next Wednesday, August 31st we'll launch the meeting with a presentation from the state's economists. We asked them to provide us with some advice on which inflation disease are the most relevant to our regulatory process and using those measures to provide us with an assessment of both current and near term inflation levels. And then after hearing from the state's economists our hospital budget team will guide us through a framework that we can use to make decisions about the hospital's budgets along with a staff analysis of the hospital's budget. I anticipate that we'll complete the review of the decision making framework and the staff's budget overview on Wednesday and it's also possible that we might begin some deliberations and voting that day. We have a large amount of time blocked on Wednesday so we will try and get through as much as we can that day, but it's a strong agenda already. We'll continue our deliberations and voting on Friday, September 2nd with additional time scheduled Wednesday, September 7th and September 8th. My goal is that we'll actually complete all the decisions by September 8th well ahead of our September 15th deadline but if not we've held additional time on September 12th and September 14th. So that should give folks a roadmap of the things to come. We have to have the budgets approved by September 15th so that's our process between here and now. Is there at this point you would love to have a motion to adjourn? You got one. I will take that from Tom Tellum. Is there a second from anybody? Second. All right, from Tom Walsh, thank you. So all those in favor? Aye. Opposed. No opposed. All right unanimously approved to adjourn for the day. Thank you NVRIH. Thanks to all the hospitals that are listening to us. We will see many of you probably next week during our deliberations. Thanks to everybody. Thank you.