 If you could introduce everyone who is going to be presenting from Team Copley and him will swear you in. Okay, that's great. This is Jeff Hebert, the Chief Financial Officer to my right and over here is Dr. Don DePuy, our Chief Medical Officer. And also Kathy DeMars, our Board Chair is also gonna be with us, the four of us here. You're on mute, Kim. Kim, you have to press star six because I had to mute the audience earlier in the meeting. Yes. Okay. Thanks, Abigail. I forgot the star six. Can you just spell the doctor's last name for me please? D-U-P-U-I-S DePuy. Thank you. So would the four of you please raise your right hand? Do you swear the evidence you are about to give shall be the truth, the whole truth and nothing but the truth to help you God. I do. I do. Okay, so Joe, you can begin the presentation whenever you're ready. Great. Thank you very much, Kevin. Appreciate the opportunity to present to you folks. We're gonna be wearing masks and we'll be doing the karate kid mask on, mask off every time somebody is speaking. So you'll notice that. Anyways, we've got their requested agenda. We tried to fulfill those needs as much as possible. We'll walk through that. I introduced the four members that are here and if you go to slide four, just background about us, independent nonprofit critical access hospital, one of eight in the state. That's actually a pretty clean fact. Service area is about 30,000 patients, 25-bed critical access hospital with about 1,900 admissions, 12,800 emergency department visits, 460 employees. And I'm just having a little bit of fun here. I have a parentheses. How do you define employees? Well, it's actually 375 FTEs, 460 paychecks, which may be considered employees, 540 active staff who periodically get paychecks, not counting travelers. So I just bring that up because it's interesting in healthcare with so many of these statistics that we look at. What are we talking about? How well do we define that? Next line, 176 members of the medical staff representing 27 specialties. They're not all active here. There's a refinement. We can go through a lot of discussion again. Welcome to healthcare. The two facts that are correct, the very top independent nonprofit critical access hospital, that's clean, clear. Everything below it is kind of, can be muddy and open for interpretation. The last one's pretty correct too. So we're $67 million of net revenue. That's all correct and clean. 2.6% of the state's oversight of the 14 hospitals. So if you go to the next slide, I always like to put things into perspective in terms of our size and what we're doing. So on the left-hand side, you've got all the hospitals listed. The ones with a star represent those that are in, asked to be part of sustainability planning earlier this year. That was a concern born out of the bankruptcy of Springfield Hospital and looking at some of the financial indicators saying that there's some folks here that are fragile and we should be aware of their performance, again, because of the Springfield bankruptcy. If you look at the pie charts, I did not pick the colors, you can blame Jeff. I have no idea how he came up with those. Anyways, we are 2.6% of a $2.6 billion budget. Again, there's eight critical access hospitals we're sort of small in relation to the rest of the system. If you look at the next slide, this just shows you, this is slide number six. Again, the eight critical access hospitals, although we're about 57% of the hospitals, that's eight out of 14, we're only 19, 20% of the actual spend and the others are the, lack of better word, the tweeners, the PPS hospitals and then the University of Medical Center, which is both a PPS but also the traditional reimbursement on the tertiary care side. So I always think this is helpful because the critical access hospitals that are very unique reimbursement methodology for allowable costs through Medicare. And so when we always talk about healthcare reform, it's important to understand where we're all starting from. So next slide. When I look at past financial performance and where we are as an organization, this is kind of a sobering chart that I did when I first got here. It shows us losing money four years in a row, each year a little bit more, some more dramatic than others, certainly the swing from FY 15 to 16 was dramatic and the swing from 17 to 18 was dramatic. I like to look at these things and I like to look at comparisons and relativity. You know, how does this feel relative to size and others and what's the comparison piece? Losing $2.3 million is a lot in FY 19. It's a negative 3.4% operating margin. In comparison or relatively, relativity is a UVM medical center and the network lost that same percentage amount, it would be $55 million, which I think would get people's attention. I know I watched a couple of WCAX broadcasts and I know they talked about 10 million or 15 and people were gas, but relatively for us in a couple of years of losses around almost 3.5% negative operating margins, big deal. So thanks for that. Next page, I guess I would have to describe this as a turnaround organization and the way that's best described is that it's a financial recovery of a hospital that's been performing poorly for an extended period of time. Turn around, you first have to acknowledge the extent and understand the problems, which we've been doing. This chart is one of them that we look at when charts over time. Consider changes in management and even philosophy to sort of turn things around and develop and implement a problem solving strategy. And so we're trying that, we're down the road. I've been the CEO here for only 10 months. Jeff, the CFO has only been here five months. We're working very hard to make sure that financially we've got a sustainability list. Unfortunately, I think when you look at who's most fragile given all of the indicators, whether it's margin, cash performance over time. Unfortunately, I think we're that next on the list. I know there's eight of them, I think six or eight in the sustainability program, but unfortunately I think we probably are the one that is next to that list. So I just wanted to mention that. It's not great to say the word turnaround, but I don't know when you say it. Do you say it after you declare bankruptcy? Should you say it before? But it does require us to really look at our philosophy, our past, our management, some of the decision-making. So I wanted to just mention that. I think Kathy wanted to make a comment. Yeah, I just wanted to say that we've got to turn the hospital around. And it is painful to say we've been watching the figures for a couple of years now, and that's the reason we hired Joe. We need him right now to turn us around to keep the hospital viable and part of the community. We really do realize there's a lot of work to do, but we also feel like right now we have the right team in place to make the turnaround happen. Thanks, Captain. Anybody else if they wanna jump in, you guys? Just let me know. On page nine, we did a major, we've made some major changes, some of them are small, some of them have been very significant. So we actually changed auditors. We've had the same auditors for 25 years, which is actually probably the longest engagement that not a term has had with anybody in the state of Vermont. But after 25 years, we said, we need a new set of eyes. We want BKV. They're quite large in 18 states, 40 offices. They have about 300 partners and principals. So there's references of six of them in Vermont. So we're happy to have them. They take care of, give or take 180 critical access hospitals. So they're giving us good advice, both from a federal level, our own personal operations, how we're doing and also knowing what Vermont's doing. So that's been helpful. Next slide, this is slide 10. This is a quality slide and wanted to talk about that because the financial turnaround is not part of a quality turnaround. And it's a big difference. So I've presented this to the medical staff and others. And of course, people can kind of be braced and say, financial turnaround, that sounds horrible. We're not that bad. Quality wise, we're great. We're actually in excellent shape and properly has enjoyed years, if not decades of wonderful patient satisfaction, safety data and it's important that we maybe talk about this. I know our chief medical officer, Dr. Hapui, qualities close to what he believes in and in his heart. And I was gonna ask him to talk a little bit about Nesquip and some other aspects of quality. Yeah, thanks, Joe. We certainly agree with the mission of the Green Mountain Care Board that the three most important features of healthcare system or high quality accessibility and sustainability. Speaking as a doctor and a patient, however, I would say that high quality is by far the most important of those three. And because you measure what you value and if you can't measure it, you can improve it. At Copley, we do a lot of measuring of quality metrics. And the list on the left side of the slide is really just a very partial list of the things that we look at all the time. I'd like to run through three quick examples if I could. The first one is the HCAP data, which is the score of patient satisfaction, essentially measures how patients feel about their hospital stay. I'm not sure it's a quality measure exactly, but it certainly says a lot about how you practice medicine. And for the last full year that we have data from mid 2018 to 19, 42% of our surveys are returned and we leave the state. And that 84% of our patients would recommend us to family and friends. And that also leads to state. So we're certainly quite proud of that data. Moving to readmission data. And this is from the Green Mountain Care Board, it's BU HDDS database, looking at 30 day all cause readmissions. For the last full year that we have data from March 19 through February, 20 copies readmission rate is 38% lower than other critical access hospitals and 46% lower than other PPS hospitals. And certainly readmission data is in fact a measure of quality and it really measures the overall quality that your hospital provides both on the medical and surgical sides. Relative to surgical quality, the national surgical quality improvement program, S-WIP run by the American College of Surgeons is certainly the gold standard and actually measuring quality outcomes. We've provided a couple of charts here to highlight some of our data. This was looking for calendar year 19. What we've shown here are basically observed data. So this is what actually happens to patients. Our data is the blue line on the bottom and the red line is the average of all Nisquip hospitals. And typical Nisquip hospitals have names like UBM and Dartmouth and MGH and Johns Hopkins and Cedar Sinai and you kind of get the point. Mostly very good hospitals. So at Copley for calendar year 19, our overall complication rate was 2.1%, whereas the average rate at a Nisquip hospital was 13.5%. For surgical site infections, Copley's rate was 0.3% and the national average was 2.1%. There is a certain yeah, but factor to that because this is not normalized data to the preoperative risk of the patient or in a case mix, but the Nisquip does account for that and they look at odds ratios and for all complications for calendar year 19, our odds ratio with respect to the national average is 0.51, which means that your chance of having a complication at Copley, all things considered relative to the average Nisquip hospital is a half and our odds ratio for surgical site infections is 0.54, which basically tells the same story. And these are both statistically significant outliers in an exemplary direction. So I think this sort of tells two stories. One is that we do a pretty good job with quality, but I think even more important is that we're always looking at it and we measure it. And we certainly believe that the healthcare system really ought to do is robust and comprehensive job of possible at measuring quality. Great. Thanks, John. Appreciate that. We go to slide 11. Wanted to take up some of our COVID time talking about quality. I think quality is really important. And I hope that every year at least, maybe we spend some time with the state just talking about hospital healthcare quality because that's important, the measures and monitors and things that we look at. So when we get into COVID, that's our website. Everybody's website starts to look the same. It's just kind of funny how all across America, every hospital was copying the same images and sort of putting a bunch of effort into managing COVID and explaining it and trying to work through it. We immediately went into sort of an incident command mode, looked at our charts and stuff that we've learned years ago around incident command system training. And we set up some teams, COVID response teams, CRT, immediately set one up in the hospital, CRTCH. Those folks met twice a day in the boardroom. A whole group of us at a team leader managed roles and responsibilities. It was pretty manic. And I think we did a great job talking through the logic, what we know, don't know. In fact, we still meet, we're down to twice a month. And so that was very helpful. The CRT and the meeting, which was Morrisville, that was actually six organizations, the hospital, the Federal Qualified Health Center, TAMRAC, which is a private primary care practice, very large, the MANR, which is a nursing home SNF, our designated agency, the Loyal County and Mental Health Services, and the Loyal Home Health and Hospice Agency. So six of us really came together and managed issues around policies, personal protective equipment, what's the latest? How are we dealing with staff, staff issues? How are we dealing with cutbacks? It became a very dynamic tight group with the CEOs, pretty much all at the table twice a week. We were actually meeting three times a week and then we went to twice a week. And then we also created CRT-LV for the Loyal Valley, which turned into a very large group. LazRock, of course, everybody likes a lot of initials. That's about 26 local agencies and liaisons coming together to talk about the same issues around personal protective equipment, policies, staffing, what's coming down from the feds, the state, grant money. So we, I think we did a good job of sort of facilitating and being a catalyst for the team and teamwork. So, yeah, and I just want to also say that I was part of this community collaborative and we really handled, I think, the work here pretty extraordinarily to have all these groups come together and work together and we still are meeting, we're meeting monthly now as a group of the six bigger agencies in the community. So I think that was a real plus for this community and Copley sort of steer-headed that whole process to get this group together. But I also want to say the staff here did amazing work through the entire process also to help all of us in the community. Thanks. So the next slide speaks to sort of testing. So when I look at sort of the three phases of what we're going through and we're still in it and that is the beginning was the PPE. What do we need? Ventilators, equipment. We still probably might have some of that as we get into the winter. The next one was sort of testing. How do you test? Test results, who's testing? You know, we have the collection sites. The last one, which we still think about is the vaccine, vaccine distribution. Who's going to get what? How do we manage that? What are the costs? So in the testing realm, we really didn't have any standing as a small critical access hospital to have access to PCR and molecular testing. That became a challenge. We did get an opportunity through Dr. Catherine Antley, who's a dermal pathologist in practices in a few locations. She helped us get a relationship with Ray Biotech. I always try to tell people sometimes it's relationships or friendships or just sort of chemistry that brings people together. You know, it's not always planned out, but we worked with Ray Biotech who's got some really noted customers like Harvard and Data Farber, Henry University, the CDC. And we were sort of working with them to at least administer this antibody test and talk about maybe its value. You know, we wanted to participate and I think Dr. DePree wants to comment on that and even the next slide. Yeah, thanks. As everyone who's been practicing medicine during this period as seen, things are novel and they change quickly in the COVID world. And we think it's very important to be innovative and somewhat aggressive in trying to do the best we can for our communities. And so we had the opportunity to do this antibody testing and sort of the idea here was, is that there are two kinds of antibodies that can be looked at. One is the IgM, which shows up earlier and is more a response to an acute infection than IgG, which is the protective antibodies that will hopefully give us prolonged conferred protection and be much of the source of the vaccine success. And so we enlisted our staff and community providers who enthusiastically came in and got tested. We tested hundreds of folks and at the end of the day, it was hard to tell whether the test was not quite ready for prime time or if our prevalence was just so low here that we really didn't have enough COVID to detect often enough to really tell how well the test was made, the test worked. So we're certainly glad we did it. We didn't have a breakthrough, but we're sort of undeterred with doing everything we can to provide the optimal testing environment for our community. As many of you, I'm sure know that Vermont adopted a centralized testing strategy for PCR. And what that ends up leaving is a sizable discrepancy between the standards of care, depending on how fast you can get the results back of testing. If you go to a hospital that has real time testing, you can know almost immediately what's going on and act accordingly. The rest of us sometimes don't have tests returned for days and days, which complicates and changes medical care drastically and basically leads to two standards of care for the state. We've been working with other hospitals around the state and we've proposed two things that the state uses in size and authority to source and procure testing equipment and supplies. And then when there is scarcity that the entire state has equal access to the limited supplies, such that we either benefit or suffer together and equally. Another thing that we're also looking at now, we've approached a company called E25 BioEdit of Cambridge who has the antigen spike protein test as a possible screening test. So it wouldn't replace PCR by any stretch of the imagination, but it's potentially cheap and fast and we're trying to talk them into doing a trial with us much like the antibiotic trial. So on the next slide, slide 16, this is just a slide to tell you about some of the volume that we've seen with our COVID-19 PCR molecular testing. Don didn't mention a couple of things, which I don't know, I figured I'd throw them in now. We've had the ability to do on-site PCR testing as we have an Abbott Gen X analyzer and we just need the little Cepheid plastic kits. I much like to describe them as maybe a pregnancy test. It's a little plastic kit that you use, we just don't have access to those. There's a few other hospitals that also have the Gen X Abbott analyzer. We just landed a Rionics analyzer out of New York and so there's a company out of New York, I think some affiliation with Cornell. That thing arrived, in fact, this morning, Don and I went to the lab and looked at it. So we actually have an analyzer and I'm gonna get us, we're hopeful. Within a few, just two weeks, we're gonna have that up and running. The engineer is coming today. We're gonna have a supply and be able to do on-site real-time PCR COVID-19 testing with a turnaround of around five to six hours, which is gonna be a game changer for us in our community. In particular, for the folks with the MV, a CRT-MV group, because all of those providers, the Nursing Home Health Agency, we're gonna be giving them preferential access and treatment, so if they've got issues with their staff, the worst thing that can happen in the small hospitals or small communities, if you've got staffing issues or a provider that is out or a key staff member, it's really been difficult, whether you're following advice of seven-day self-quarantine or another test. So we've all been committed to supporting the team and we're gonna be doing that, very exciting. And I think we're going to be the test for that in the state of Vermont, isn't that right, Tom? Yeah, that's true. Yeah. So we've done, well, we got a lot of donations, the most masks, we have so many cloth masks, knitted, sewn, I'm sorry, by people, thousands, gloves, equipment, shields. Concept two actually landed 500,000 masks out of China early on when this thing hit, their relationships were such that they actually secured 500,000 surgical masks. And we were a benefactor of that, as have been others, but that was a kind of interesting, more useful story. So next page, talking about dollars, money, and all the anxiety that COVID brought upon us. This was a quick assessment, we had a bunch of hospitals all be asked, what do you think the change in net patient service revenue is gonna be going forward? We were the biggest concern, biggest loser, I'm not sure the terminology, but we were very cautious and thought that literally we're gonna lose 70% of our revenue because of this. What we were looking at, the numbers, some of the hospitals thought it would be in the 20s. I'll tell you what happened is that unfolded, if you look at the next quick charts, this is number 18. We lost 61% of our gross revenue in charges. The next chart, our operating margin plummeted to negative 2.3 million. That was a huge problem. Next chart, inpatient admissions dropped 58% from 168 to 71. Next chart, our surgeries dropped 85% on the inpatient side from 60 down to nine. The outpatient surgeries dropped 62% from 109 to 42. And just wanted to share with you, this is a method that we use with both our finances as well as our operating statistics. We take a two-year, one-year look back for a fiscal year and the current fiscal year, and then we have a couple of bars on the right that show you year-to-date performance. So it's been helpful, but all the signs were that, yeah, this was horrible and everybody sort of felt the black hole of dismay that enveloped everybody in the country. If you look at emergency department visits, they dropped by 55%. And we are still sort of working through that issue. And lastly, the next one, weekly gross revenue, that dropped by 71%. So we were collecting on average around $2.75 million and we immediately plummeted into around the $700,000, $800,000 range. So that was hard to figure out what the future was gonna bring. We immediately started a process of looking at the state estimates for where this was gonna go, best case, likely demand and worst case, we plugged it against the actual. And probably by April 15th, we kind of got a good indication ourselves that this was not gonna be as bad as people thought, thankfully. And the state based upon a lot of efforts, communication, everybody being good stewards, abiding by policy, social distancing, et cetera. As a state, we kept it extremely tight. And their estimates went to six, two, and that's where we sort of stopped the chart. But thankfully, we did well in that. And then for our community, we kept track of this from the beginning of time. We sort of peaked out in March 27th, not that it was a big peak, but if you look at the volume of cases from March, they sort of tapered off and now and then we collect one and two. A couple of false positives that occurred, but that's a whole nother discussion about what's a false positive and how do you verify that. So this COVID thing sort of settled down financially, sort of post initial COVID. We found that a lot of patients, a lot was going on, a lot of folks were just avoiding healthcare completely. A couple of things. One, they were initially told to avoid hospitals for fear of, disrupting the hospital as its demand for taking care of patients. So don't go to the hospital and give them an undue burden of your visits unless it's necessary. And then later that sort of evolved into people saying, well, don't go to the hospitals because you'll get COVID. So there were two reasons, I think nationally. And if you look at what happened all throughout the world, a whole bunch of care was delayed and people literally having strokes, heart attacks, significant conditions, and not going to healthcare hospitals. So we started a campaign. Don't put your health on hold. We actually got the six partners to all participate, which was great. We didn't ask the nursing home because the nursing home, although they are part of the team, didn't want anybody to even think about visiting. But that worked really well. And I know Kathy was part of that and I'm gonna make a comment. Yeah, I was thinking that probably was very helpful in this for us, where some of us are smaller entities and we don't have marketing people and things like that. So for probably to take the lead on this and include all of us in this was very helpful. And you'll notice at the bottom, all our logos are there and we even took turns moving them around so that it was totally fair. No one was in the lead per se. We were all equal partners through that. So it was very helpful as a community for a copy to take the lead on this also. Thanks, Kathy. I wanna just move on to some of the income statement slides. Jeff's gonna walk through some of the finances first. All right, so we're on slide 30. First slide is the income statement. And what we've given you is we have 2020 projected, 2020 budget and 2021 budget as well. On this slide, our projections, was kind of a very unique year as you guys know. And the projections that we put out there, we just closed our July financials and it is on track. But again, that is a projection moving into our net revenue. Overall, we asked our managers in a very short time to put together a budget. They did it in a month. It was a really great team effort. For that budget process, we gave them volumes that were pre-COVID. So it was October through March. When we took a look at those, we were actually as an organization doing very well. We were at eight budgeted expectations. But when we got the budget back from our managers, we saw that overall, they only realized 95 to 97% of that increase. Looking at our payer mix, we definitely budgeted differently here, more specifically when we get into the Medicare payer mix, this population continues to age and we continue to see that we have a higher percentage of Medicare patients. We also increased our payer mix in Medicaid and self-pay. The reason for that is due to the economic conditions caused by the pandemic. And then overall, that came out of our commercial payments. Last was our rate increase. We are requesting an 8% rate increase. That totals about 5.4 million for the year and 674,000 represents 1%. So looking at our payer specifically, Medicare, one of the things that's special about Copley is we are a critical access hospital. Due to that status, we get cost-based reimbursement. That is based on allowable costs. When we took a look at the increase in our cost per service unit, we feel that that is going up commencement with our rate increase. So we realized the majority of the 8%. Right now, as an organization, Medicaid is unknown to us. So there's no dollars in our budget due to the Medicaid 8% increase. And then for our commercials, overall that varies based on contract, but we are realizing the majority of that as well. Next slide is what I'm gonna call the other revenue COVID slide. I apologize on this slide preparation. I really should have grouped this into loans and into grants. I'm gonna take that opportunity to communicate that right now. First being the loans. Overall, we got Medicare advanced funding. That was 11 million, we received that in April. We then also got Blue Cross Blue Shield, about 2.3 million. We got that in two monthly installments, April and May. And then the final loan that we did receive in May was our PPP loan of about five million. Looking at our grants, the federal funds that we received, we received those in April and May from HHS. These were specifically granted to us to offset our revenue losses. That totaled about 5.8 million. The state also had a program out there called the Medicaid Retainer Program. The conditions of that program was to continue operations of organizations. We actually got three disbursements in the months of April through May, and that was about 911,000. And then the others were grants to offset expenses, and those totaled about 131,000. We received those April through June. Moving on to expenses. Overall salaries and wages. We are seeing our FTEs increase by 6.3, of which we are seeing 4.3 of the FTE increase due to COVID-specific. These are screeners, food and nutrition and environmental service positions. Overall, this one is a salary that we can tag through our budget process. And we're looking at an increase of about 200,000 that we're thinking this is for the long haul. This isn't a temporary thing. These are built into our budgets. Our benefits overall are going up about 5%. Our pharmaceuticals are going up 5.5 to 6.5%. This would have been actually higher for topoly. And the reason it wasn't is because this is our first year in a group purchasing, which can't that inflationary increase. Moving to the change in charge requests. When we take a look at it, again, just recommunicating, we're going for an 8% increase that is overall worth about 5.4 million for the full year. 1% worth about 673,000. Taking a look at the financial pressures, what's why we need to do the rate increase. For 2021, Copley right now is budgeting a margin of about 5.6 of a percent or in dollars, it's 439,000. Copley over FY 16 on a previous slide that Joe had shown, demonstrated for fiscal year 16 through 19, we had negative margins. We have always the inflationary concerns, those being labor, those being travelers or contracted services, as well as pharmaceutical increases. And we are seeing payer mix shifts with more towards our Medicare and Medicaid population. We need to, as an organization, get back to financial stability. The reason we definitely need to get there is to rebuild our cash reserves so that we're able to invest in our equipment and our infrastructure, as well as to invest in the staff here at Copley and the community services that we offer. The next slide I wanted to go over with you is just looking at our, this is slide 37, our increases over time that we've asked for and were received from the state. So the first set of columns is the five year look back, Copley's in blue, I've taken out the other hospital's names because I don't think that's relevant to this discussion. Five years, average submitted was 2.94%. The average approved was 0.64%. Makes us the lowest average approved of any of the hospitals by a lot. The highest was one at 4.54%. Now, if you go back even 10 years, we asked for a 3.5 to an average, we got 2.37. We were the second lowest, the lowest was 2.17. The highest was 5.5. That was their average approved over 10 years. And then if you look at the 15 year look back, again, we were the lowest of any hospital by far at 3.01%, significantly lower than anybody. The highest was 5.99%. So the discrepancy of 3% per year for 15 years has really put to Copley, I think in a really difficult position. I know over time, there have been great efforts to reduce the cost of care and keep our prices down. And I think we've done that really well, but there's sort of a price to be paid for that. If you wanna go to the next slide. This is that same slide, and I talked about the fact that we were the lowest of two of the three categories in the 10 year category with the second lowest. And if you look at the most recent 2018 all-payer cost of care data that's shown by service areas slash county, we are the lowest coming in at 4.43 per member per month. More importantly, if you look at the next slide, we've got six years of that data collection methodology. We are the lowest in the past five years and the sixth year we share a tie with Chittenden County by a dollar. So pretty much, I guess, we're both lowest. So just wanted to give that perspective of some of the data. There's a lot of data out there. And I think historically, no matter how you slice it or who looks at it, Copley has been really good stewards of the cost of healthcare, as well as the rate increases. So if we look at the next slide, this is one that we took from the Greenmount Care Board. They were looking at the Northwest Medical Center mid-year rate request, happened to see this. And again, Copley's on the bottom at 0.6% significantly down there. If we look at the next slide, this relates to that same presentation compounded annual average increase over a 10-year period of time. Again, Copley is always there, it depends upon how you hold the chart. We are clearly the most lean, humble in our requests, and yet we've been cut a lot too. So next slide. Another interesting perspective, this is one, I think, from Rutland in a presentation. Again, if you look at their data, I mean, all the data is relatively close. It's not exact and why that happens, I don't know. But the five-year average of approved rates, we are negative 1.3%, which is kind of interesting. So we are off the chart in the wrong way. And then lastly, a couple others, when you look at operating margins, I think Jeff referenced this, we're at the top four years in a row of negative operating margin. And we know that Springfield, again, is in bankruptcy, Grace Cottage, for some reason, always budgets a negative operating margin, and I think has benevolent kind community members that make up that difference, which is great. But we're definitely one in the heart locker. And if you go to cash, this is CH five-year data, days cash on hand. We're five-year average of 80 days. I think before we went into this COVID experience, we were at around 65, 70 days. So in this particular timeframe, it shows 80 days, the only person worse than us in Springfield, again, they're in bankruptcy, and then you've got, again, Grace Cottage down there, but it's a significant operating margin, the days cash on hand, I could go into capital improvements and a bunch of others. I think Jeff wanted to mention the Optum study, which I wasn't around to know about that, so to get the benchmark data, we did actually go to the January 2019 report on financial health of Vermont critical access hospitals. When we got in there, we were able to see that one of the key indicators under liquidity was the days cash on hand, and we utilize those benchmarks. The two benchmarks that we were able to get out of that study was the Vermont critical access median average, as well as an average from Optum, which represented Northeast CAHs. The point on this is to get us to the Optum average of 93 days, overall, Copley would have to basically squirrel away about 5.5 million, and to get us even close to the average for the other critical access hospitals would be up to 12 million that we'd have to put away in additional cash savings. Jeff's gonna go over some more balance sheet. Yeah, so I'm on pages 45 and 46, our balance sheet and cash flow statements. Again, on both of these, our projection on 2020 budget and 2021 budget, and again, our projections, at least for the first month with August and September seem to be right on track. When I look at these two statements, one of the things that we gotta be very conscientious is going all the way back to the COVID other revenues, understanding how these loan paybacks will be happening for Copley in the year 2021. The first one is our Medicare advance loan. Expectations was after 121 days, these were supposed to start to be paid back through our remittance advice. We're still waiting on that. And when we go out and try to understand what's going on right now, you'll see that Congress is looking at these Medicare advance payments. So at this point, we still have that, but in these schedules, we do have them being paid back by the end of 2021. The other loan that we had that I discussed earlier was the Blue Cross Blue Shield. That was 2.3 million. That one had pretty clear guidelines. They will be taking back their money to the months of October of this year, November and December in three monthly payments. And then at this time, we are still waiting on hearing the final rules for our PPP loan. And until we get the clear understanding, if we qualify to have it turn into a grant, we are assuming that that will be paid back by September as well. Service line adjustments, overall for Copley, we feel that the services that we currently offer are appropriate for the community. So we have nothing to report and changes on our service lines. So under sort of risks and opportunities, just three large categories. The risk going forward is certainly lingering COVID-19 concerns and there's still a lot of speculation and discussion about personal protective equipment, testing methodologies. There was a discussion a few weeks ago about gloves. So we're concerned about a number of things going forward. That's a risk that we can't really predict although we're trying to be as prudent and cautious as possible. We're not scrolling away in undue amount of anything. We just sort of see how this unfolds. Staffing is always a risk and concern for us moving forward just because it can lose any key providers or key support staff or nurse managers or even billers or folks in the leadership team that always creates instability. And so that's a risk for a small critical access hospital. I think all eight of us have that same concern. And then the sustainability issues. We were chosen to be part of that group. I think we're probably the poster child of one of the members that probably needs some more attention and help and understanding as to what's going on given our losses and the stresses that you've been under. Next chart. I think Jeff gets me a lot of charts. I appreciate that. This is from the Vermont Hospital Association. That risk of cash. This was a type frame of around April 30th to May 4th and you know the two worst are Springfield and Copley. You know in this particular time frame we're at like 35 days to zero Springfield at 20. So cash is cash is king for us. Cash is a little bit of a challenge. The opportunity side there's always opportunity ongoing. We see a lot of that we're just trying to get through the financial stressors to be able to afford to to have some opportunity to even invest which is important and look at opportunities. We're always looking at our clinical quality. Adon references that but we were pretty obsessed over providing excellent care and I think people travel far and wide to come to Copley which is really an honor. Our orthopedics program in itself draws people from all over the state and then some and we've got a great surgical team and we've got great staff extremely competent folks. So that's that's part of the patient experience. It's important. That's why part of the decision making process although it's not entirely clinical in the whole coordination of our care and services. I know even on the orthopedic side we've been doing some outpatient hips and knees and our our surgeons push themselves. They're that good that they just push themselves to always do better to refine to you know eco improvements in small and in big ways. Master of facility planning is a big issue for us. We haven't had that in years if not decades. We're trying to work through the process of looking at our campus looking at all the investments in buildings infrastructure changes improvements so that we're not spending money inappropriately or not to find that five or ten years down the road we shouldn't have done that. So we have been working on that. I think Kathy let's make a comment. Right. I just want to say that I've been at Loyola Home Health for over 25 years and we are neighbors to this facility so I can tell you that I have seen the lack of work being done here or not being done. It's been nice to see in the last couple of months just new roofs put on some doors replaced paving taking care of a few trees planted. So to see those capital improvements happening has been good as a community and it's good for the neighborhood. Yeah good so an opportunity is we continue to coordinate with our local folks here. So the hospital tends to be a bit of a hub although we're really open to share again whether it's personal protective equipment for. So what's the name of the witness that just testified. Oh that was Kathy DeMars the board chair of the hospital and she's also the executive director of the Memorial Home Health and Hospice next door. Okay I thought you slipped in and a witness hadn't been sworn in yet. Is my voice getting higher maybe. I'm just seeing you and Jeff so go ahead. Okay thanks. So just wanted to say that I think it's really imperative for us to work with these local organizations again the designated agencies the private practitioners the nursing home. It feels like we're really developing some teamwork. It feels like when we talk about health care reform or assisting each other with staffing whether it's clinical staff or administrative staff I feel like this is a small little microcosm of what could happen in Vermont. I know we're a tiny part of the state but if we can get coordinated that's worth a lot and we've been working on that. Jeff wants to talk a little bit about capital. Okay so we're on actually slide 51. Overall our capital atop just basically is a demonstration by year. Capital for many years we unfortunately have been underfunding it due to the cash concerns we have here at Coblee. For budget 21 we do have substantial need to you know get at capital. We have that set at 4.2 million. Some of our specific areas that we're looking at definitely meeting on some capital improvements is a lot of needed upgraded IT infrastructure and that's coming in at 688,000. We're also there's a category called ancillary. This is imaging lab and other diagnostic equipment equipment here at Coblee and that has a you know a price tag of 687,000. And the last one that I'll just go over is our nursing which includes our acute and swing units and that's coming in at 345,000. Good so we've got a lot of extra time. I think we're finishing up. I wanted to just summarize by saying that I think over the many decades Coblee's done a really nice job and very modest in their requests. At this point we'd love to get at least the average or just a little bit above average given the years of needing funding. We do have a lot of operational program investments that we need to do. Hopefully you get a sense that we are fragile. So if you're looking at that sustainability group and trying to figure out who needs a little bit of extra help we do need some help to sort of work our way out of that. And we try to deliver above average performance. But again our costs are our cash is a concern for operating margin. And so I hope there are some good questions and we can sort of talk about all of that. So thank you Kevin. Thank you. We're going to start with Maureen Youssefer. Maureen. Thanks. And first thank you for the presentation. Thank you for everything you've been doing during this crisis. It's really appreciated. When you just just a couple of things on some of the charts that you've gone through when you talked about the PPP money and the assumption of having to pay that back. You know it seems like the payroll protection program that you would be qualified for that. And although when you reconcile it you know it's possible if you can't justify 100% of it. But you know it seems to be very conservative to assume that you'd be paying back that $5 million. So I guess I just want to get a little more handle on why you think you'd have to pay that back. You know because obviously that's separate from all the other funding that was received. Yeah I'll jump in and then Justin jump in after. I think the the federal government's response to COVID-19 has been dramatic and significant. I think many of us particularly our audit firm and others when they look at the potential audits that are going to happen or the realization of what can we afford as a country. I'm not sure early earlier on I would have said yeah I think the PPP monies are going to be forgiven but nobody knows that we've got an election we might have a complete change in the White House. And I think there's still this reconciling as to how much money has been literally poured out if not shoveled out into America. And those that have accounting backgrounds asking questions like how are we keeping track of this how are we making sure that it's abiding by the rules and regulations. So my confidence in that becoming a grant has actually diminished over time. But that but it's it's up for speculation I don't know the answer that's all I have. And a follow up on that. Sure. So there were rules of the game that were put out when you applied. And I think a different way to ask you the question is Joe is how much do you think you should get. Well Kevin in regards to the rules definitely they keep constantly changing that's our concern. When we first they applied for the PPP loan they actually had an eight week window in regards to getting all your employees back into the saddle. I believe it was like almost a week after we received those monies and we turned that counter on that they did move it to 24. You know we are hoping that you know this will be ultimately a grant opportunity but until we know for sure that's why we're treating it this way. I get the conservative approach but it's just ironic that it's five million dollars and it's only five hundred thousand less than what you show is what's needed to reach the optimum target on your cash on hand or to look at it a different way. If you look at 674 thousand per percentage if you multiply that times eight I think it comes out to five point four million. So this is only four hundred thousand dollars less than that if you were to have it forgiven. But that's just one way to look at it. And I if I were in your shoes I'd be presenting it exactly the same way. So thank you and thank you Maureen for letting me follow up on that. Can I just it's hard when you say Kevin how much do you think you need or deserve. I think we have worked tirelessly to apply for every grant that has come by. And I know people would say that's a great thing that you've done if there's a federal opportunity to bring those dollars into Vermont. Joe I wasn't trying to insinuate that you didn't need or deserve it. I think you do. I was just trying to rephrase the question and probably not very artfully. So to ask you if you if you were being asked by the federal government how much would you think do you think you should be asking for. And obviously you'd be asking for the full amount. I would hope you would want me to do that. I would. Thank you. If you weren't Joe I'd be very upset with you. I'm going to continue a little bit on the line this line of questioning which is really if the five million was forgiven and if you knew what was going to be forgiven when you put your budget together how would that have changed your budget proposal. Well I'm Jeff can jump in. I would assume if it does get forgiven we're going to let you know and you guys are going to look at our budget and probably make an adjustment accordingly given the fact that that is forgiven. That's what I would suggest you do. I haven't calculated that but if we've got five million dollars of additional net revenue that would be extremely helpful for us and I would think that'd be a windfall for the state and all of us and state money but I don't have a dollar amount right now. I don't know what that would do to the rate request so I apologize. Right right and I guess that's where I'm going and I don't you know obviously we know you know you've done a lot of support showing where you've been and the history and you know of course we know there's a little more background to some of that history but we understand you know that those are the rate increases that you've received over the years and of course a compound. So you know I'm not going to the place of saying for instance if you got it all that you shouldn't get a rate increase. However we did have the opportunity this year to put in a COVID only rate increase so you know so maybe it's possible we could we would link some of that to this not all of it but you know it could be something like that for the component. And the other piece related to the COVID only piece is you did show some support of jobs that you need you were hiring that we're continuing on next year related to COVID and just wondering why you didn't put any of your 8% request into a COVID piece only not for the commercial rate because you are one of the highest rate requests we have this year so. Yeah so with the COVID request again to communicate you know FTEs I can you know easily tag that and you'll say that here's the overall salary increases that we're expecting as well with benefits. The other stuff is really built into the budgets of our department managers increase testing which is not as easily acquirable to get out as well as to put in a time frame so that's why we we just didn't have that ability at this time to get that detailing. Okay this thing's like the increase test and maybe some inefficiencies and how you know how many patients you can accept and things like that those types of things could go into a COVID increase you know with the hopes that in 2022 they would go away right that we wouldn't need some of the COVID piece who knows but and if we needed it maybe they would continue on but there was we would have that option to put that in there. Okay when you look at your your NPR you were tracking like 8.4 percent ahead through February and I guess first can you talk a little bit to to that you know increase because you had a pretty big approved increase from your 2020 budget was over 6 percent so you're tracking 8 percent above through February. So can you talk about what was driving that? Yeah so when we looked at this we looked at it in many different ways it's our volumes we're definitely above budgeted expectations the but volumes in our surgical area our ancillary testing across the board we were oops I lost you. Yeah you just froze guys at Coppola you may have to log out and log back in I don't know but you're frozen. We can't hear you at all. Now you came back a little bit we lost you. Sorry we saw that you guys froze up too so did you oh so you didn't hear anything that I said? That's correct. Oh sorry about that. Overall it was it wasn't one specific key area we were definitely outperforming in our OR but we were seeing those increases in our ancillaries our diagnostic imaging our lab testing as well as you know meeting you know we were just exceeding expectations throughout the organization wasn't one specific key area that I was just out doing better than anything else. Okay and that just just touch upon I guess the surgical area and the volume there I mean obviously you had had some personnel changes there and that had brought on some declines you know in the last year you know are you back on track for where you think you need to be for surgeries for both I guess more for 2021 what you're forecasting would you would you say you're kind of back on track to where you would have been historically? Yeah we think we work through the the deficit that losing Dr. Huber as a daily surgeon provided and we do feel as though we're essentially fully staffed and operating the OR at significant efficiency. Okay great that's good to hear and I know you guys were forecasting that but there was a little bit of uncertainty you know about whether you would have the staffing and capacity to be able to do that so that's good to hear. When you look so just getting back to the NPR so you were about 8.4 percent ahead and now in this budget as you talked about you're you're looking at some declines against that trend I think you were down 1.7 in inpatient 3.7 in outpatient 4.7 in clinic but can you can you also give us that number related to budget just so we have you might not have it now so I'm assuming you know from budget you're probably higher over volume from where you were trending through February you're lower but one of the things we're tracking is it's just kind of like where where are people you know in 2021 in their 2021 budget where are they relative to their 2020 budget for what they're assuming for utilization. So if I could take the opportunity I'd love to get that back to you guys I'll write that down. Yeah I kind of like rough out a number I mean it's it's it's above you know it's above zero it's not it's above zero it's above 100 you know it's above 100 it's so that's okay. Just looking at the the P&L and your margins obviously you're still looking for a relatively low margin for 2021 and what can you tell us about any cost saving programs that you have you know because clearly you've had a lot of financial challenges you're going to continue to have those when you work on thin margins and you know if you don't get the volume next year we've seen what we've seen in the past is the expenses don't come down and then you you know hospitals lose money and that's you know that one chart you showed where a lot of hospitals were losing money one of the reasons for you know several of those hospitals is they had too high forecasts to begin with they didn't come in with their top line they came in with all their expenses and more and they lost money and so you know it's really trying to make sure that the top line number you have is achievable as well as then what cost saving programs do you have. So that's a great question. We do have an entirely new methodology of presenting finances to the board even to our staff and the providers physicians pretty transparent about all that we use run charts over time to cover two years by month so we really do look at operational statistics as well as the financial statistics so our controls and understanding what's going on so we're not chasing noise or being concerned about variation that's natural in the system so if you look at ER volume visits and other stuff that's actually helped us not run around with our hair on fire so we do have a lot more controls and feedback in place we have actually made a lot of significant decisions one of them is that there was a commitment that I inherited that we would get a new information system and go to Cerner and drop CPSI we're one of the oldest CPSI customers probably in New England if not in America and there's that great lesson about information systems it's like a marriage half the problem is you it's not always the other person and you're probably more than 51 of the problem so we've come to realize two things one that we can't afford to swap out our information system and start from scratch you probably know if you've been around Vermont very long that most every hospital that estimates and even re-estimates how much it's going to cost they always undershoot it costs more it becomes a disaster it ends up being millions and millions of dollars more but not close to ten million dollars more so we've realized one we can't afford it two we are a big part of the problem so we're making a very concerted effort we're preparing for January 1st restart reboot recommitment to our vows I'm just making jokes here but to actually invest in cpsi and make sure that we are using it to its full advantage it's not a bad system it's a pretty good system so we're working on that that should be saving us millions of dollars and expected capital that we talked about years ago and we're trying to be very dynamic with the budget and all of what we do so even an approved budget doesn't mean it's approved so we actually say to folks just because you've got approved capital or labor or any issue we're always looking at the organization's performance our operating margin how well we're controlling costs and so getting through the budget process through a finance team it's just the first step but we're always looking at whether or not we can afford those fds or those changes and if we do have an emergency and something urgent we will go purchase that because sometimes we have not done that and we have to pay double if not triple because we never addressed a problem that should have just been quickly addressed so we're always looking at that approach what can we afford we're trying to manage labor over time we'd like to reduce travelers we're looking at shifts people ask to take time off during common holidays so that we don't have staff around being inefficient so we're working through a number of issues also the revenue cycle to make sure that we are collecting and getting credit for all the work that we're doing because there are cases where we're missing potential charges reconciliation sort of leaving money on the table because of the administrative back end so it's a matter of cost control but also making sure that your operations are really tight so and Dr. de Puy is raising his hand so I assume he wants to say something I hope that's what it means yeah yeah thanks so not not being a finance guy I sort of get baffled by the the question about cost cutting because all our supplies just keep getting more expensive they don't get cheaper in a hospital mostly the people are the most expensive thing and the people really don't get cheaper either and we like all the other hospitals in Vermont and it's a worse problem for the critical access problems is because we're all very thin on staff we all wear a lot of different hats is not a lot of extra people so whenever you have to use travelers it's it's very painful both financially and just as a operational point of view and so we have a couple programs here that that we're working hard on cost containment with we we train our own surgical texts we send them off to school and then they come back and have a work obligation and we do the same thing with a well similar thing with nurses right now we have nine student nurses uh up on the floor uh largely with the idea not only to provide more nurses for Vermont but also so we can have more nurses and use less travelers so uh I think cost containment is a much better concept than cost cutting because it's you know nearly impossible to cut the cost well being a finance person I would look at it a little bit differently which is um you know there are always cost saving opportunities and efficiencies that can be had and you know we'll hear a bit about the low-hanging few you know low-hanging fruit has already been you know we've already got all the low-hanging fruit but there's there's always something and when times get tough um you know we see people come up with new solutions or or talk about um the ability to save money cut costs not just by cutting salaries and things like that by optimizing efficiencies by by looking at your mix of services and um you know understanding you know where where some of those drivers are you know looking at groups to purchase supplies and looking at different ways to get pharmacy so I mean I understand what you're saying but there's you know any any company I've ever been there's there's always a target to improve gross margin and you know continue with cost savings and um you know so it's something I'm going to continue to ask every every year and uh and again it's it's not to say no cut the people it's it's trying to say I mean you know I I don't know if you could say that uh there's everything in your hospital is completely efficient you know and there aren't ways to save money and you know we brought in things even on some of the surgeries right where there's been reviews of surgical costs and the time for each each thing and waste of things being thrown out and you know how to optimize that so it's really just putting the challenge on of trying to say you know how do we try to keep some of these costs down because they get passed on to the consumer who can't afford it so Maureen yeah I would say I'd say 100 percent um and we're certainly with new management we've had a lot of new eyes looking at things in a different way and we've been able to create quite a few efficiencies but and without being overly argumentative I would say that that certainly all those are they're asymptotic over time I mean you can only cut so far and then you're efficient so yeah Maureen one thing to the efficiency is that's why I'm really excited to have the opportunity of having a new audit firm you know actually come in here take a look at it again it gets to the different eyes looking at different processes more importantly we're also taking the opportunity to have this group look at our revenue cycle make sure our flows and processes are working efficiently as well as our patient access they'll be coming in and making sure that you know we are performing you know the right appropriate procedures to register our patients from start to finish so we are looking at it different ways there's different exciting things going on on BKD coming into this organization one of those okay great um and I just have one other question which is on your the gross to net reconciliation for your for your NPR and it was on slide 30 but basically you're showing and I'm going to whether you do it off the budget of the projection your gross revenue was going up about 17 million dollars from 125 to 141 you know or 14 percent but when you get down to the NPR you're only you're only reaping five million of that 17 million and I know some of its payer mix some of it is you know bad debt and free care or higher but it does seem like maybe that's a little bit conservative and it it ties more to them you know your operating expense which is up you know seven percent so your operating expenses are growing more than your NPR it's certainly less than your your growth so you know you know here might be an area of opportunity right if your gross is going up by 14 percent why aren't you retaining more when it gets to NPR so that it would offset those expenses if you make more money on the bottom line yeah and I agree you know and you know when we looked at it we looked definitely closely specifically at the the budget analysis the payer mix that was submitted you know we do see that the payer mix is going down and we looked at it and it is you know unfortunately attributed to increases in our Medicare and our Medicaid payer mix and decreases as well as you know on bad debt we have you know recognized in the budget that you know it's different times out there it's a pandemic and a lot of people are unemployed so there's a little bit in there as well yeah okay all right thank you that's all I have thank you Maureen now for Dr. Holmes Jess great well thank you um and again I think we're all echoing each other here with with thanks for all the work that you all have done during the crisis to protect your workers to protect your community the late hours the long weekends all of that so um a genuine thank you for that I also wanted to um express my appreciation for your emphasis on quality in this presentation and taking a data-driven approach to maintaining quality the NISQIP data is is compelling you've shared that before and um I guess I would love to see all the hospitals um you know becoming a member of that organization and having that uh access to benchmarks how much is that a year to get that data to be part of that do you have a sense um Don can answer that but I I was told that years ago through an MVP process of um giving back to the state that pretty much all the hospitals used to be on NISQIP NISQIP sorry did I say it wrong yeah NISQIP years ago yeah all the hospitals used to be on NISQIP and uh and in Maine a large percentage of them are and uh Don can speak a little bit more to that too yeah I I don't remember the actual number uh precisely but it was about 40 when you consider both the feed paid in NISQIP and the uh the half FTE that we use to uh as our abstractor okay well so all right and I wanted I guess I was going to ask you about if there were any um early insights from your new auditor I think that's an interesting uh approach to trying to um you know think differently about your financial turnaround but it sounds like it's a little bit too early and I know you answered Maureen's questions at length so I'm not gonna go there but I'm looking forward to this time next year hearing about what your auditor says um about opportunities well you know um our previous auditors um you know uh they were great firm and stuff but some of the things that um we've already got the benefit of with um you know looking at BKD is their experts in um reimbursement their experts in cost reports and obviously they're very large uh auditing firm some of the benefits that we're getting is understanding that we are capitalizing everything um on our allowable costs so we've been working closely with them given that we're coming into the year enclosed um but they've been very helpful when we announced or asked that we needed to do a look at patient access and the patient access flow they were really excited because one of the things that they said that um you know a lot of organizations need to do is to understand how you incorporate the COVID screeners into that flow and into that process and so they were like uh you know really actually very uh beneficial and the last thing that I'm really looking forward to you know with BKD is you know when we started talking about doing what Joe called the reboot of CPSI i.e. keeping the system but making it more efficient in its table maintenance and um in its data capabilities they were so um almost I heard a sigh of relief from them saying we are so glad that you're not deciding to go with a new EMR and uh you know sticking with your firm. All right uh and noticed on the uh the BKD list of references north country is one of the references does that mean that you share the same auditor now they're using that you I am assuming that. Yeah I believe uh they have their lead if they're still with them again that slide is a little bit older and stuff was a gentleman on first name Brian our lead will be different it would be David Taylor so they are um I do remember that from days of old. Well the reason I ask is we just heard from um you know from north country that their auditor has an interesting software package or there was some mechanism by which they were able to do estimate contribution margin by service line and I was just actually occurred to me that maybe you would be able to do that too with BKD if it's the same auditor so. That's excellent. Something to look into but it sounded like they have that capacity which seems like a really helpful one when you're in a financial turnaround. Yes thank you um so I and I you Maureen touched on utilization and I think we're all trying to get a sense of each hospital's assumptions around utilization uh for next year compared to budget compared to projected really trying to figure out what's the COVID effect and I know you're going to get back to us with actual numbers but I'm curious just to hear more of the story of what you're expecting um you know there is some decline that you're expecting and I'm wondering are you thinking about that in relationship to the fact that there's more sanitizing that has to be done that the the work patient flow is going to be slowed down because you have to you know there's more uh that needs to be done in between visits or is it patient fear of you know utilizing services I'm just trying to get a little bit of a sense in your community um what's behind some of those actual assumptions. Yeah that's a that's a great question certainly you know how do you do medical care in the time of COVID and and still be anything like efficient uh is difficult because the primary concern is is safety overwhelmingly um and you know the telehealth experience is actually kind of kind of interesting uh about that and in April uh we had yeah I better put my glasses on yeah we had 300 total outpatient visits for the whole month and a fully 60 percent of those were telehealth whereas in July when things have more or less gotten back to normal we had 1,300 visits and only about 1 percent wow we're we're from we're from telehealth so it's certainly a little more expensive to operate in in the time of COVID but uh you definitely can do it efficiently because not everything is done serially like you know screen a person and then they go in you can screen the next person while the next person's in so you just have to think through how all these things work and uh as long as you're keeping your your eye on the ball of safety we can get pretty close but yeah we definitely is going to be more expensive you have to do a lot more cleaning and so you need more people to clean and certainly if we had a lot of COVID patients uh in the house uh that would be very tiring for the nursing and we'd have to operate at you know lower patient ratios well it's just been very interesting for us I think is a board to go from the rate review hearings where we were hearing about a lot of pent up demand that the carriers were expecting to see in 2021 and to hear from hospitals that they're anticipating 90 percent of utilization or 95 percent of utilization or sometimes over 100 percent of utilization so there's a lot of you know just differences and assumptions which completely makes sense given the uncertainty of the situation so just kind of try and understand your perspective and I know there's no crystal ball so um yeah there certainly still remains some you know trepidation about seeking medical care uh in the community I'm sure you all saw the data that uh over March April and May the cancer screening and children's vaccination rates went almost to zero I mean it was just it was just horrible and although most of that has come back I don't think all of it's come back yet and and I don't know how to forecast that right yeah I think nobody does that's why we're seeing such variants in those forecasts um so I would I would agree with Maureen it would be great to see what the expenses for the four and a half or 4.3 FTEs for COVID are and if you if there is a way to pull out any of the COVID related expenses for 2021 that would be helpful to us um the the medical inflation slide thank you for providing that because that's one of the areas of inquiry that I've been trying to understand over the course of the hospital budget process and I'm wondering if on slide 35 um you could just briefly talk a little bit about um the benefits five percent increases benefits that sounded high relative to other hospitals and I'm wondering what's driving that yeah one of the um specific benefits and it's due to uh um utilization that we're seeing the increases offering more plans is our dental um you know increase the other one on the main one the big one was our health insurance and we do have a three percent inflationary increase on that those two added together are getting us to our five percent got it so even though utilization is projected to go lower your health benefits are projected to go higher well our health are going you know just inflationary three just inflation yeah um it wouldn't be possible to just give us and not now obviously um but submit it is just a weighted average of those components so we can get a sense of the overall medical inflation that you're anticipating for the benefits yes or no the whole thing like compensation non-salary pharmaceutical you don't have to do it now obviously but you know obviously you know as you've said compensation is the largest part of your expense budget so weighting that more heavily than you know utilities or pharmaceuticals so just a weighted average of what your medical overall medical inflation would be can i um you know we've been listening you know in on this kind of a unique forum so it's very easy to turn it on yeah yeah then he's dropping uh so we did you know i've heard that common theme um and you know when we take a look at our salaries uh you know our contract services our benefits as a percent of total expenses that's coming in at 58 percent for um properly okay we take a look at our medical supplies now the thing with medical supplies uh it's how you uh you know um identify or define what a medical supply is these are medical supplies that are chargeable as well as non-chargeable in our budgets those are coming in at 14 percent of our total expenses okay and then when we move down to the drugs um the oncology drugs and drugs those are coming in about six percent of our total expenses okay that gives a lot of context thank you yep um you said something interesting and i i wanted to hear a little bit more about this the eight percent increase in charge you're expecting the majority of that to flow through in medicare um via the cost report and that seems a little bit different than what we've heard in some of the other hospitals i'm wondering if you can just speak a little bit to that yeah and so the cost reports you know they add and flow they go up and down you know on but overall if on the cost per unit on a cost report if it increases you know um at eight percent on that then would uh you would basically you know net your full eight percent rate increase because for our patients it's a cost to charge ratio that they utilize and so then you would be able to capitalize on that however if you know on if that cost report we're to see the service unit costs go down and you had an eight percent it would be going in the other direction so when we take a look at our budgets that's how we look at it is to make sure that that cost to charge ratio is going up commensurate with our rating increase okay so you wouldn't for example be expecting any cost shift due to medicare next year and that we not in that component no that component yeah okay um and lastly i thought there was an interesting comment in the narrative uh around that eight percent uh charge it was cobbly uses these rates as a basis for discussion with our commercial payers as a basis for our discussion so i'm wondering if you can tell me from your perspective how those conversations go and if you don't get the full rate the full charge that you're asking how do you adjust your expenses downward what are you going to trim if you don't get let's just say the board gave you eight percent but the commercial payers in their negotiations don't uh how do you then adjust your expenses downward and how do those conversations go okay so again our commercial payers are always you know i just actually got a call today you know saying that they wanted to look at them a lot of the contracts actually uh you know have built into them the green line care board aspects of the rating crease you know they talked about it and stuff um you know so again it goes back to what joe said you know nothing is guaranteed it's a budget and so you know if we need to if we need to look at you know hey of those you know on 6.8 fds we have to look at them because we didn't get the full that's how we go back and we you know adjust it nothing's ever guaranteed you know it's a budget and we have to you know on basically you know on manage accordingly to that budget as well as to what actually is happening okay those are all my questions thank you so much appreciate it i just wanted to comment jessica on the bkd slide of those other hospitals in vermont those are just hospitals that have used bkd over the years their references but they're not actually potentially the not current clients with bkd we don't know if those are you know what i mean but they have used them in the past got it okay yeah appreciate it yeah thank you jess now we're going to move to board member lunch robin thank you i only have a couple of questions because many of my questions have already been answered one of the benefits of going towards the end um i i thought it was very interesting that in your telehealth experience you you mentioned you were around 60 percent of outpatient visits which seemed pretty standard for a lot of what the other hospitals are saying but you've now gone down to one percent which seems a lot lower than other hospitals so i wonder if you could talk a little bit about what you think is driving the telehealth use or lack thereof currently and how you see that developing in the future well i i think it's because most of our outpatient clinics are essentially surgical we don't we don't have any primary care uh the primary care partners we have in the community we talked to them they're still doing quite a bit of telehealth and uh it's and it's just the nature of the business and surgery that you got to look at things and touch things to really do the job appropriately and and i think it's it's just that and uh and it's probably you know the relationship of being in front of your surgeon is probably a little different than uh if you're having cholesterol medication that just i don't really know that because i don't adjust cholesterol medication but i just i suspect that's the case that makes sense to me i i suspected that might have been a root cause but i didn't want to assume um in terms of that my other question is relating to travelers um could you and locums can you talk a little bit about where you're at pre-covid how that progressed through coven and where you expect to be moving forward so well uh jeff can jump in i i don't think we have enough detailed information given the time frame that we've been here to actually understand and appreciate the travelers expense it's not one that i appreciate i i know that folks have needed them because of coven and even more so because of some of the scheduling problems with students that we're coming into but it's best if we could really pare down the travelers as much as possible if you want to talk about a cost-saving idea that moraine was sort of talking about earlier i've always dreamed like why doesn't vermont have its own traveling company why doesn't the state endorse you know a hospital maybe like coply starting a traveling organization and you know we could export travelers all over the country because we pick up travelers from texas louisiana minnesota i mean it's kind of an interesting profitable venture that every hospital in the state of vermont utilizes i don't know why people wouldn't want to live in vermont and then travel to chicago et cetera so if we ever figure that out i'll be looking for your endorsement um they are expensive we're not happy about them it'd be great if we could have zero travelers but on the surgery side things get very complicated with scrub nurses and in tex and so forth that's probably where most of them are for us but i'm not not really happy about it they do a great job they're really nice people but it just bothers me the expense and the profit margin that goes to those for-profit companies that are not based in vermont i don't know why new england or i don't i don't know between dartmouth and uvm medical center why they don't have a traveling arm i'm going to start that though let's just you can write that down and so do you know about how many you have currently i don't we don't know that do you want us to get back to you that would be great just as a comparison and it makes sense that you might be quite frankly a little on the higher side given the surgical focus but we did see actually a number of hospitals get to zero travelers over covid time period and some of them are saying they think they can stay there so that was heartening um yeah uh i think that's all my questions i think everything else has been asked thank you thank you rob and next we're going to move to board member pelham tom thank you kevin and thank my fellow board members who went before maybe makes this uh easier being near the the end and i'll be very careful not to talk about cost cutting i'll call talk about cost incisions how's that try to use your language um my first question i've been covered a little bit um it's in the arena of bad debt and free care and i'm just seeing that uh 20 21 is on a combined base this is a 59 percent increase over 2020 budget which seems pretty big and that that 59 percent is a combination of your 48.5 percent and your 87.5 percent you know on your uh operating statement so uh but 59 percent seems steep to me um if you could uh dig into that just a few you know for with a few few more sentences yeah a few more sentences in addition to us you know shifting to medicare and medicate we are uh you know understanding or we did build in that there would be shifting to uh on the private pay patients we also um right now on field that that um that population will be growing um and we did build that into our budgets um at least for the next year um we're hoping that uh you know once everybody's able to get back to work um we'll see that come down but right now our current experience we are seeing that those numbers are going up and that's what we put in the budget okay um looking at your the COVID-19 grant funding um you referenced that you got a 5.8 million dollars in federal funds and you booked 7 million of it in uh 2020 and so that leaves the balance of a little over a million bucks and you didn't uh profile that on the COVID line on your income statement so is that just something that's fallen to reserve and just sitting there for 2021 and uh if it that is so um one other hospital kind of you know let that fall to their reserves and but they're also worried that they might not be eligible for it so it's uh you know they're um they're being cautious uh in terms of spending the full amount because they think the president can change and the congress can change and and and could make things a little bit more miserable so so that so uh where is that one point that that additional million dollars in federal funds? Yeah it's a great question um and uh it's one that um you know we're honestly at this point uh we are working with BKD quite closely to get the final regulations um you know when these monies first came out the HHS monies you know they were communicated that they were for revenue losses but one of the things that um everybody kind of was throwing the red flag up well how does that impact your cost reports you know what is it going to you know mean we've been learning consistently each month um a little bit more about these monies um you know we did finally learn um just actually um about two weeks ago that the HHS monies aren't going to be touched by the cost report you know medicare's already communicated that you know that those will not be factored into it so it comes down to what you were communicating from the other hospital we are just trying to learn you know um what the the regulations are and at this point it is you know in our um you know on our balance sheet as reserved. Okay makes sense to me um the medic the Medicaid number um uh in NPR is up 23.9 percent you say in your slides in your narrative that you didn't budget for any Medicaid increase on a rate so is that all um uh volume driven that that is all my apologies yeah that is all volume driven um you know we're figuring that um and where you are starting to see it now that you know at least for this upcoming year we feel that the Medicaid paramedics will increase. So so if that's what that's a volume up but then in terms of your uh inpatient volumes down 1.7 percent outpatient services down 3.7 percent clinic visits down 4.7 it sounds like a little bit that the Medicaid is kind of going against the tide. It's going against the tide but unfortunately if you take a look at the commercial numbers that's where the paramedics is shifting it's coming out of the commercial it's going into you know the Medicare to the aging population and it's going into Medicaid and self-pay. So thinking about uh the commercial um do you have any uh certainly you wouldn't take it to the bank but um a lot of people I know up in store are saying boy the number of out-of-state plates we see around here and uh people are coming you know look and real estate values are going up etc. Do you think rather that it could could go the other way given the pandemic that that the Medicaid population will be somewhat if it is rising somewhere you know offset by second homers uh deciding to uh reside in the store area? I don't know how to answer that one. Yeah it's a good question there's a lot of speculation people always complain about the out-of-state cars I don't know if they see one New York plate I think they counted as three I don't know it's kind of funny I've heard that real estate is very hot and stow in other parts of rural America but we haven't seen it yet we haven't budgeted that it's who knows what the economy is going to do I mean I listened to a lot of Bloomberg news these people are all predicting the second drop the second you know big giant drop in the stock market you know we're going to have a hangover again I just stopped listening so I don't I don't know anything about that till I see it happen. But you are seeing increases in in Medicaid case loads and Medicare case loads yes that's on the ground okay um the provider tax it looks like uh you know relative to your 2020 projection of uh in 21 year it looks like a six six and a half percent increase the rate is six percent is is that just um you know is so I guess I'm asking is is why are you budgeting that at six and a half percent over the best number you know now for 2020 in 2021. That was a number that was supplied by the state of Vermont and that is the number that we inputted into our budgets right but so that's the number that the state gave you for um for the tax that they're asking of you in 2021 yes our state fiscal year 2021 yes um other than that it sounds like your staffing issues that you know you've talked about before you know you've brought that into a soft landing um but you still do cited as a risk are there any other of your your key money-making staff uh you know talking about retirement or leaving or um well we we have that all the time you know I'm not sure how much I want that on record or played over again by folks at home it's kind of you know just sort of personnel issues so I think everybody has that we've got our fair share of people that are close to retirement or should retire or are interested in retiring and when somebody gets gets struck by disease or accident or you know that is you can't predict those things we did have a very significant orthopedic surgeon two years ago come down with an issue it's hard to predict that so you know it's not like we have a reserve for unexpected illness by a key provider I'm not sure if we could do that that's probably not legal is it Jeff but you know I mean I'm not sure about that but it weighs over us because we're a small organization so anytime you're a small organization people really have to pitch in be flexible take other shifts be cross trained I mean it is a lot more difficult when you're dealing with that that is a constant risk it's not just a risk that you know and you see you had that as a risk but that's just a constant risk it's always there it's a constant anxiety yes you know so on another issue we the board approved a c o n for an entity called silver pines which is a 32 bed medically supervised withdrawal treatment center in stow have they been in touch with you at all are you I want to hear that it's the first time I've heard of it right now is that recent that just happened within the last three or four months so nobody at the table we're all kind of surprised it's at the former hockey academy Joe okay yeah I know what that is yeah I didn't know that that's interesting nobody's ever even contacted us we've never had any discussions in the ER nobody's even we're all looking around the medical director nobody home health agency nobody so thanks for that tip I appreciate it Robert Robin and I thought that your ears would be ready well we were talking about we were talking about your ER um so anyhow those are my questions thank you yeah thanks Tom so um you talked about the different forms of grant funding that you were eligible for um you didn't mention anything about the state CRF or FEMA are you applying to either one of those yeah so by the time that we had you know supply our budgets you know we were still in the process of filling out the FEMA grant that could they get submitted last week or two weeks ago for us we also did meet how much was that for Jeff that is two prior we requested a hundred and twenty thousand and then when we get another piece of machinery which we were building into it it could go up to a hundred and eighty thousand okay and for the state 275 we did fill out all the paperwork um for that and we're just waiting to hear again you know I've heard a lot of questions like you know how much did you request and that's not the type of grant that it is it's they're going to kind of communicate back to us but the FEMA is strictly a swap for a capital purchase correct the FEMA is um it's a two-parter the second part that on the difference be you know the sixty thousand is a piece of capital the other pieces are direct offsets to expenses over time tp me okay great I think my colleagues did such a good job and you you guys did such a good job in your presentation that that's all that I have for questions so at this time I'm going to turn it over to the health care advocate Mike Fisher Mike are you on Eric you're muted still muted Eric there you go there you go wow this is our seat I am um so I just have three quick clarifications questions and just one I was wondering if you could talk about what's driving the 2020 B to 2021 B change in free care and bad debt so I'm guessing that's partially due to the payer mix but I was wondering if you could expound on that a bit yeah again it's our payer mix it's uh based on you know the conditions that we're experiencing now as well as the continued conditions that you know we're expecting to see into the future you know we do have a substantial population up here that are unemployed and we don't see that you know I'm in the you know immediate future that rectifying itself and that's the reasons for the increases okay that's helpful so I just want to I want to ask you about the response to the HDA's question about reimbursement rates by individual commercial payers so the answers to those questions kind of fell in a few categories some hospitals were able to break it out others responded that they weren't able to break it out due to legal restrictions or contractual restrictions some others said they just didn't collect data at that level of granularity and then and you and a few other hospitals just you gave us the overarching category of commercial could you just explain like I'm just trying to understand why why that category so is it due to data issues contractual restrictions or what's what's causing that yeah you know I don't feel that I'm getting it down to additional detailed data is a limitation here at Cobley we can definitely do that and you know get it down to different categories the thing is is I guess you if you could give us more clarification on categories there's a lot of different ways that we can dig into the data and it's just getting you know on which pairs or which pair groups would you like to see sure I can read before that so we did have a table in that question with individual payers listed out so I guess I was a little confused with just the commercial response and perhaps not surprisingly for me I want to echo board member Holmes's comments that it sounds like you guys are doing an excellent job looking at quality metrics and I wanted to really because I think it's important for all Vermont hospitals talk a little bit you know it's not just measuring things which is of course necessary but also how you're using that data or information and you know translating that into changes in individual and organizational behavior so it's one if you could give an example or two about how you're using your analytics to drive change yeah probably probably the best one is the antibiotic stewardship program that that unfortunately the state ended the funding for but but certainly coupling I think the other hospitals are mostly going forward with it and and the problem was to consolidate antibiotic usage in such a way that you get away from drugs with unfavorable side effect profiles and had we're getting higher degrees of resistance some drugs we just really we can't afford to be resistant and as it turns out most of the drugs that you tend to want to move toward turn out to be basically older and much less expensive drugs but they're really just as good but people sort of get into usage habits that are maybe a little different and so we looked very carefully at what our actual usage was and we put some time and effort into that and then we decided what we wanted and we just kept telling everyone what they were doing and what the goal was and then slowly over the three years we had dramatic improvements the use particularly the use of the flora quinolones and pepperic psyllone went down dramatically and also we use safer cheaper drugs and obviously it hasn't decreased the effectiveness of our medical care at all so that that would probably be the you know the prime example of how that really that really works and there's a very tight coupling to measuring publishing and improvement thank you for that that's all of our questions thank you Eric at this time i'm going to open it up for public comment on the copley hospital budget is there any public comment remember to unmute yourself if you are on your computer or hit star six is there any public comment hearing none i wish to thank team copley for their presentation and as other board members have mentioned but i think it bears mentioning again we're very grateful for all the incredible hours and the great work that was put into addressing this crisis that's in front of us and also i want to thank you for not being afraid to think outside of the box by at least attempting the serology even though it didn't have the type of results that many people had hoped for but at the same time somebody has to be willing to think differently and i know that you often hear of that thinking differently at copley and that's a good thing so thank you for your budget presentation and have a great rest of the day thanks very much thank you thank you do you need a motion yes i moved to adjourn second it's been moved and seconded to adjourn all those in favor signify by saying aye aye aye any opposed thank you everyone thank you kim