 and it's 8.30 on my computer, so I think we will start if that's all right with everybody. When it looks ready, we'll get this morning off to a good start. So my name is Jessica Holmes and I'm currently serving as the interim chair of the Green Mountain Care Board. Today is day four of our Green Mountain Care Board hospital budget review process, week two, but day four. So we'll be hearing from Rutland Regional Medical Center this morning and we'll hear from Mount Ascotney Hospital and Health Center this afternoon. Just as a quick reminder, I've been saying this at the beginning of every day, but for us to arrive at decisions for each hospital's budget, we look to our statute, we look to our hospital budget rule for guiding principles, just as a reminder, we're gonna have to balance several often competing factors that need to slow the growth and healthcare expenditures while also trying to ensure that our hospitals have the resources that they're gonna need to recruit and retain healthcare workers and also to provide the high quality care that we expect in our communities. So as we're attempting to balance cost containment access quality and health system sustainability, we're gonna have to be mindful of this year's unique circumstances and the significant headwinds that we're facing. Historically high inflation rates, workforce shortages, provider burnout and the continuing impacts of the pandemic. So both nationally and in Vermont, hospitals are facing unprecedented financial challenges as our businesses, families and individuals. So over the next few weeks, our immediate task is obviously gonna be to set these fiscal year 23 hospital budgets for the 14 community hospitals that we regulate. But I wanna remind everyone that the board is working closely with the agency of human services to begin the work outlined in Act 167, which aims to move us closer to a sustainable hospital system that will ensure our monitors have access to high quality affordable care. And that work is gonna involve extensive data analysis and hospital and community engagement, but the end result will hopefully be a more sustainable path forward. As we turn back to the hearing today, I wanna extend a thank you to both Rutland team and the Manuskatni teams for the time and effort that they've taken to submit the documents for our review. It will be a really interesting and informative day. A few housekeeping notes about the hearings today. This presentation is a public meeting. It's being recorded and transcribed. So there will be a publicly available record. If a hospital's leadership team believes that there is some confidential information that the Green Mountain Care Board should consider, either as part of the hospital's presentation or in response to board or staff questions or HCA questions, please alert us before responding. If needed, we can go into an executive session and review confidential information from hospitals. Executive sessions would have to be limited in scope as provided by the open meeting law and limited to just that information such as contracts and information that will be deemed confidential under the Public Records Act. So if an issue of possible confidentiality arises, I will call on the board's legal counsel to determine the scope of what could be discussed in executive session and if deemed appropriate and at the appropriate time, I would then ask a board member for a motion to go into executive session. So housekeeping out of the way, I think at this point we will proceed with Rutland's presentation. I will hold all board and staff questions until the end of that full presentation. And with that Russ McCracken, would you mind swearing in Rutland's witnesses? So anyone planning to present or answer questions today, please participate in the swearing in process. Great, thank you, Chair Holmes. This is Russ McCracken. I'm a staff attorney with the board. For the RRMC team, who is gonna be speaking today? So Russ, we've got myself Claudio Fort, president and CEO. Judy Fox, our CFO. Dr. Matthew Conway, one of our general surgeons and medical staff president. Dr. Allison Davis, who is the medical director of the emergency department of emergency medicine and Courtney Collins, one of an experienced emergency department nurse and one of the clinical nurse managers for our ED. Perfect. I will go ahead and swear you all in. If you would raise your right hand. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth. So I'll help you, God. Thank you. Great, you're all sworn in. It would be really helpful for us and for the court reporter if the first time you speak, if you identify yourself by name, it helps with the transcription. And with that, I will turn it back over to you, Chair Holmes. Great, thank you. I guess with that, I'm gonna turn it over to the Rutland team. You can, if you have your presentation, you can bring it up now and the Microsoft Teams floor is all yours. Hey, good morning, Madam Chairperson and members of the board, staff, members of the Health Care Advocacy Office and others. Very pleased to be before you this morning again to present the story of Rutland Regional and provide a little bit of the background into the budget we submitted about six weeks ago to you. Our story will not be very different from what you heard last week. Unprecedented challenges here in the healthcare space. I've been a hospital CEO for close to 20 years in Illinois, Northern Vermont and here at Rutland Regional. And I will tell you, I have never seen an environment like we're dealing with today because we've never seen an environment that we're dealing with today. The modern healthcare system has never been through this. Nor has our society and it all kind of converges here at the hospital. As I said, we have our team here joining us to tell our story tip this morning. We also have that have logged in on this or members of our board of directors and staff from the hospital participating, not participating but observing these meetings. As you know, Rutland Regional is requesting the second highest commercial rate increase in the state. And as you can see, there's a high correlation with the size of the organization and the scope of services that it offers and the size of our budget requests. Just to kind of give you an overview, Rutland Regional is the second largest hospital in Vermont and independent not-for-profit community hospital. We're governed by a 19 member board of directors that include the leaders of some of the largest businesses in the state and some of our key health and social service agencies here in Rutland County. We serve about 60,000 people and we are the oldest and one of the more socioeconomically challenged communities in Vermont. Our patient volumes and the acuity of our patients has never been at this consistently high level. Our emergency department, as you're gonna hear later on, is ground zero. We are the community stop gap. We're the place of last resort, not just for medical issues, but we're the relief valve for the epidemic of socioeconomic problems that have emerged from the COVID-19 pandemic. Go to the next slide. Over the past two years, our board of directors has revised the mission and the vision and the values of Rutland Regional. To be in line, we have revised our mission to be in line with the state of Vermont's healthcare delivery and payment reform goals. So in the past, our mission was more to the lines of to provide the best care and treatment for you when you come to us sick or injured. This says something very different today. Our mission is clearly to improve the health of our community by delivering high value care through collaboration, which means we can no longer sit back and wait for you to become sick or injured in the first place. And that's where the collaboration comes in place. We'll talk to you a little bit about some of the efforts we are doing to collaborate in this health service area with other health and social service leaders. So that we can deliver on that mission. And this is a pretty, you know, our vision and our mission is a pretty far reaching, high attainable thing. And I will tell you, we are still, and as we've emerged from the crisis part of COVID, we're refocusing on our mission, but I will tell you, it is a heroic effort day to day just to keep the lights on and the emergency department accessible and the beds open. So kind of the scope of services that you see here at Rutland Regional. We have a 12-bed dedicated intensive care unit staffed by specially trained board certified ICU nurses and critical care clinic physicians and advanced practice providers. We have a 16-bed medical step-down unit, a 23-bed dedicated surgical floor, a 35-bed general medicine floor, a maternal child health, labor and delivery unit, nursery. We have a 19-bed inpatient psychiatric service and we are the only acute care hospital that does. In addition to that, we have a six-bed level one involuntary inpatient psychiatric service. Rutland Regional started that in partnership with the Department of Mental Health after Hurricane Irene abruptly closed the state psychiatric hospital and we've been operating that ever since and it has been a good partnership and they're doing incredible work every day up there. Here in Rutland, most of our specialty physicians in the health service area are employed by Rutland Regional. No primary care physicians are employed by Rutland Regional. Most of them are organized in a large federally qualified health center. Thus, the change to our mission to collaborate with these folks more closely because the key, if we're ultimately gonna change this equation is how do we work more closely, especially with primary care to try to improve health and delay folks from getting sick enough they have to come to the hospital or to some of the specialists that we employ. We also here at Rutland Regional operate the only comprehensive health hub for medication assisted treatment services for those suffering from opioid use disorder. We provide suboxone or methadone treatment and wraparound counseling and supportive services. There's about 400 people on any given day that we've given a large part of their lives back. And when I came to this community back four and a half years ago, our former police chief, Jim Baker, who was here during that time told me, he said, Claudio, when Rutland Regional opened the Westridge Center for Substance Use Disorders, property crimes in Rutland County went down by about 30%. Incredible impact on that. And I think you're gonna hear from us today that our senior clinical and administrative leadership here at Rutland Regional after we submitted the mid-year rating crease, we went back and revisited this level of services that we're providing. And we went back to say, hey, is there anything here that we can cut back on that is redundant, that aren't essential services for this community in the service area? And what you're gonna hear today is we didn't find anything. And we'll talk to you a little bit about the impact if we are forced to go back and to do some of that. So on the next slide, I think our challenges are clear and again, they're not unlike other challenges that you've heard last week. We are gonna sustain an operating loss of a little over $12 million this year. Combined with our loss on investments, our total bottom line will lose about $25 million this year on a $300 million budget of revenues. One of the things that's unique to Rutland Regional that we're experiencing is we are in default, technical default on our bond covenants at this point in time. And I think I wanna make sure that Judy's gonna talk to you about that in a minute. I wanna make sure that people listening understand this is technical default. We still are and still have the ability to fully make our debt service payments. But because of our financial situation, there are some things now where we will have to do to work out with our lenders. And like you've heard earlier today, the root cause of this loss is the unprecedented inflation we are experiencing. And again, this is not a Vermont problem, this is a national problem. And as you can see, I'm sure you read about it every day and in your work that you do in academics and in policy, you see what's happening. We are at a tipping point, certainly here at Rutland Regional and I believe in the state of Vermont. It's a fundamentally altered landscape and it is an uncertain future. There are opportunities. And I think we are working and there are opportunities that we can capitalize and change the trajectory. But at this critical point in time, we've come to you with this request because we have no other options. And the impact of not being able to sustain these services and the cost of that, the economic cost as well as the human cost on that, we believe will be much more impactful than the rate increase that we are asking for. So the budget is pretty straightforward. First and foremost, stabilize our financial performance after about five or six years of underperformance. This budget allows us to continue to prioritize workforce and everything we're talking about today, everything that we do in healthcare, in the acute care hospital space, it's all about workforce. None of this stuff matters. We will not get costs under control. We will impact our quality, access, satisfaction, you name it, workforce, it all hinges on workforce and we're doing a lot of work in that space. And then the final thing is, as we said, is to continue to ensure access to critical services for the Rutherland Health Service area and as you will hear this morning beyond. So this budget that Judy is gonna get into, there are no new service offerings. There are no material increases in staff except for some security focused work and there are no new programs. So we'll turn it over to Judy Fox to walk you through some of the financial pieces and just, I meant to say that, just so you know, Dr. Conway will have to leave us at about 10 o'clock. He's got some cases scheduled in the OR. So he'll have to leave before we'll be able to get into the questions folks. So, Judy? So good morning, Judy Fox, the chief financial officer here in Rutherland. I wanna spend a moment to just talk about our balance sheet. You'll hear us talk about the fact that our balance sheet has been destabilized and deteriorated a bit. And I wanted to really draw your attention to why we say that. Looking at this slide, this is our balance sheet. Really two moving parts here, cash and our debt position. So with our cash, if you look at our performance from 2020 to 2023, you see a decline of cash in $24.2 million. This is the spend down of our cash that is related to the operating loss that we are experiencing this current year, that $12 million loss is being funded from savings, if you will, on the balance sheet. While we could suffer the cash loss, what has been problematic as Claudio has alluded to is that our operating performance will drive us into that breach of our debt covenant and namely our debt service coverage ratio. What we have at stake today is about $46 million of debt that is held by TD Bank and USDA. So we'll talk about that. But those are the pieces in our balance sheet that we really wanna draw your attention to. They're what has our focus. Everything else is fairly stable. So digging down a bit deeper is cash flow. The budget that we are presenting to you today does drive about $11 million of cash flow. So cash used to fund purposes for the hospital. Those purposes we've outlined and we did elude and share with you that we are trying to anointize our pension plan. There's a contribution cost to that that we've targeted at about $5 million. That helps to de-risk the balance sheet. We have principal payments and then we do have a delay in spending for the MRI which is really related to timing of the arrival of the equipment. What you don't see here is our capital or depreciation. We have level funded our capital budget with depreciation this year. This is the second year in a row that we've done that. What that means is we are not keeping up with inflationary factors and you see that aging of our plan in 2022 and 23. That is a direct result of shortening our funding if you will reducing our funding in capital. We did that if you look at the top graph in response to just that days of cash and that decline and the need to prioritize cash to take care of the operating loss. In terms of our breach and debt covenants we came to you in March with the mid-year rate increase asking for a rate increase to help us manage this particular risk for our organization. And what we spoke to you about has come true. We see a declining position in this debt covenant related to our operating loss that we have suffered month after month such that by September 30th we will be in breach of the debt service coverage and I'll talk to you about what that response is. From an income statement perspective we're gonna look at the detail. Won't spend much time on this slide here but starting at utilization and revenue. We'd like to ask you to consider our budget from projection 22 and not budget to budget and we'll look at a slide that gives us some demonstration if you will as to why we'd ask you to do that. When you look at projection to budget and this is gross revenue, this is not net revenue. The only difference is our rate increase with a small reduction in revenue that's really related to physician vacancies and timing of service. This budget is predicated on an occupancy rate. You can see outlined there on the left. Those occupancy rates are year to date. If I were to run those occupancy rates just for the last two months our medical surge, net surge occupancy rate would be near 90%. So volume is not letting up just the opposite. On average we have 10 patients a day waiting placement whether that's a nursing home placement or a psychiatric placement for another inpatient psychiatric facility. That's 11% of our volume. From a nursing home placement standpoint that's a revenue loss. There's no revenue stream for those patients are very little. On average we will lose between two and a half and $3 million on the care of those patients waiting placement. Again our utilization is based on actual volume. We expect that volume to continue the last couple of months. We've seen an increase. We've not built that into our budget. And then we will continue with our recruitment plane of our physicians. And we'll look at those physician vacancies. From a rate increase perspective we are asking you to approve a 17.8% rate increase. We arrive at that in a couple of different ways. First and foremost is our pharmaceutical and supply charges. Those charges are based on actual acquisition costs. Due to the approval of the budget we're not able to change those costs mid-year as we've faced inflation. And so this budget rate increase strategy takes our most recent up to dated acquisition costs based on a tiering structure. The result is our pharmaceutical prices will go up on average about 11.2% our supplies 11.9. Again, highly driven by inflation which we'll see in a later slide. All other services are at 19 and a half percent. You've asked about the effective commercial rate. If you look at that schedule on the bottom you see that this rate increase generates $123 million of gross revenue but only $24 million of net. Most of that underfunding comes from state and federal programs the Medicare and Medicaid program where we are in this budget expecting to get a 1.6% increase a $1.6 million increase in funding. Where the bulk of the net revenue comes from is the commercial carriers the 22.1 million. If you asked me what the effective rate is I would tell you it's about 10.8%. The reason it's not 17.8% is related to the contracts that we have in place with our commercial carriers those discounts that are supported within those contracts with a fee schedules. So our effective commercial rate is about 10.8%. I do wanna be very transparent and tell you at the time that we put this budget together we were working under proposed inpatient Medicare rules. As you know those rules were just updated within the last few weeks. Based on that new update moving from a 3.2 to a 4.3 market basket update we would increase our net revenue about $600,000 for the Medicare program. That's equivalent of about a half a percent of rate increase. This has been a very difficult decision for our community, our board and our management team. We understand the concern of affordability but we're also concerned about access. And so we have tried to be very concerned with how we approach this rate increase but also make sure that we're really advocating for the patients through our free care program and trying to provide them support in this arena where we're seeing just these, the high costs. From a reimbursement perspective this is really cost shift, right? And if you look at the top graph compared to the bottom graph you can see what this rate increase does. If you look at that green portion of the pie graph you can see that our commercial carriers from the growth standpoint make up just under 30% of our volume but from a net revenue they're at 54%. That is the difficulty in putting through a rate increase. The rate increases become more and more ineffective each year. The non-participating rate increase is about 31%. Those are the Medicare and Medicaid programs. We also are including a full year of sequestration which is going to be reinstated for the Medicare program. And again, you see that update at 1.6 million. Again, $600,000 not included there with the new rate schedules. On average because of this cost shift and who participates every dollar we raise in a rate increase we collect about 19 cents. This is a really important slide. There's a lot of noise. There's a lot of variance in our performance when we look from 2020 to 2023. The red line on the graph is what the Green Mountain Care Board would have allowed in their net patient growth rates year over year starting in 2020. The green line is our actual performance. You can see the impact of COVID in 2021, 2022 and then the resurgence of that revenue in 2023 where we're saying we're holding the utilization holding the volume but because of the inflation do have to pass on rate increases. The result though is that we are nearly on target with the Green Mountain Care Board growth rates when you look over those four years. So an important slide. We understand that without the collaboration of our care providers in our community we are not going to be able to change demand for services here at the hospital. As a result of that and Claudia alluded we've changed our mission and we are participating in all ACO programs that are being offered. For us that's about 26,000 lives or about 30% of our revenue basis. Unfortunately we're participating without knowing all of the rules. And so as we speak this morning we have signed all agreements but we don't yet know what those risk corridors are and what that risk is that we could be facing. We have not built any reserve into our budget to cover what could be a potential loss of at its highest estimate $7 million. At the lowest estimate 3.8 million. None of that is included in our budget. And why that's concerning to us is if you look at our ACO performance over the last four years can see that the program in that last column costs our hospital about $1.3 million to participate. Coming through as administrative fees some withholds for our share of funding population health payments. But what's concerning about this slide is that if it weren't for years 2020 and 2021 which is our COVID years and the shutdown of services we would have suffered a loss. We did suffer a loss in 19 the first year of our performance and again in 2022. We're hoping that 2022 is not indicative of our performance going forward. And again that risk of us suffering that loss and that risk program. Having said that in correlation in response to our changing mission we're very deliberate. If you look at 2020 and the Medicaid settlement you see that we were provided $2.1 million. Again, related to shutdown of services with COVID. Regardless, we took $500,000 of that settlement. We have placed it in the fund to support our work with our community partners in care collaboration. There's a slide that we'll talk about that a bit more. We call this the triple threat. As Claudio alluded to we really have not performed in our budget from an operating margin perspective in the last four years. What we have been surviving on is other revenue. That other revenue is namely our 340B program that's our pharmaceutical savings and revenue program COVID funded and investments. Each of those programs in 2023 are not performing to levels that we had seen in prior years. 340B revenue, we suffered a loss of about $3 million this year due to manufacturers changing the way in which we can participate in requiring some extensive reporting. We are going to follow those reporting rules and look to regain and recapture some of that revenue but we won't recapture at all. COVID funding we feel from a state and federal perspective that PFR funding is completely exhausted. We've run all of that and realized all of that in our performance. Not included in this budget again another late change our FEMA application grants. Those rules changed in July allowing for full 100% funding through the end of June and then 80% funding going forward to a day undetermined and end date undetermined. We will be filing a third application for FEMA but we don't expect a huge windfall here. If we look at the first two applications in total each of those applications we were awarded about $750,000. So we're anticipating less than a million dollars in that FEMA program but nonetheless felt it was important to share with you and to highlight that that was not included in the budget. From an expense standpoint you can see our expenses are increasing by about $36 million from a budget of 290 million to 326 million. 58% of that increase we are recognizing as inflation and we'll look at the detail behind that. The rest of that relates to either volume and the care for the patients that we're providing. The healthcare provider tax so that's a 6% tax on any increase in net revenue as you're aware of and then the increase participation fees in one care the $1.1 million, those are the large pieces of our cost structure. If you look at the graphs to the right expense per adjusted discharge this was deliberate in us trying to get away from those COVID expenses and trying to come back to a state of normalcy and reflected in that the inflation. Salary per FTE we've also been very deliberate trying to get away from all of the COVID premium pay incentive pay and coming back down to a normal pay structure. That has been very, very difficult. We've got 168 open positions. It requires premium pay to ensure we have staff to take care of the patients. So in terms of that 58% of increase in our cost structure about $20 million you can see here at the lineup it is very broad based. Begins with our workforce inflation includes energy costs, supply costs, our drugs, contracted staffing and food. This is not speculation. This is actual increases that have happened for the most part with the exception of a bit of pharmaceutical inflation projected for next year. When you look at our wage inflation it is the result of a three-year contract that we have negotiated with our union that covers a third of our staff here. It includes the premium or the increase in minimum wage that we put into place last fall was part of that request for a mid-term rate increase. And it includes available pricing on our medical and office supplies as well as contractual obligations primarily with temporary staffing and our energy costs. So this is real not speculation. We made numbers out of the air. In terms of staffing despite inflationary run up this is where we've tried to be very deliberate in holding our cost structure. So if you look from budget to budget even though we see extensive increases in volume we've added 12 FTEs and we've prioritized those FTEs for two reasons either safety of our patients or our staff or access to care. Access to care comes through the advanced practice providers in response to some physician vacancies and being able to provide more access to some of those specialty services. And patient safety and employee safety really is on the units and some of the high touch resource intensive patients that we're dealing with in response to patient safety and staff safety. We had 149 incidents of staff violence this past year. 44 patients or employees were hurt and then maintenance and security. What you see here is a 17% improvement in staffing as measured by FTEs for adjusted occupied bed. This helps us mitigate the impact of inflation. If not for this productivity management we would see significantly higher requests in terms of rates and inflation. Our margin trends looking at all we've talked about utilization, reimbursement, our cost structure. You can see that over the past five years we essentially have been a brief event organization when it comes to looking at the performance of our mission to provide care to our patients. Where we have subsidized our mission if you will is in our investment income and that's the red portion of the graph. That has been problematic over the last two years. And this year in particular, driving $13 million of additional loss and we're projecting to try to get back to normal and break even for investments next year. But this loss again is attributed to the breaching debt covenants requiring that we hold investments back into our services here and really trying to diminish the deterioration of cash. And talking about capital. So we have level set capital with our depreciation expense that allows us to spend about $12.8 million of capital this year. In addition to that we do have the delay in the MRI project, a project that you approved in April or January of this year that won't start in earnest until the fall. You can see where we have prioritized spending largely again relating to patient and staff safety. Kitchen hoods, the OR refurbishment, both safety issues for either patients or staff, security cameras and access to work control all employee safety. When you look at again that strategy to try to mitigate the deterioration of cash with holding capital you see that aging of plants. This is not sustainable in something that we are going to need to address next year. You've asked us about our certificate of needs. At this point we do not have any new CONs that we are planning to request of the board. However, we are currently evaluating our building workflow for efficiencies and services through plant capacity for some imaging and some surgical volume. Nothing that we know of today but certainly those are on our radar screen. We do have three open CONs, the MRI we just spoke about that's 3.1 million. We're awaiting that equipment will be providing updates as we move forward with that project. Our psychiatric renovations project, happy to say that that project is for, most purposes closed 4.1 million on budget. We will be looking at the final invoicing and submitting a request to close that project in the next couple of weeks. And then our medical office building project that's been our cornerstone project over the last few years, 23.8 million. We do need to delay the close of that due to a facility issue that we're dealing with in one of the office locations. Having said that, we expect that project to come in under budget by about 2.5 million dollars. You have asked about some of the work we are doing to advance diversity, health equity and inclusion here at Rotland Regional and in our service area. And as you could see at the outset in 2020, the Rotland Regional Board of Directors adopted inclusion as one of our four, diversity, equity and inclusion as one of our four organizational values. We're actively working to advance this work, to figure out how to measure disparities and health equity in our service area and to address those. A lot of work that's being done on this, but I think the most important piece of health equity we can do this year really rests in your hands. This budget is really a health equity budget. If we're not able to fund some of these programs and services, it is going to be the most vulnerable among us that are gonna be impacted the most. It's not gonna be the people here that have privilege that you see testifying before you. We have the means and the resources if we can't get care or services in the Rotland service area to get to Burlington or to Dartmouth or to Boston. A large part of the community that we serve here at Rotland Regional Medical Center do not have those means and that privilege. So this is an important part of what we're doing and an important part of why we're at a $12 million, why we haven't made some reductions already, why we're here sustaining a $12 million operating loss. So the second piece of the presentation is really responding to information that you have provided us around our market area in our patient demographics. So we did review that data and found it to be consistent with data that we look at on a routine basis here. What that data suggests is that our market share is very stable or consistently treating over 85% of our local residents here. You see that both in the inpatient and the outpatient side. In terms of Rotland County residents and our payor mix, that high Medicare Medicaid population is reflected in our demographics. You see from 2014 to 2019, we've had a 20% increase in our residents age 64 older. It is those residents that demand more care, require more resources. We've also seen a comparable increase in the patients who have one or more disabilities. We've seen a 16, 17% increase in that patient population. Both of those drive costs. And when we look at our costs as was provided and look at those services where we were shown to be a high cost provider, it's not surprising to us. It's the type of service we offer. Claudio talked to you about being a level one state psychiatric center here that drives costs. Our oncology services, highly correlated with pharmaceutical inflation. And our clinic services really relate to the type of service that we provide to our patients where we offer in office treatment rooms testing services. But again, it relates to that demographic basis with the aging and kind of complicated patient base. So nothing that we were overly surprised with there. Looking at our wait times, are highly correlated to our ability to recruit and retain physicians. We have about a 14% vacancy rate in our physician basis, which is equivalent to about 11 physicians that you see down through the areas, particularly where we have the longest lab time. In response to that, it's important to know that every patient that calls seeking services to our clinics is triaged. And based on acuity and urgency is placed in the schedule. We also, we talked about the investment in advanced practice providers. When feasible and when appropriate to be able to respond to a physician vacancy, we are recruiting advanced practice providers to help with access to care. In some instances it's just not economically feasible to look for a low content. Those costs are extremely high and exorbitant, but each and every physician is evaluated and again in process for recruitment. Over and above what we're seeing here, Dr. Conway is gonna talk to you about new demands that we're seeing here in our service area. Where patients outside of our county, of our catchment area are seeking services here, whether it's in our clinics or in our ED or surgical services. Dr. Conway will talk to you about that in a moment. In terms of risks and opportunities, we'd like to share a few. This is really a recap of what we've talked about this morning, so labor management. We have 186 positions, 77 RNs open, despite the fact that we invested into our workforce about $17 million last year. We have planned initiatives for childcare and housing. We're still highly dependent on traveling staff. Our budget calls for 50 or supports 50 travelers. Right now we have about 70 on staff. You can see the quarterly vacancy rate. We were somewhat successful in the early stages of our investment in our work plan. That has since come back up. Continued inflation, we've talked about this. Really wanna impress upon you. It's more than workforce. It's more than temporary staff. You can see the four slides here. High volume spends for our organization. The top slide is in our supply chain where you see inflation from eight to 16% high volume medical supplies for our staff. Bottom left is our drug inflation. These drugs are used in our treatment of our cancer patients, our oncology patients, Crohn's disease. Again, high volume for us, looking at 10 to 25% inflationary factors for this drug set. And then our energy and utility inflation. Natural gas, free oil, propane are all obligated through contracts. Electricity, we can't in the state of Vermont have contracts in place for that. So we're not exactly sure there. And then temporary staff. Temporary staff has come back down. I will tell you what we're paying today is still above what we've included in our budget. We are continuing to work with those agencies. We've talked about the risk of the lack of ACO reserves for any risk. Again, that four to $7 million risk that we could face depending on performance. And it's really important to know that those cost thresholds in the ACO for these risk programs are meant to cover both inflationary factors and utilization. As we're seeing here in Rutland, this high demanding utilization puts more pressure on our ability to meet those cost thresholds. We're gonna talk to you about an opportunity that we've invested and funded in and trying to curb that utilization. But suffice it to say that's a long-term gain. Right now, we're really worried about the next 12 to 18 months. That coupled with the fact that we have used our cash to support the operating loss. Again, just doesn't provide cash reserves as well. And the last risk we wanna talk to you about is the breach of the Covenant. So by September 30th, we will be in technical default. There's about $46 million of debt that we will be at risk for. We are in discussions with our partners at the USDA and TV bank who hold the debt for us and are looking to enter into a forbearance agreement with them. Unfortunately, the forbearance agreement is likely going to require that we have an increase in our days of cash Covenant. So it will be something we'll need to consider. Again, that risk is highly managed and mitigated by our ability to create a margin, to generate a margin. Opportunities don't wanna spend a whole lot of time here because we did share this with you when we presented our mid-cycle rate increase. But highly, highly involved with all aspects of education here in our community, both at the high school program, trying to really promote interest in healthcare careers, adult programs, trying to increase our LNAs, and then at the college level, where we're providing faculty as well as increasing clinical experiences and space for those students to learn and grow in. Today, I think this number has changed I think we've had about 23 new grads agree. Similarly, again, recruitment, again, looking at ways in which we engage in our community and really promote health careers. And then our OR experience, where we have had a significant challenge in recruiting and retaining OR staff. So we've developed our own education program that involves an OR simulation. We have our own instructor really meant to help us recruit, train these new staff into the OR. The Rutland Health Alliance. So this is our collaboration with our care providers here, VNA, community care network, community health and Rutland Regional Medical Center. So mental health, home health, primary care in the hospital. This is the $500,000 investment that we're making to promote a collaborative decision-making structure to really mature our care management activities with the thought and the goal of providing the right care at the right time in the right setting. And so this project is underway, really meant to try to curb some of that high-cost utilization in the ED. So to wrap up, we understand that the budget that we put before you is high-cost, but we did that deliberately. And we did that to ensure access to care. Without the investments that we've made, we would have had to curb some services, either by hours of operation or delaying treatment. And so that cost, if you look at the factors that are promoting access and the cost, travelers are projecting a $16 million cost this year, 10 million next year. Our investment in our staff over the last 18 months, retention program, increasing minimum wage, and then our salary program. And all of those vacancies and open positions, our staff have come and really committed their hearts, their minds to our organization and to our patients. Our staff have filled 272,000 hours of vacant shifts. This is over and above what they've already committed to here at the hospital. There was incentive pay related to that to really ensure and recognize them for their commitment. The result is $12 million loss, a 17.8 rate increase, but full access to care for our community here. Thanks, Judy. Now we'd like to turn it over first and foremost to Dr. Matt Conway, general surgeon, medical director of general surgery and our current medical staff president to talk a little bit about what he's seeing and experiencing here in kind of the post COVID or the endemic COVID era. I'll turn it over to you, Dr. Conway. Good morning. Good morning to members of the board and to everyone in attendance this morning. My name is Matt Conway. I'm medical director of our group. I'm a general surgeon. I'm also currently president of the medical staff. Except for two tours of duty, one in Afghanistan and one in Iraq as an army surgeon. I've been here in Rotland now for 23 years, 10 of which in private practice in the last 13 employed by Rotland Regional Medical Center. I've seen a lot of changes obviously and I have a strong commitment to Vermont and to the Rotland community, not least of which having raised four daughters here. But I've seen some changes over the years and Mr. Ford asked me to talk about those. I have a couple of short examples I can share with you which represent some of the challenges. Everybody uses the word unprecedented and that is true but frankly, they represent challenges. As a hospital and as a provider, especially I'm interested in surgical services, we I think have done a good job of providing that care to our local community to Rotland County and the members within the Rotland County. And that's reflected by Judy's numbers with regard to the 85% catchment that comes with keeping those patients here that wanna stay here that are appropriate for the care that we serve. We have interestingly in recent history seen a change in that. We've seen requests and pushes for care from outside our typical community to come here, both outpatient referrals. There was a time that we would outreach and try and increase our outpatient referrals. We haven't been doing that not since COVID but we're getting increased outpatient referrals for all of our services. Frankly is requests from patients and from providers outside the typical Rotland County community which has presented some interesting challenges for our clinics. But additionally, we're seeing some challenges from transfers from inpatient to inpatient facilities and from ER to ER facilities due to the fact that the current environment with repressures, those patients aren't able to be cared for at tertiary facilities. It's just capacity's not been there. I thought I'd share with you a couple of vignettes of what are frankly a myriad of examples, increasing number of examples that I've never seen in my 23 years here in Vermont. The first one was a 37 year old woman who was 16 weeks pregnant, it was her fourth pregnancy. She presented to a hospital in Northern Vermont, a small community hospital in Northern Vermont with what turned out to be a appendicitis and then stayed in that emergency room for what ultimately was nearly 20 hours with an inability to get her to a tertiary center and both of our local tertiary centers were approached as well as community hospitals that were of a size that were closer to her. And I happened to be on call the evening that I took the phone call from this emergency room doctor who was not surprisingly very concerned about what he was going to do with this woman. At 16 weeks pregnant, there are real challenges should she go into labor, not least of which is that the fetus would not be viable. And appendicitis in and of itself as an intra-abdominal infection will eventually lead to labor, just as a matter of course. So for us, and this speaks to one of our challenges, for us receiving that phone call put me in a difficult position, because keep in mind, while we're the second largest hospital in Vermont, we are a community hospital and we are compared to the nation, a relatively small community hospital, 100 plus beds, but we are finding increasingly being asked to provide service that one would say would be beyond our typical scope of practice. We thankfully have the capacity to do that in some respects, but it presents challenges for us in terms of what we should do. So I accepted this woman in transfer after speaking to our local OB service, keeping in mind that we don't have a NICU, we don't have high risk OB, but this woman is, the clock is ticking with regard to the development of labor for her. And ultimately ended up operating on her 2.30 in the morning for what was by that time a rupture dependence with a very high risk of progression to labor and loss of the fetus. We were fortunate, or I shouldn't say she was fortunate and we were fortunate that that did not occur. We did the surgery, she recovered from the surgery, she stayed with us for a few days on antibiotics and ultimately was sent back to the small community hospital, which keep in mind is three hours north of us, three hours north of us for that care, three hours by land transport, ambulance transport, at least on the evening that she came to us. That's an example of care that we would not typically be expected to provide. In fact, that is someone that we would typically look to transfer from our facility to a place where there is high risk care available. That's one example of, I've got more than a dozen easily in the last year. But additionally, here's, I have a separate example of some of the challenges we faced with regard to getting patients from us, again, a relatively small community hospital providing community care to a higher level of care. And again, this is an example of mine. It's easiest when I speak to things that I know closest, although I'm familiar with some of the other care issues. But, you know, I found myself of an evening being called by our emergency room with a gentleman with a necrotizing infection. That's a, they used a popular vernacular flesh eating bacteria, but a necrotizing infection. He had a BMI, let's just say his weight was nearly 500 pounds. And this gentleman presented in extremis septic with a necrotizing infection at 1231 o'clock at night to our hospital, which has on-call nursing services for surgical emergencies is myself an anesthesiologist on call. And I was fortunate enough to have a physician's assistant available that night. Typically that patient would be appropriate to go to a tertiary facility. Sadly, one tertiary facility turned us down to outright. And the second one told us that they would like to take the patient, but they did not have capacity and this patient needed an operation. I found myself again about three o'clock in the morning operating on a patient, myself in a PA on someone was 500 pounds floridly septic with no, with limited resources. Thank you, we have an ICU. We got through the surgery, it was difficult. Was that the best care for the patient? I would say, I would argue that that's not the case. And sadly, the challenges for us is that this is increasingly becoming the norm for us as the second largest hospital in Vermont, keeping in mind that we are what we are. And I don't see it changing. I see an increase in those requests. And you can say, well, from an outpatient standpoint, you could shut those patients, who request to come to us for elective stuff. But what do you do for the inpatients that can't get to the higher level care? We find ourselves becoming the receiving line as the next level, not at our request, but as a consequence of the care that's necessary, that needs to be provided to these people, that we are unable to arrange for their care in other places. So these are some challenges that we face. And I don't have a solution for it, but I can tell you it definitely puts pressure on our facility, it puts pressure on our staff. And I would say for most of these examples, and I have others, they would exceed what I would consider to be the average scope of our practice, but it's becoming increasingly the scope of our practice here in Maryland. Oh, that's what I have to share. Thank you, Dr. Connolly, appreciate that. Courtney, you wanna take the next piece? Sure. Good morning. My name is Courtney Collins, I'm one of our clinical managers here in the emergency department at Relin. And similar to Dr. Conway, this is my home, I grew up here, I was born here, I'm raising my children here. So this is very meaningful to me too. And I'm gonna talk to you guys about workplace violence and the impact on our staff. I think it's important to recognize that as a rural emergency department, we are often the only resource our community members have. And we're certainly the only resource that's available 24 hours a day, seven days a week and every day of the year. And we take this mission very seriously and we're very proud of the work we do here in the emergency room. And since COVID, we have seen, I'm gonna use the word unprecedented volumes and complexity in our department. We are frequently severely and dangerously overcrowded and our wait times are long. And that in turn causes our patients to be tired, frustrated and have diminished coping skills. So as you can imagine overcrowded ER, busy, long waits, our patients have a propensity for aggression and our ED staff is an easy target. Every day, we are having incidences where patients are raising their voice. They're using expletives, threatening language. Sometimes they are posturing in threatening ways and even acting out with violence towards our staff. And not only do our staff have to endure these events, they have to remain engaged in patient care. They have to be willing to deescalate these patients and their family members, just as they would have to care for patients with traumas, heart attacks, strokes or other life and limb threatening injuries. Since January, and you see the number in our, should say our, Judy's PowerPoint, 44 incidences. And I just wanna impress upon you the significance of those incidences. We have had a highly publicized case where one of our very pregnant nurses was assaulted. She was punched in her very pregnant belly before being knocked to the ground. We've also had staff members staying significant injuries with broken bones, one requiring a surgical intervention. And our staff witnessing these verbal, physical, sexual and emotional violence is causing our staff to reconsider their career. And our staff are burning out and they're leaving. Last week, we've had two full-time employees give their notice. So we utilize, you know, very expensive travelers to augment our staff. Our leadership team is working weekends, nights and holidays to help staff our department safely. But it's a real challenge that we're facing. If you ask our staff, I would say every single member of our team has been assaulted in some way. And I bet they would all tell you that it's been within a week that they've experienced them, it's that frequent. There's risk with every career, of course, but it is getting harder to ask our team to come to work every day, knowing that they may and will be verbally or even physically assaulted. And that's a really hard thing for us right now. And as I said, this community is our home. We're caring for each other's family and friends. And so the stakes of this feel really high. And I can't imagine doing the work that we do with less. I can't fathom how that will impact our staff or our patients. We are working really hard every day to provide excellent care for them. But I'm just worried that the impact of this on our staff, we are caring for them despite some of them kicking, biting, punching or spitting on us. I will continue to care for them no matter how they present, but my fears that our staff are gonna continue to leave. I'm afraid that without the resources we need, that we'll be unable to fulfill our mission and care for the most vulnerable members of our community when they need it the most. Thank you. Thanks, Courtney. And we'll wrap it up on our end with Dr. Allison Davis. Dr. Davis. Good morning. Thank you for the privilege of speaking with all of you today. My name is Allison Davis. I'm the medical director of the emergency department here in Rutland. I came here from Boston. I graduated from Harvard Medical School. I finished my emergency medicine residency in 2009 at Mass General Brigham. I've been at Rutland Regional for 11 years and I've been the medical director since May. As Judy alluded, our goal at the hospital, but especially in the emergency department is to be providing the right care at the right time. In the right place. We're committed to both quality and to innovation that will increase the value in the care we deliver. At the same time, we're committed to serving our community and our greater catchment area with services that they may not have the resources to access elsewhere. Over the past 12 months, we've seen that our patients need us and the services that we provide more than ever. And this year's 20% increase in emergency department visits reflects that. Our department is being asked to hold and care for psychiatric patients, nursing home patients and patients waiting for beds either at another facility or waiting for transportation to get to that facility. On top of that, we remain ready to care for the next trauma patient or the next child with a mental health crisis. We need your support to preserve access to high quality care. I wanna share a couple of stories that illustrate what our days are like in the ED, but also some of the steps that we're taking to address these challenges. As Dr. Conway alluded to, tertiary care centers are almost always full. And when we say that we're being asked to care for sicker patients here, in addition to the surgical patients Dr. Conway described, to give you one example, we now regularly admit patients here in Rutland who are actively having heart attacks, despite the fact that we do not have the interventional capabilities to address those patients' problems. And that's because of a lack of space and ability to transfer. So we're left hoping that those patients that we're going to be able to keep them stable here while they're waiting transfer to a tertiary care hospital where they can get the definitive treatment they need. But I can tell you that it certainly keeps me up at night worrying about outcomes. Often those tertiary care centers agree that our patients need to be transferred again, as Dr. Conway mentioned, but they're still not able to help us in the short term. So I took care of the patient, not long ago with a bleeding tumor and herosophagus. Controlling that type of catastrophic bleeding requires a level of interventional radiology and thoracic surgery that we don't offer here in Rutland. I called 11 hospitals that night, including every tertiary care hospital in Massachusetts and without success. Fortunately, during the many hours the patient was in the emergency department, the bleeding subsided because we really had no option except to admit the patient here for observation. It was a very scary, scary evening. Nonetheless, in the emergency department, we're taking proactive steps to improve the care of boarded patients and to further the appropriate use of the emergency department. So one troubling trend that we've noticed is that the volume of pediatric patients presenting to the ED for suicidal ideation is up 12 and a half percent. At the same time, the average weight for a psychiatric bed for those children has gone from less than two days in 2018 to over five days now. So we are currently working to partner with the Brattle Girl Retreat to develop a telepsychiatry program to provide consults for the children who are boarding in our emergency department waiting for beds at the retreat. And our hope is that with that intervention we'll be able to decrease the length of stays for those patients in the ED and to decrease inpatient utilization of beds at the retreat. At the same time in this area, and you know, a rural part of the state, access to pediatric psychiatric care is a real challenge. And our hope is that with this service, we're gonna have a larger positive impact on our community. We're also actively collaborating, as Judy mentioned, with our FQHC locally, so with the community health centers of the Reltland region. And we have a program in place now to identify high utilizers of the emergency department and to look for ways to tailor outpatient interventions to decrease their reliance on the emergency department. And that program is already bearing fruit. I can give you a positive example of a patient who is coming in almost every night to the emergency department with anxiety. We were able to identify that patient to collaborate with the patient's outpatient providers to increase services in the patient's home. And the patient's visits to the ED have fallen dramatically since we were able to put those processes in place. These are really the types of projects that excite us because they increase the value of the care that we deliver while improving outcomes for our community. And I would love to be able to come back to you and report on further successes that we have. Right now though, we need your help to provide for our vulnerable patients here in the Reltland community. And we ask for your support today. Thank you. Thanks, Dr. Davis. So folks, this is not where we wanna be. Right now, but it's where we are. And typically, if you know, and those of you who have been here year after year, you know, Reltland Regional has always tried to play it straight and comply with the guidance and the guidelines of the Green Mountain Care Board. We have done that. And typically, when we don't get exactly what we asked for, we're able to find some way to make up the difference, to make sure these folks to my left are supported and have the resources they need to do their jobs. But we simply at this point in time, this critical point in time, don't have any more rabbits to pull out of our app. If we did, we would have done it back when we came to you back mid-year and made those adjustments. We sustained as a leadership, myself as the CEO, probably one of the most unprecedented operating losses in the history of this hospital. Our board, this was a very difficult budget for Judy and her staff to put together and for us as management to come up with and to go to our board with. Because ultimately, they have the leaders of Cassella Waste Management, of Foley Services, of smaller businesses that are doing really innovative things in the space, like Ann Clark, Cookie Cutters, and major health and social service players in our community are on our board. They unanimously approved this budget because they recognized they understand the impact of this cost. But I think they also understand the cost of not being able to provide these services we believe will be much greater. And they won't be known until we get there. And by that time, once you lose a service in a rural delivery system under these pressures, it is, I would say, impossible to reestablish or very difficult. So that's our story this morning, folks. I'll turn it back to you, Madam Chair, and Dr. Conway has a couple more minutes left for us. So if you've had any specific questions for him, I will turn the floor back over to you. Thank you. Great, thank you so very much. Thank you for the presentation. Clearly, thank you for the hard work you're doing for your community during these challenging times. We keep saying, should we use the word unprecedented? But frankly, I'm not sure there is a better word than unprecedented, though. I just want to acknowledge that. And also just want to appreciate and acknowledge that collaborative nature of your redefined admissions statement. I think it's an excellent example of the direction that we're hoping to move in this state. So I was really happy to see that. I guess I would ask if there's any board members that have any questions for Dr. Conway, maybe we should ask them now. And then I was gonna suggest a slight recess so that folks can stretch and have a bio break and then we can return to board questions. So does any board member have a question for Dr. Conway before he has to leave and care for patients? No question from me, this is Tom Walsh. I just wanted to thank Dr. Conway for joining us and giving us more insight into his day to day. Robin, do you have any? I was gonna, I'm not sure if this is for Dr. Conway. So I'll mention it and then the Rutland team can tell me how they want to take it. But I was interested in getting in the narrative there was information included about discussions related to hospital at home care. And I was interested in getting more information and details on that. So if that's something we need Dr. Conway for I wanted to raise it and if not happy to hold it till afterwards. Yeah, I think it's more of an initiative, Member Lunge, that we've been doing from our hospital medicine service. We don't have our leaders here today from that but we started looking at that during the crisis phase of the pandemic as a stopgap measure at first. But then I think what we're seeing is through any type of crisis you see some innovations that really sparks some innovations like what we're doing right here as we speak that we would never have done previously. And so we're looking at how could we adopt that to free up beds, break down the cost of care and that is exactly the type of work that we're trying to create this Rutland Health Alliance clinically integrated network to be able to explore these opportunities and accelerate that more than we can do on our own. Do you want me to say anything about the return program? Yeah, Dr. Davis might have a... So I can share one program that I think has the ideas that this would be sort of the framework that we would use. So during COVID we were really concerned about capacity about our ability to transfer patients and was there a way to be able to identify a subset of COVID positive patients that could be cared for at home. And it was a really great initiative and once we kind of had the framework in place we thought, well, we've done all this work and would we be able to leverage this going forward? But the idea was that we have a good transitional care team here at the hospital with RNs who reach out to patients at home. So we were collaborating with our transitional care team, visiting nurses, we were utilizing telehealth services and our hospital medicine providers to do telemedicine visits to the patients in their home. We partnered with the medical equipment to make sure that patients had the oxygen and the medications that they needed in the home. And then just a really tight follow-up plan to make sure that patients were improving and that we knew how we were gonna get them back to the hospital if they weren't doing well at home. It ended up that we didn't have quite the capacity concerns that we necessarily needed. We were able to flex in the hospital and utilize kind of all available space. So it wasn't utilized as much as maybe, which is a good thing, I think, because in terms of sort of how we fared during the past 18 months, but we could certainly see how a program like that might be really beneficial in the long run for patients with, for example, COPD, sort of chronic lung issues, chronic heart failure. And so we're looking to kind of build on the success of that program moving forward. Thank you, that's super helpful. It's a very interesting concept and it's very exciting that you're exploring it. So I think that was the only one that I was worried my touch on Dr. Conway from me, so. Tom Pelham, did you have any questions for Dr. Conway? I don't accept to say thank you for bringing me who is not in an operating room. The experience is that you see quite often of extraordinary magnitude. And it's just as you're looking through spreadsheets, it's also very important to have all that in the back of your mind as to how this money serves your purpose. Then I guess that's just for me, left for me. And I just have one question for you, Dr. Conway. Your story is about the increasing number of transfers that are coming from other areas of the state and the requests to expand your scope of practice are really compelling. And I'm just wondering if the new Dartmouth-Hitchcock bed expansion will relieve some of those pressures as they add 65 new beds and potentially more tertiary care capacity. Do you see that as any relief? We haven't to this point. In fact, of our two tertiary facilities that we go to when we are looking for assistance, we've, I mean, just historically, we have found recently more obstacles with regard to getting patients from here to Dartmouth than we have getting patients to UVM. I would hope that that would represent increased capacity, but amongst some of the patients we have accepted in transfer, but on more than one occasion, have been people within the Dartmouth network at facilities that were part of the Dartmouth group. And so to this point, I can't say that we have seen that serving, that increased capacity serving us in terms of decreasing the pressure. We hope that that'll be the case. Yeah, I know that that's a big initiative. So one would hope that that would alleviate some of that. Yeah, always looking for the glass half full, hope in the future. So I think the construction ends this fall and the beds will be open sometime in 23. So just to the degree, is that gonna help? Sounds like may or may not. You know, I will comment also that we are fortunate unlike other places I've been where it's a lot more cutthroat and competitive and if you're not in the network, you don't get the, you know, people don't give you much credence. Both Dartmouth and UVM, we're an independent hospital but both of them work very closely with us and partner with us. And so we don't see that because we're not a network hospital in the Dartmouth or UVM system that they're saying, you know, we're not gonna take your patients or so forth. So we're very fortunate in that regard and I don't think every, I know that not every area of the country is in that situation. Well, I mean, and so to your point, that's part of what makes it unprecedented, right? Because we have good relationship with those. We've never had those issues before. And we've just not had those issues before. And it is not that there's been a breakdown in our communication with them. It's been strictly a capacity issue on their end and inability to provide that care. And so consequently it represents an increased pressure on us as not surprisingly a downstream consequence of that. Makes total sense. Okay. Well, thank you so much. I think what we'll do now is for no objections, we'll just take a 10 minute recess. I'm gonna come back at 10, 10, getting some feedback. I'm not sure who's maybe could be muting. Everybody can mute themselves. That will help. I'm gonna ask it. Thank you. So if there's no objections, I'm gonna ask for a 10 minute recess. We'll allow folks to stretch their eyes and walk around a bit. And we'll come back at 10, 10. And I'll start off with board questions for the Rutland team. Okay. See you back in 10 minutes. Thank you. All right. It's 10, 10. I see the Rutland team is back. Thank you. I see Tom Walsh. I see Robin Lunge. Tom Pelham, are you on? Not seeing your face, but there's Tom. Great. I see Tom. Court reporter, I assume you are on too. Yes, I am here. Perfect. Thank you very, very much. Okay. So with that, I think I will turn it over to board members for their other questions. And I'm gonna start with board member Lunge. Hi, all. Good to see you this morning. And thank you for being here. And as always, thank you for a very clear and thorough presentation. I really appreciate that. You've very clearly outlined your financial assumptions and the rationales behind the assumptions, as well as providing us with some stories and contexts that help us to Tom's point, CB, on the spreadsheet. So I very much appreciate that. So as a result, I only have like two or three questions, not a lot. In your budget, it looks like you've budgeted a decrease in your traveler usage from projected and as well as some, as you mentioned, Judy, some changes in the current COVID related wage structure. And I was just wondering if you could speak a little bit more to the balancing act there. What we've heard from a lot of the other hospitals is that they've really focused on the wage aspect in an effort to reduce the travelers. So just wondering about how you thought about that tension and how you came to a balance there. Sure, so this is a risk in our budget. We had projected that our traveler utilization would be around 50 at this time. And that was really based on that occupancy percentage going down. We showed you on that slide with that tick back up, we've got some work to do. And so we've got work to do and retention and recruitment and we have kind of a full court press there. We also have some work in terms of negotiating payments with our traveler resource companies. We've included about $100 an hour in the budget. And when you look at new contracts coming in play now, there are about 120. So both fronts. We have tried to balance travelers with investment in our staff. We have looked at market studies and tried to be not ahead of the pack, but certainly midstream. And we have at this point to our advantage a union contract that's in play for another two years. So that gives us some predictability there. We have increased our market budget knowing that we have some very high profile, hard to fill positions, both clinically and from a senior administration position that they're very hard to recruit. And so we have tried to provide more funding there to give us kind of more of a leg up in those recruitment efforts. I think also to add on to what Judy said, Member Lunge is we're doing a lot of work trying to mitigate workplace violence. It is one of the biggest initiatives we have. I was asked by a reporter a couple of months ago who said, Claudio, how do you expect nurses to come in to the emergency department day after day in the face of this? And I said, clearly I don't. It's not acceptable. It's not why they went into taking care of people. We are doing everything we can to protect them and to mitigate those issues. We are also pursuing housing and childcare, two big issues, but we wanna be careful that we don't get out over our skis. There are also very resource intensive issues that are not a hospital's typical core business. We've got to figure out how to do it, but how to do it in an economically rational way that doesn't exacerbate some of the challenges we're having right now. Sorry about that. I was muted. Thank you. And I am very sorry to hear about the workplace violence issues. That just must be incredibly, incredibly difficult for your staff. And I'm just terribly sorry about that. Another area that I wanted to just get your thoughts on is in the qualified health plan process, premium process. We heard some data around utilization and the impacts of COVID surges. And I've just been asking hospitals whether this is something that they've been seeing just to get a sense of how that particular analysis for that particular population, whether that's holding true more broadly or not. And that data showed that with increase in COVID cases, there was a reduction in utilization, but primarily in urgent care and ED and that other utilization for outpatient or surgery, pretty much over time, evened out. But really, of course, the reduction in ED or urgent care, if people don't go they may have a more acute episode, but they're not gonna postpone their ED visit and then go two months later, for example, for the same thing. So I was just curious if you saw any of that in your utilization data, if that sounds similar to what your experience are really not at all. I can start. Can you start, Julie? Yeah, so our ED is extremely busy. We have not seen any relief there. If you look at our last couple of months and you project that going forward, we'll have over 30,000 ED visits this year. So we have not seen that quietly, quietly, if you will, in our ED. We have some wait times in surgical services, both room capacity and workforce capacity. And so we don't see any change there in the near term. We're running as full as we can with the staff in the room that we have. So I think that volume has been fairly consistent. Where we have seen a slight change is in our inpatient admissions. They've been down a little bit, but you're not gonna see that in our utilization in our census data, because what we're seeing is patients are staying longer. For instance, last month, the impact of length of stay was that we had seven additional patients every day. Great, thank you. And then, oh, sorry, go ahead. You can just talk a little bit, Dr. Davis. So ED volumes definitely went down at the beginning portion of the pandemic, but they've been rising steadily since then and are back at pre-pandemic levels. What's different is the acuity of the patients that are coming in. So the number of what we would call non-urgent visits to the emergency department is down 27%, but making up that difference is what we would call urgent or semi-urgent kind of patients and those patients require more resources. So it's kind of the difference between somebody showing up with an infected toenail versus somebody showing up with abdominal pain or chest pain. It's just much more a resource-intense visit to the emergency department and that translates into longer lengths of stay in the ED. And one last thing to round that out is we're actually being impacted by our staff right now more than patients. So you don't notice it here because our policy is that we're all comfortable and we're in a secluded room. We can be en masse, but once we walk out that door, we're gonna mask up and in the emergency department, they're continuously wearing masks and we continue to revise our protocols, but still COVID is such running so rapidly that we oftentimes, on any given day, we have between 10 or 20 staff that are out with COVID and where we've been impacted on urgent care is a couple of weeks ago, we had an urgent care clinic and some primary care clinics close suddenly and abruptly because their staff all contracted COVID. And so all of a sudden, that creates an incredible surge of patients that show up at unpredictable times. We kind of know the cadence of the seasonality of ED volumes, right, but this adds a measure of uncertainty that we've never seen before when that happens. Thank you, that's very helpful to have that picture. And then lastly, I've been asking all hospitals about cost savings initiatives and Judy, you had mentioned both the 17% increase in productivity, which addresses some of the budget issues. And also I think in your materials, there is a little less than 500,000 cost savings budgeted, plus of course, travelers and wage stuff. So I just wanted to make sure that I didn't miss anything in the materials and if that sounds about right and of course interested in anything else you'd like to add on that topic. Sure, yes. So the $500,000 is really a result of our partnership with Visient for group purchasing for both our medical supplies, some office supplies and pharmaceuticals. We're very active on their boards, both from a purchasing standpoint and a pharmaceutical standpoint, also an administrative standpoint. We take advantage of any program that we think is appropriate and relevant to the hospital. So those savings are all associated with our participation in those programs. But you're right that the cornerstone savings was really in productivity and that's based on the commitment of our staff and that those volumes without matching an increasing workforce. Thank you. I'm all set, Jess. Great, thanks. And I will turn it over to board member Pelham. Well, thank you. I'll mirror Robin here for a very thorough and nuanced presentation. You always do that well and you did it well here telling your story. My first question has to do with Medicaid. In the payer mix table, it profiled an 18.2% increase in Medicaid and in one of the reconciliation tables, I think table one it profiled a 17.4% increase. But as well, you've kind of indicated that you don't expect any reimbursement in Medicaid rates so that any increases that we're looking at are utilization based. And so, so I'm just wondering and that stands out to me because if you look at across all hospitals the expectation about increased Medicaid revenues in 2023 is 1.4%. And so I'm just wondering if you could talk a little bit about what you see driving the Medicaid utilization revenues. Sure. So our Medicaid population is highly correlated with our participation in one care. And although we see trend factors there, those trend factors have to support both inflation and utilization or seeing utilization outpace what the trends are provided in the one care program in those costs thresholds. So that's the primary piece. The other piece is just in the services that we provide and those benefit structures that Medicare or Medicaid, I'm sorry, pays for those services. Physician services highly correlated with some of the increase and there isn't any reimbursement increase for those types of services. But also, remember, Palom, I think what you're looking at that 17% is a budget to budget change. And we've seen from our last year's budget to this year's actual and now which becomes next year's budget. We've seen higher utilization. Patients are flooding back and they are sick and they are anxious and they've got a lot of mental health, substance abuse and deferred medical issues. So we're seeing some of that utilization come back more than we had predicted in the last year's budget. So it sounds like it's a combination of attributed lives and people coming back with higher degrees of illness because of the pandemic. Kind of trying to put it away in my simplistic mind. So let me ask you this. And this is kind of, I don't think it's a political question. I think it's a practical question, but in the last legislative session, 2023, the Medicaid budget for global commitment was reduced, actually reduced. And there was a rationale for it. It wasn't just a cut. It was based on, it's a word I'm trying to think of. It was based on fewer numbers of Medicaid patients statewide. And I'm just wondering if you engage at all in the legislative process when it comes to trying to undo what Judy kind of has said is a leveling of Medicaid rates by the state. Yeah. And let me just finish that. I worry that the Medicaid is just become kind of a background thing that people feel there's nothing that they can do about it because it's kind of a background cost shift. It's really not that visible. Yeah. Well, it's certainly, as you know, certainly as visible to you as our regulator and us and Judy, especially in trying to balance the budget and what we're doing. You know, I can't speak for the agency of human services, but I will tell you, I've been around for a while and I've seen our new secretary of AHS really trying to understand the needs on the front lines and find resources to support that. And the challenges are incredible because not only does that, the acute care hospital community have incredible needs. So do the nursing facilities. So do the mental health agencies. So do the home care agencies through. I have no idea why the, why CMS is going to cut home care at this juncture and devastate our home care system. It makes, you know, maybe it's something that we got put into place a long time ago, but it makes no sense and will be very challenging as we try to continue this long recovery from the pandemic. So we're at the table, Member Pelham, and outlining what the challenges we're at. Clearly, there's not gonna be enough money to go around. You, I've heard you say that and your concerns and so forth. Hopefully we are able to get some Medicaid relief and to hopefully temper some of the incredible cost shifts that we're experiencing. So my next two questions are kind of bean counting questions, but I just, I don't fully understand the increase in the ACO dues from $400,000 to $1.2 million. I see the numbers on, you know, you know, in the spreadsheet in the income statement, but I don't understand why that would be as a big an increase in one year. Yeah, so part of it is a structural change and how the ACO is collecting fees for PNPM payments. They used to be a withhold and not included as part of administrative fees. And we didn't budget that way last year. So if you're looking budget to budget, that is the most significant change. We do have an increase in lives and an increase in net revenue, which is how the ACO fees are assessed. Okay, so it's not something that really affects the bottom line is more of an accounting change. That fair? There is a piece of growth in that revenue, which is used to assess fees as well as attribution, but there's a significant piece of that that's a reclass from a withhold to an expense. And I have one more bean counting one is just wondering why the revenues from cafeteria and parking revenues went up 47%. It's a very small number financially, but just it's a very big percentage. And I see a big number like that. I have to ask about it. Yeah, so we closed our cafeteria during COVID. And so our cafeteria is open and accepting both employees and visitors. Makes sense to me. My next question has to do with kind of the pace of, I mean, we're living in a very volatile time. I mean, none of us have any really kind of tight risk about what we think about what's going on. There's still a whole bunch to be revealed. And I look back at your operating margins in 2020, you were at two tenths of 1%, which is $545,000. Although you did have a large non-operating revenue back then of 15 million, which is not what you're experiencing now. But I'm just wondering, there are things that have yet to unfold. There's the hospital sustainability process. There's the execution of the new 1115 waiver. There's the recommendations of the healthcare workforce advisory group that just came out in, well, October of 2021. And hopefully maybe continued mitigation of the pandemic kind of on its own. And I'm wondering whether or not it would be reasonable to say to hospitals, say to Rutland, look, we got to get you in the black. In 2023, we got to get you in the black, but it might not be the 2.6% you're looking for. It might be, I mean, back in 2020, it was two tenths of a percent. So let's say a half a percent or nine tenths of a percent, but something less than where we're at now. Well, I mean, I'm sure your reaction to that would not be favorable, but how unfavorable would it be? Okay, so I'll start with the numbers response and then Claudio can follow up. The 2.7% operating margin was something very deliberate and it's based on our cash flow needs. And we felt it is extremely important that we stop the decrease in the underfunding of our operations and the negative impact that that has on cash. That coupled with the fact that we are working on a forbearance plan, not knowing where that days of cash requirement will land. And so the margin is really a product of sources and uses of cash and cash flow. And I would also say you have the data, if you look back over the past six years, in 2017, Rutland Regional did the unprecedented thing of reducing our rates by 6%. 2018, 2019, 2020, we're basically break-even years. We had a little bit of relief and paradoxically in 2021 because of the COVID federal relief and state relief funding. But this year, all of that has been taken up and then some by our laws. I can't speak for our board of directors other than to say that they're concerned about the financial situation and the bigger picture of sustainability for this hospital. And we don't think, I think, you know, if you look across the country, I mean, I guess right now is an unprecedented time, but 2.75% is not, we're not asking for 10% operating margins. We're not looking for five or 6%, which A-rated hospitals and systems typically, at least in the pre-COVID era, that was kind of the benchmark. We're looking for not even 3% because as Judy said, we think that's where we need to be to stabilize this year. Fundamentally, the work that needs to be done and the work that you're gonna be leading and so forth, Rutland Regional will be at the table in good faith, rolling up our sleeves to try to advance healthcare payment, fundamental payment and delivery reform. We've been there with our participation in the all-payer model in the ACO and it's tremendously important for us to continue that work. However, I don't think we're asking for, you know, this is really kind of what we feel, playing it straight like we have what we need to sustain. So I don't know what the situation would be if we're not able to at least try to do that. And that 3.75%, as you saw, Judy outlined, has a number of risks in there, more risks than opportunities. So. And my final thank you for that. I mean, I don't expect the concept to be increased, but I'm just looking to find out what the range of opportunity might be. So my final has to do with travelers in that you're looking in 2023. And sometimes I get this wrong because it's very hard, sometimes given the way hospitals are presenting the travel information and know where the all in number is. But I think I found it in yours where you're looking at a $10.4 million travelers request in 2023. And that's down from an $18.6 million projected budget for 2022. And as we've gone through this process, there's been some hospitals that have kind of taken surprising approaches to travelers. Southwestern isn't budgeting anything for travelers. They're basically have taken the approach of investing in their staff and but also taken a big risk with that too, which they readily admit. Up in Northwestern, they have an approach where people on their staff, their permanent staff are allowed to leave and go do some traveling work to take advantage of the good times, but are guaranteed to have a position when they come back. So maybe they work a quarter of a year on the travel circuit and come back. And so I'm just wondering what is it behind your efforts in Rutland to bring that number down from $18.6 million down to $10.4 million? Do you have a strategic plan behind that or is it just kind of a broad projection? So the biggest piece of that is rates. And that $18 million that we're talking about current year is related to rates at the height of the pandemic where an ED nurse was over $200 in Helen. So we're seeing significant relief in rates. That's what's driving the decrease in cost. As I said, we still are projecting a slight decrease in utilization to 50, we're around 70. And that's where our retention and recruitment primarily with higher ed, our great role in programs are coming into play as well. We're supporting 10 students here to engage in role in nursing practice and we're providing flexible schedules and support for educational costs. But the major piece in full transparency is rate relief. So did you, just one follow-up. So did you, so what you're saying, I think is that you're seeing a decline in travel rates. And so did you budget based on what the rate currently is now and not what it was six months ago, but currently now or did you project a continued decline going forward? Yeah, so this is a risk in our budget. We have base traveler rates at about $100 an hour. If you look at current rates today, they're about 120. So we've started that. Thank you, I always find your presentations thoughtful and answers that make sense given. And so thank you very much for that. And I'll pass it back to Jess. Great, thank you, Tom. And so I'll pass it over to board member Walsh. Thank you, Jess. And good morning. And thank you, Nurse Collins and Dr. Davis for joining us and sharing your experiences. As the other board members have said, it does help to give some context around the spreadsheets. I also, I wanted to salute your presentation, but also just it really comes through when your voices and your stories, your commitment to your community. And I want to recognize that your commitment to being innovative, the regional alliance that you're working with. And I think it was Robin who pointed out the hospital at home care model that you're diving into. I think those things are terrific. Also the justice, equity, diversity and inclusion work. And it's in there that I have some concerns that part of the struggle that we're doing with the board is to balance these concerns. We certainly don't want healthcare providers going out of business or bankrupt or the community members that they serve. And I worry that the higher prices that are part of this year's budget cycle, those get passed on through insurance companies and are felt as increased out-of-pocket expenses by the community members. And some of our community members are already struggling, right? And they're already the mental health stress, the frustration with the log jams that we're seeing across our country and all industries. And we know from Medicaid experiments, the Oregon experiments, that when people gain insurance or gain better insurance, their mental health is the first thing to improve, right? And so we understand that when people lose insurance or they drop down to a different metal level or different things, even small increases and out-of-pocket expenses, they forego a $15 increase in the cost of a medicine, they stop taking the medicine. And so I have this worry of a cycle where there are increased out-of-pocket expenses, people not taking care of themselves as well. And then ending up with unplanned and less reimbursed inpatient stays and ED visits. And then the response, the way that we've built our systems to date from a hospital administration standpoint is seeing those losses, then the response is to increase prices. And that cycle is at the heart of the sustainability process that we're in. And so I don't have a solution for that this morning. I hear your commitment to your community. I wanted to share those worries, that the equity diversity part, the families that are likely to feel some of this the most are working class families who are just making enough to not be on Medicaid and to have employer subsidized insurance, but the subsidies are lessening. Those families are often single parent families, so women are more affected. Oftentimes members of historically economically disadvantaged communities. So there's an equity question there too with our rising prices. And I also think there's a connection to the violence that we're seeing. People are already so frustrated with their lives and mental health is such a struggle already adding more expenses or not being able to get healthcare because you can't afford it just adds to that. So I see your commitment. I wanted to share some of the other things that I and I know the other board members are trying to keep in mind as we try to work through such a difficult time. And so thank you again for everything that you're doing. It's noted, it's appreciated as a new board member hearing your history in the past of returning funds to ratepayers. That's an appropriate place to also say unprecedented. So thank you for all that you're doing. And with that, I'll pass it back to Chair Holmes. Great, thank you, Tom. Can I just add one piece to Member Walsh's concerns? Sure. One of the things that we, I don't think we've presented in the budget in the data that we've sent is when you look at Rutland Regionals, Chargemaster or Charges, and where we're at the market or where we're below the market, one of the areas we have tried to keep below the market has been in lab costs. When Judy, part of the problem is rate increases are decreasingly effective. And Judy has often said, where do you apply rate increases because there's not much room on some things and so forth. But one of the areas we've tried to hold the line on has been on lab charges. And it's because of exactly what you said, Member Walsh, the health equity and also the population health type of a thing. So that we might not be able to be the low cost emergency medicine provider when you have that critical isolated thing. But we are trying to hold the line on lab tests that you need to preserve your health. And oftentimes we hear, especially in the clinics, the docs telling us every day they have patients who say, Doc, I know I need to get this blood test. I just can't afford it. We've tried to be below the market in those areas that are kind of the bread and butter things that improve people's, that maintain people's health and prevent them from coming to see Dr. Davis and there's Collins in the emergency department and having it exacerbate to a full medical crisis. So we are trying to do some work in that area even with these price increases. But thank you for that. I like hearing the thoughtfulness that you're applying even within the Charge Master. And I agree with you that looking at the rates and like where do we apply them? How much impact does it have? We need a different discussion in the future to really try to get a handle on the sustainability part because the charges and the rates aren't probably not the best means to achieving the goals that we're after. So thank you for just sharing that. It's another example of your commitment to really dive into the details and look at things. So I appreciate that, Daria. Great. So I guess I'm up last and not surprisingly, Judy, you anticipated many of my questions. So I appreciate it very much. Clearly you've been doing your homework and listening in on other hearings. In particular, I wanna thank you for your estimates of what the effective commercial rate is. I think it's really helpful for us to understand that relationship between a change in charge and what in effect commercial rate payers will feel in their pocketbook. So that was a really helpful number to have. And I anticipate if we can ask for that in advance in the hospital budget hearings and submissions next year, I think it'll help and save everybody a lot of time on the fly trying to figure it out now. I also wanted to thank you, Judy. I know you put some numbers around that annual cost of the borders that are awaiting placement in psych or in post-acute settings. And it sounds like your estimate around two and a half to $3 million a year, that's a pretty significant cost. And since I know you've been listening, I'm trying to, you know, and Voss and Mike Del Treco has agreed that this is a number if we can quantify across the state would be really helpful. So your quantification of that number is really helpful in that endeavor. If we can start to see what this impact is in terms of costs, we might be able to start making inroads into alleviating these bottlenecks if we understand how large a problem it is. Am I right then that for, you know, for Rutland's annual boarding costs that that might contribute as much as two to two and a half percentage points in cost in your rate ask? Yes, you are. Is that right? Yes. And I would argue not only is it expensive, it's the wrong way to care for these patients. Absolutely. They're not in a good setting. Inappropriate care settings, you know, impact the quality of care delivery and they impose a cost on the system. So it's a problem for access, quality and cost without a doubt. So thank you for that. That's really helpful. My next question really is about, you know, with this possible and maybe optimistic end to the public health emergency in 23, have you given thought or are there any assumptions in your budget if there are Medicaid redeterminations about what happens to those folks who are on Medicaid then no longer are eligible after the public health emergency expires? What proportion do you think will switch to private? What proportion to become uninsured? How have you all thought about that? So we have not postured and had a position in that. That's something, again, another risk in the budget and unknown. It's likely that some of those patients would become uninsured and we would have to pick those patients up in our financial assistance program. We do have a fairly generous program. We provide full free care up to 300% and partial free care up to 500% of the federal poverty level. We have increased free care slightly but not enough to take care of a significant transition of a patient population from an insured Medicaid status to uninsured. Yeah, and there's some opportunity for some of those to switch to the QHP with the subsidies. So I think it's anybody's crystal ball to figure out what is that, who moves where. So I will say this is one service we're really proud of at the hospital. We have a financial counseling office that we have three certified advisors who can work with patients who do work with patients to enroll them in the exchange. We're very active. We were somewhat inhibited and limited during COVID to have these conversations with the patients but certainly poised and positioned to re-engage in all of those conversations. And I think of our role there as really advocating for the patient as a service that I think Roland is proud to offer. Yeah, that's fantastic, especially with the extension of the subsidies. So hopefully there are many folks who were eligible for those subsidies but didn't purchase on the exchange and so lost out on that. So hopefully that information can be transmitted and people can take every advantage of those subsidies in the upcoming year. You're one of the few hospitals actually to highlight many of the important efforts you've been making to improve productivity, particularly as a strategy to navigate the workforce crisis. So I really appreciate and wanna acknowledge that important work. And I just wanted to hear a little bit about your views on the pros and cons of using and I think this is the measure that you're using to assess productivity but the FTE per adjusted occupied bed. Whether one of the pros and cons of using that as a proxy or a measure of productivity are there other ones that you also considered and saw improvements in? Well, it's one of the ones that is a standard out there that you can look at some benchmark information. Judy, you wanna talk about challenges and other things? Yeah, so it's a proxy, trying to look at inpatient volume and adjust that for outpatient activity. It's price sensitive, right? And so that is a challenge but I will tell you, we have measures at the department level here that are based on individual utilization for whatever that service lab test imaging test the visit. And we look at productivity at that level. That's an enormous amount of information. And so we roll that up the result of that in this industry standard. Okay, thank you, it's really helpful. My last question is actually a little bit around the wait times and I wanna thank you for the data and on the information on how you're seeking to address some of the access issues. It's really helpful. And I'm wondering on that slide, 27, I think it was, are there specialty areas that are your highest priority to address? Given the look that you have there for the clinic visit lag, are there areas that you're really focusing those efforts on in particular in terms of recruitment in terms of scheduling changes? Any of the things that you might be doing to address that? Yeah, a couple of areas, one of the biggest challenges we have right now is auto-alarm garlogy. Our senior ENT surgeon is retiring in the next couple of weeks. In the four and a half years I've been here at Rutland we have put a full court press on trying to find a replacement for him. We'll be down to one, your nose and throat physician and surgeon in that practice. We're trying to, that's one of the areas that we're working at trying to do some innovative things to augment and support that service with advanced practice providers. But there's limitations to that. So that is one challenge that we are focusing on. I think some of those specialty areas, member homes that provide kind of the mix between advanced care and primary care are really important. And that's where we're trying to work with our primary care partners and others in the clinically integrated network because we have a limited resource in board certified cardiologists or endocrinologists, right? And they, as the stresses and pressures on the primary care system also increase significantly, really where the frontline diabetes and the primary hypertension need to be managed is in the primary care setting. You don't need a board certified cardiologist to do that work. And as a matter of fact, when you've got limited resources, it could crowd out some of the more important work. So how do we work better together to try to do that? And ultimately, the holy grail in this is to prevent the predi, to identify the patients at risk of prediabetes, like stressed out overweight hospital CEOs who don't really exercise as well and maybe don't eat as well as they should before they end up with a major event and end up in the care of these people because we're probably not the best patients. That's where the holy grail of this is, right? If we can do that and we can work together to prevent that, there's a whole stream of costs downstream that we can interrupt hopefully. Hard work, uncharted work in a lot of ways. But that's where we're trying to manage that when we're managing access to specialty care. And we're also at like, hey, we're also working with the clinics to make them as productive and efficient as possible so we can see as many patients as possible with those resources because the reality is in a rural area, these folks can't do it on their own without the resources of either a larger group which you don't have enough economies to scale in Vermont to do or the only other alternative is to be hospital employed. No, I appreciate that answer and I appreciate your passion. This was our first year trying to collect this kind of referral lag and visit lag data. And I think to varying degrees hospitals we're able to, I would say doing the visit lag data would seem to be easier than the referral lag, right? Because collecting that information on the data referral is made seems like that was available for some hospitals and not available for others. And I'm wondering if it's possible to going forward collect that referral data so that referral lags are something that you collect as you probably know referral lags in some parts of the state are real sources of frustration for primary care providers and patients. And so to the degree again, if we can't measure it we can't fix it because we don't know what's a problem. So I would just ask if that's a possibility to consider in your EMR system and collecting that data. I do wanna give you a shout out though because I am one of those patients who came from out of the area into the Rutland system, you know, moving over I had been waiting for over a month for an MRI to be scheduled. Literally the referral lag was more than four weeks and super frustrated I gave up, I called Rutland your team set my appointment that afternoon and I was seen within a week. So to the extent that your teams are doing a great job kudos for making that happen but I do think it'd be helpful for us to really understand where those referral lags are. But memorable, isn't that a great indication of the incredible stress that our system is under? MRIs are one of those few things that Judy's happy about the increased volume because we make money on those. The one of those smaller and smaller group of things that subsidize the myriad of stuff that we don't. And so when you can't get in to get an MRI it's certainly not by hospital administrators and it's because the system is tenuous and breaking down that we can't even get the lucrative economically lucrative stuff done. So which is that's where the incentive is today, right? In the fee for service world. And so that's part of, you know I think that's a great illustration of the challenges that we have ahead of us as we try to recover from the pandemic. And just a word. I thought that was a bad day. Your challenge to us, if it was solely up to the hospital we might have half a chance to get your referral lag but it's really based on physicians and their adoption of electronic medical records. One of our busiest physician practices here in town is on paper. And so paper processes do not lend themselves for this type of reporting. This is where despair at EMR is trying to come together. It's a challenge. So we'll continue the work but we don't necessarily control the inputs and that will forever be a challenge here. I appreciate that answer, thank you. My last question is just a standard question I've been asking everybody but obviously I'm asking if you would share any known or likely changes to federal or state payments, relief funds, any unexpected increases in Medicare and Medicaid reimbursement rates. You've already done that. I recognize the 600K from the Medicare pump up. Just since your budget submission or anything that happens in the next few weeks it'd be helpful if you could send an email to Sarah Lindberg if there's anything unexpected in terms of changes in those payments or opportunities. With that, I'm actually gonna just turn it over to our hospital finance team to see if they have any questions. Hi, thanks, Chair Holmes, Russ McCrack and I'm gonna stand in for Sarah Lindberg today to realize I think just one staff question or perhaps request. So we're looking at the slides in the presentation on slide 13. It shows a net rate increase impact for Medicare of about 1.6 million. I recognize some of that is newer from the Medicare inpatient rule. Looking at the budget submission and the appendices in slide one which is a reconciliation appendix it doesn't carry forward any rate effect for Medicare. And so we were wondering if you could provide an updated appendix one. Yes, so all of this information is consolidated in the rates and utilization, pay or mix line, I believe is the name of it but we can certainly provide that information to you. Oh, I see, so it's for Medicare it's not broken out as a rate effect it's factored into the reimbursement and pay or mix line. Correct, yes. It is included. I think that addresses our question but if there's more, Sarah and team will follow up with you directly. Thank you Russ, appreciate it. Yeah, at this point I would like to open it up to the HCA for questions. Sam, is that you? That's me, thanks so much, Chair Holmes. I'll kick things off and then I'll pass it to Mike Fisher. Sam Pish, Health Policy Analyst of the Office of the Health Care Advocate. Good morning everyone, I think it's still morning, yeah. Just wanted to start off by commending Rutland Regional on a couple of elements that you spoke to today and also really shown through in your narrative particularly the DEI strategic plan. I think it's notable that you have attached clear metrics for evaluating your progress towards this and as well as a timeline to hold yourself accountable. And also wanna recognize, and this is a small point but I think it's important, recognize the importance of re-evaluating your registration process to ensure appropriate language and tools to capture racial and gender identity to really wanna commend you for that. I think a part of these efforts really led into the loan institute ranking you the most socially responsible hospital in the state in 22. And I think it's notable that you didn't mention that so that demonstrates some clear humility. And also wanna highlight the work you've done updating your patient financial assistance policies to come into compliance a little bit early, making some progress towards Act 119. So the first question that I have follows up a little bit on the area of health equity. It came through pretty clearly the impacts on your community that you estimate or project if your charge requests aren't approved as requested. But I was wondering if you still plan to follow through on your race equity and DEI focused efforts regardless of what the decision is made by the board. Yeah, I think absolutely. I think we've seen the national reckoning in the summer of 2020 and the challenges we have, every organization has in dealing with this. And we are absolutely, I think our board, that's why they created intentionally and redid our whole values as an organization to create diversity, equity, and inclusion as one of four core values. I don't see that changing regardless of the economics of the challenges that we have so forth. It's those are things that we're dealing with as an organization and they're seeing in the emergency department, my colleagues here, every day the impact of those challenges on our community. Thank you, I appreciate it, that's great to hear. I just talked about a little bit, but I'm wondering if you could talk a bit more about the ramifications if you were to violate your debt covenant, and if there are any efforts underway independent of the charge requests to resolve the issue. Yeah, so we have been very proactive in working with both TD Bank and the USDA. We are deliberating a forbearance agreement. That forbearance agreement has not been articulated and agreed upon yet, but certainly we've been engaged in conversations with them for the last two months. Thank you, I appreciate it. Now, last question for me before I turn it to Mike. At the UVM Health Network hearing, we heard a little bit about their decision to invest $3 million to create a population health services organization, which would incorporate Morning Care Vermont. I'm wondering if you could speak to the obstacles and opportunities that this change potentially presents for your involvement with that organization. Do you have anything on that? We were active partners in Morning Care sitting on any available board or committee that we can. We would certainly partner going forward with UVM. Can't say we can comment on what that looks like, but we do believe in population health and are very committed to that. Yeah, yeah, I think without knowing how that really looks. Damn, it's hard to fully comment. Other than I gotta tell ya, we wouldn't be where we are right now if it wasn't for UVM stepping up and creating One Care Vermont. No one else had the resources to do that. We certainly didn't. As the second largest hospital, UVM and Dartmouth when they came and founded that. It certainly isn't perfect and there's certainly a lot of work and challenges, but I'll tell ya, they've invited us to the table. Anyone who wants to participate, it could look very different and it does look very different in other parts of the country, right? Where the ACO is just for system members. This is a very different model. It's not perfect. We acknowledge it. Judy's on the finance committee. I'm on the board. They've invited us to be part of the governance of it. It's not perfect, but I think in Vermont, we recognize the academic medical centers and even our partners across the river in New Hampshire realize with this population and the medical culture here and the challenges we have, it's a different type of environment that we work as hospitals together, large or small. So I don't see any big threats that this will create. Thank you. I appreciate it. I'll turn it over to Mike. Thank you, Rutland. Good to be here. Over the years, over the last couple of years, we've been very articulate about our appreciation of Rutland's free care and bad debt numbers. Your 21 actual numbers are indeed the best in the state. And we arrived at that appreciation, not only because of the numbers, but after having visited with your financial advisors and getting a firsthand view of how they approach their work. So in that context, I just wanted to ask you to, as I look at your 22 projected numbers and your 23 budgeted numbers with regard to free care and bad debt, they get progressively worse from our perspective. And I wanted to ask you if you could talk a little bit about why you think that might be happening or if that's a concern to you. Sure. So our projected numbers, our budgeted numbers for 23 are based on actual utilization. Any dollar that we can transfer from bad debt to free care, we will work very hard to do that. We are seeing a difficulty in having patients engage in the application process and submit data. Happy to share what those statistics look like, but suffice it to say that it is extremely difficult. COVID didn't help when we shut down access face to face with our financial counselors. We are at the point where we're re-engaging, inviting them back into our facility. So I'm hoping that we bend that curve and we see more utilization in our free care program than our bad debt. We also have looked at the new regulation. We've adopted the household income modification early hoping that that would also help us in transitioning some of that bad debt. Yes, thanks. Sam recognized that a few minutes ago, we very much appreciate Rutland before having an opportunity to ask you the question when you would be moving towards adopting, you went ahead and do it, did it, and we appreciate that. Okay, maybe on that same line, I think I'm looking forward to continuing to hear from you about just what it's like to make sure that the people who are getting bills who can't pay them are given the level of support. And that makes sense to me that there was a COVID dynamic there. Be interested to see how that plays out over the next year. One more question. Honestly, I went back and forth, have gone back and forth today about whether to ask you this question. We made a decision very consciously to ask, I don't know if you heard our question to UVM Health Network about race corrections, about clinical health equity dynamics. We made a very conscious decision to not ask smaller hospitals that question to save it for UVM Health Network given that they're teaching hospital and their scale. Yet, as I sit here with you and look at your leadership, frankly, on health equity, I wanted to raise the issue sort of as a concept. I fully recognize that we don't generally ask a hospital like Rutland to question clinical standards. Yet, when we see something like a race correction for a spirometer measurement that according to the Lancet has, there's no genetic locus that varies by race. And any presumption that African-Americans have smaller lung capacity than their white counterparts is based on racist presumptions, I think, or racist history. So, and I really just bring that up as an example. I don't know whether that's happening at Rutland or at all Vermont hospitals, but my question is, how do we ask hospitals like Rutland to challenge themselves on this kind of a level around clinical practice? So, for example, pulse oximeters don't have the same readings for folks with darker color skin, lighter color skin. Some of those, what are we doing to identify some of those? I will tell you, and none of these things are easy. One of the things we've done over the past year is reprogram our EMR to put in place a field for your birth gender and how you identify. And there's a whole process that goes along with the technical piece of that, make sure that we capture people's gender appropriately in the ED and it impacts how they're cared for. So we're doing some of that work. I will tell you, not that I'm a UVM apologist, but this is where we need an academic medical center in the state of Vermont. No one else has those resources. No one else has the research capability of the folks to do this. And some of that, they're gonna set the standard and we're gonna work with them and take their lead, I think. I don't know if you have anything to add to that from our clinical theories. I would just say I think that that kind of education is happening, sort of in section meetings, in nursing training days. And we have been seeing paths. There's a difference certainly as far as transgender care, both in terms of the way that the EMR tries to give the providers an accurate, accurate information about a patient's gender and chosen name. I mean, even the name that they use, that was something that was really hard to be able to see on the screen. And there's been a lot of work in terms of making those modifications. And that has paid off. We had a patient not that long ago who posted to our Facebook about how from the moment the patient entered the department, the right pronouns were used. Every single person who interacted with that patient used the patient's chosen pronouns and they gave a shout out and it made us feel really good about the work that we've done, the respect that we're showing our patients and that it were a safe place for people to choose to receive their care. Thank you. Thank you, Chair Holmes. That's all our questions for today. Thank you, Mike, appreciate it. Important questions. At this point, I would like to open it up to public comment. If anybody would like to comment on the presentation today or the budget submitted by Rutland Regional, please use the raise your hand function and I will acknowledge you. And if you are calling on the phone and would like to just speak up, that is okay too. I'm seeing no hands raised and hearing nobody. So it doesn't sound like we have much public comment. Thank you to the Rutland team for your time today, the clarity of your presentation and most importantly for the work that you do for your community. You've given us a lot to process as we approach deliberations over the next couple of weeks but thank you for your time. And with that, we're gonna take a recess for lunch and I'm gonna stay on the schedule. We'll return at 1.30 to hear from Mount of Scottney. Thank you all, appreciate taking you all this morning. Thank you very, very much.