 Good afternoon everyone welcome to the Green Mountain care board First item on the agenda is the executive director's report Susan Barrett. Thank you, Mr. Chair Couple of announcements and reminders first reminder, please sign in up front if you have not already We also have Recently posted our Green Mountain care board agendas or schedule for May I will let you know we have two meetings that we don't have a board meeting scheduled at this time But if we need to we will that's May 16th and May 23rd on May 2nd We're going to be hearing from our staff on the Green Mountain care board all-pair implementation update And then on May 9th, we're going to be hearing from vital on their budget in their presentation And then we have on May 30th of vital budget vote, which is a potential vote schedule and then we'll also have a I hope at that point May 30th the legislative session will be over and we can Present to you a legislative update from this session So again, this is posted on our website And the other Announcements and just update that I wanted to give to folks is last week. We were up in St. John's Berry For the day for our traveling board meeting I want to thank all the folks in St. John's Berry who taught us a lot about the great things that they're doing up there with their community and We will be out on the road again soon that is to be determined probably The fall and we haven't decided our next community But we really enjoyed getting out there and learning about the fine work. They're doing up there and With that I guess I'll just close and I want to thank both of our presenters today because they're The folks presenting now from out of Skutney are coming up from the Southern or bottom part of the state and then the FQHC folks are coming down from Burlington and taking time out of their day to To give us some finance updates on their institution. So I Appreciate that and wanted to thank them Thank You Susan Next item on the agenda are the minutes from last week's meeting April 18th Is there a motion? So moved Is there a second? Second, I will second because you were not there. Well, I can second something Okay, that's been moved to approve without any additions deletions are corrections any discussion Seeing none all in favor signify by saying aye. Aye. Any opposed? Let the record show that it was a four to zero vote. I abstained well three to zero Because I wasn't okay. Okay So with that Susan would you like to introduce our guests? We have Dr. Joe Perez the president and CEO and CMO of Manus Kutney Hospital in Windsor, Vermont Then we also have with him David Sandville who is the chief financial officer for Manus Kutney Hospital and Health Center and the purpose of both of our presentations today is to get into the finance one-on-one for for this Presentation of a critical access hospital and then we'll hear from the FQHC Okay, great Thank you, Susan and thank you, Mr. Chairman and the rest of the board The opportunity to share some insights into the process implications Vermont's critical access hospital. I have a few introduction remarks, and then I'll hand it to Right-hand man Dave Sandville to take it from there I came to Manus Kutney five years ago and spent my entire career in large academic medical centers Despite being born in New Hampshire. I fled to DC and then to Boston for a number of years And all my experience was in PPS hospitals and at BRG driven world Came up to DHMC in 2001 and while my role there was largely clinical I did serve as the medical director of care management at DHMC focusing my time and attention on contracting issues with payers utilization review Working with basically doing the black bag job that no doctors ever want to do but for some perverse reason I enjoyed dealing with payers It was clear upon my arrival at Manus Kutney five years ago that there was an entire Paradigm of possible finance that I needed to digest After two years of kicking around Windsor and picking up snippets of cost reports and allowable costs As well as well with the DRG for this and not a DRG for this it's clear that I needed more exposure Thankfully David Sandville our CFO at Manus Kutney bring brought a wealth of experience Both based in New Hampshire and in Vermont in years of financial work at a number of Vermont hospitals We've CVMC and Gimbert. I've benefited greatly from working with Dave He serves as a resource for some of the other CFOs in Vermont hospitals as well and in New Hampshire for that matter a Few months ago. I sat down for an informal breakfast with Susan Barrett at Lou's In Hanover which I haven't had any courage to get to Lou's and handle breakfast And we discussed the black box that CAH financing can be for providers administrators and the public At that time I offered to come up and discuss the model that the board Really I offered Dave So here we are We'll focus broadly on CAH finance to start and then provide some real-world examples of the cost report And some of the inflationary pressures on Manus Kutney hospital and health center I hope this can be an engaging discussion for all for board members for members of the public in the audience And folks calling in and with that I'll hand it over to Dave So again, thank you for allowing us to come up and share some information with you I'm going to give What I consider to be a fairly high-level summary primarily cost-report But it does speak to a lot of other issues as well I'm happy to go down into the weeds with you, but I know you have an agenda And I'm happy to make questions at any point in any slide As you as the need arises So that's my presentation Yeah, the laptop see the laptop it's on this will work in my house I Otherwise this can become like an awli north presentation There's a light How's your senior dancing ability Actually saying fairly well So critical access hospitals, what are they and again, there's you know volumes of regulations and Standards relative to critical access hospitals But the short story is in 1989 it was federal legislation written to protect the livelihood of rural hospitals and And so they have a series of standards that relate to Qualifying for this one is your state must participate in the rural flexibility funding mechanisms to your hospital must be 35 miles away from the nearest other hospital and Of course, they have provided an exception on state-by-state To have as little as 15 miles between facilities depending on the terrain the weather and some other conditions So our state applied for a waiver to get down to 25 miles away And that was accepted by the federal government and so Qualified that amount of scuttle. There are conditions of participation The guide whether you can participate or not and the biggest one is you're only allowed to have 25 beds For acute and swing services and swing is subacute. We'll use that definition for the moment And you are allowed by statute to have one additional distinct part unit Whether it's a inpatient rehabilitation unit, which is what we have Or a psychiatric unit So you have 25 med surge beds for a simple definition and you're allowed to have up to one other Designated unit with up to 10 beds. So amount of scuttle. We have 25 med surge beds We should take care of acute and Subacute patients and then we have our 10 beds for the inpatient rehab unit We are audited and accredited by CMS through a contract with the state of Vermont In other words, a lot of the pps hospitals you'll you'll see and talk to you know They have joint commission come in we actually have the state of Vermont come in on behalf of CMS and they audit us against the conditions of participation that we were required to maintain our CH status and We're obligated to have 24-hour care in other words We must have an emergency room in order to be a CH will never find a CH with no emergency room Or the ability to provide care around the clock We also have one other standard that makes us a little unique and that is that our average length of stay for acute patients must be 96 hours or less and So we can have a patient that stays five days We can have a patient that stays two days, but at the end of the year the average when the cost report is filed And they come out and do a field audit is that we have an average of 96 hours or less and and that has recently manifested in a requirement that as soon as we determine a patient is not likely to be out within 96 hours from acute status that we begin looking at possibilities for transfer to someone like Dartmouth or another facility and So those are kind of the high-level Guidelines that drive who we are and what we do the purpose of the legislation was to again secure care in rural areas throughout America and I view I try to always find the simplest definition for everything Which annoys my wife quite often, but Insurance policy is the best term I can use for a good black house hospital cost-based Reimbursed it's an insurance policy if we get too busy a volume goes up We never really fully enjoy the upside of of being super busy Also, we never really feel the full pain of not being so busy because the cost report is Costs reimbursed on a per unit basis in its simplest form So if you're busier by definition your fixed costs get divided up between more units in your units of cost Go down if you're slow, then more cost gets attributed to each unit and your costs go up and Medicare pays cost like so We never really make the margin we would if we were a PPS hospital is your than expected and We never feel the full pain of having an off-year volume either We do feel some pain and some happiness, but not to the extent that others would find or experience At Mount Scania, we also offer in addition to acute inpatient rehab acute med surge and swing bed We also have patients who are waiting for nursing home placements, and we have some respite services We provide here and there, but they are a small single-digit percentage of our census Far as Mount Scania itself. We're about two percent of the Vermont hospital system budget about 30% of our business comes from across the river and We are involved with not only all of the Vermont Medicaid and exchange program But also most of the all of the New Hampshire Medicaid and most of the exchange programs there So whatever we have to know to operate here in Vermont. That's essentially double Because we're also having to be aware of what's going on in New Hampshire We are a member of the Dartmouth-Hitchcock Obligated Group We are an affiliate and essentially we're wholly owned by Dartmouth-Hitchcock We are the number one recipient of transfers For acute rehab swing bed and and some acute We take over 500 admissions a year just from Dartmouth Primarily we focus on swing and rehab on an inpatient basis and Community care on an outpatient basis. We are the leader I believe the leader of all integration efforts at Dartmouth-Hitchcock Health So everything that they want to do to better integrate with their affiliates Generally, we're ahead of the curve on that one whether it's group purchasing Whether it's financial application, whether it's clinical integration We're the ones and to be frank with you Joe having come from there and knowing many of the players there is a huge benefit For us getting through a lot of those processes And we are the only hospital member of the Dartmouth-Hitchcock health system across the river So that causes some unique rungs within the overall system because they are different for us I want to talk a little bit about where funding comes from for us So the large blue slice of pie is Net patient service revenue. So that is what we actually get paid for taking care of patients When I did this presentation for one care of Vermont or parts of this presentation for one care of Vermont a few years ago that 85 was 80 or 89 and As I think we testified in our budget hearing last year The net patient service revenue pie is shrinking as a percentage And so we've had some relief over recent years with the meaningful use funding Coming from both the Medicaid and primarily the Medicare program But because we've run through our first several years on our EMR That's a diminishing return over time and will no longer subsidize operations and operating expenses We also have tried to maximize the opportunity with 340b Which also gets above the line Because that is allowing us to be able to provide the care that we provide to our community And you'll see the other one's grant revenue is a small slice other operating revenue, which includes 340b Catheteria is a rental Revenues that we have Contributions, donations, investment income, non-operating gains and losses. That's what contributes to our Our livelihood Just to roll on through this one We're within Our patient care world where is our our money come from on the acute and swing bed units 75 percent of our Revenue associated with Medicare patients 15 percent our Medicaid Commercial is nine percent and and self-pay is Essentially one percent when you move over to inpatient rehab That number for Medicare diminishes a bit and it goes down to 66 percent and nine percent for Medicaid 25 percent for commercial and outpatient you see the pie from Medicare shrinks even more down to 54 percent And and the reason we're showing this slide is later. We're going to talk a little bit about how cost reporting actually manifests itself onto the bottom line And you can see when we talk about aging population. That's that's what we're talking about with Medicare that we see Three quarters of our business on the inpatient side is associated with Medicare and as we move to Less intensive services that that percentage diminishes So number one myth about cahs is cahs are cost reimbursed. So they're all they always cover their costs And and I just want to spend a minute or two talking about that The first I have set this little grid That kind of helps us kind of walk through how we get paid By some large payer groups and for acute services the first row We get what I call cost light. So just because our accounts payable check Uh Clerk writes a check for a particular service Doesn't mean that that expense is going to be considered in a loud expense for Medicare An overwhelming majority of our expenses are accepted by Medicare well over 90 percent However, there are things that they find Unallowable Sometimes if we were to leverage the investment market and the treasury market for some Funding and some loans if they find in their determination that those interest costs are unnecessary to how we operate They will disallow interest costs. They will disallow certain supplies They will disallow any expense associated with a non-covered service So there is actually a fair amount of wrangling that goes on with our cost report to make sure We're getting all of our allowed expenses in And and wanting to not get audited by having issues of non-allowed costs within the cost report So when people say well, you get your cost. We don't actually get our cost. We get cost light For medicare acute, you know, we receive a per diem based on cost Medicaid we get a drg and ask both from mehampshire and vermont And for commercial most of our acute business is paid on a percent of charge And there are some ancillaries that are paid on a fee schedule basis For swing and I put slash sniff so skilled level of care as opposed to intermediate level of care like You see nursing homes offer mostly icf and some sniff Sticking to the sniff, which is a a significant amount of nursing effort Again, we get cost light paid on a per diem for medicare Medicaid really pays us about $240 a day on something that costs us over $800 a day And that we don't always get paid Commercial also if we have a contract negotiated from those services will pay us a percent of charges as well Rehab is paid on a cmg, which is the rehab version of a drg So if a patient comes in with certain demographic Scoring certain clinical scoring they translate that and say that's worth $14,000. We don't care what you do So whether we have them there for 10 days or 30 days We get that $14,000 And and that's from medicare We get a drg from medicare, which essentially works the same way This is what's wrong with the patient. This is the patient demographic and we're going to give you $14,000 and Take care of them till they're done And then commercial again is a percent of charge on an outpatient world So outpatient lab outpatient radiology outpatient general surgery or surgery We're again paid cost light from medicare We get an apc from both the montananscher medicare And we get a percent of charge and or some fee schedule work So some of our ancillary services radiology laboratory things like that Some of those contracts with payers are on a fixed amount per cpt So one thing you should know is that we're a non acronym board Okay, I apologize so far. We've we've had to figure out what cop is what law says what a dehog is So you got to tell us I've kind of rolled through that and I apologize. So so cop is conditions of participation Our accreditation standards Dehog is a Dartmouth Hitchcock obligated group. So it's it's the holy old entities that share liability And and resources The drg is is how inpatients are paid for many payers specifically for your pps hospitals Medicare and Medicaid And is a perspective payment system pps Where they give you a prospective payment and then they call it good So i'm not really sure how prospective that really is but that was the intent many years ago Uh From a physician and professional billing, uh, that's pretty much all fee schedule driven So it doesn't matter what we charge. We can pay an x amount for a certain payer for that certain cpt So what was the apc? apc is uh, oh wait spend years actually since I uh Ambulatory payment class. So an outpatient service is a cpt level you get paid. So if you run An x-ray 72140 cpt they give you 110 bucks every time you do that So on the swing Line um under medicare um The supplemental though will only go 21 days right the supplemental You're saying costs light, but once somebody is is past that 21 day period They don't pay anything that's no longer medically necessary Right. So if we kept somebody beyond Uh, uh a skilled level of care that is no longer medically necessarily don't pay us Okay, up to that point. There is no specific number of days associated We have swing patients who come in for three days. We have swing patients who who go to 100 days Depending on their condition and the treatment plan so They may determine it's not medically necessary, but if there isn't a nursing home willing to take that, uh person So a great question It's stay with us. Is it all free care? Uh, it's it's close to it the state of vermont did enact something in the medicaid program that if you Have not applied for long-term medicaid coverage i.e. nursing home coverage They will Honor that for 30 days while you go through the application process as a patient which we assist them with And so we'll get paid for those first 30 days that they're no longer covered by medicare And their level of care is below skilled And uh, and and so we really push to get that through in 30 days and to be frankly State of vermont has greatly improved their turnaround on those applications. So for the most part that works out pretty well for all involved Uh, and then we work to get them placed to a nursing home I also think is probably worthy Of mention is that many of the nursing homes now are reducing the percentages Of census associated with medicaid. So we are going to be seeing a backup We have seen some and and some patients are just difficult to place because of their clinical needs But we there is fewer and fewer beds available. There are fewer fewer beds available for medicaid patients as time goes on we had we had 2016 and 17 had two patients that each spent Well over 500 days in the hospital their medical problems had had largely resolved but significant mental health issues and And lack of social supports led to no nursing home in Uh, north of medicaid. So we take under these guys and eventually We did worry with discharge one and another gentleman died of a natural death in the hospital We're getting spent the last year and a half of his life. So it was right. We're we're seeing this now Those are good questions and I think they they are system issues Moving to the next slide A revenue source by reimbursement types. So this is kind of How do we get paid? Well, 42 percent of our total business is covered at cost 13 percent is medicaid is essentially On a fixed schedule and when you really think about it about 50 55 percent of our business is medicare and medicaid which pays us less than cost So I'll kind of segue back to the prior slide that ch has always get paid cost the better Is actually Not true So since since that really kind of Recaps what you did several slides back as far as your revenue stream by payer One of the questions that marine sent me since she couldn't be here today Is whether or not you could um provide us with a breakdown Of the operations contributions from each of those payers Because you could you could uh have identical revenue from A multiple sources, but depending on how that feeds through so You could be doing a lot less work for one piece of that revenue. So we're curious You know, basically this gets into the cost shift and other things Yes, it does. So maybe I'll go jump to the next slide so, um I did this overly simple but somewhat illustrative With example yesterday To kind of maybe speak to that point a bit and I don't know at what level She would like to talk about contribution to the operation by line of business by department. I'm not really sure Yeah, see what we don't see on here is your margin for each of these so you know It's it's one thing to have the percentage of revenue, but If you're not showing what that what that actually is bringing down to your bottom line I believe that on a payer basis we provide that already in our regular report team I'm happy to double check that but I believe That you that is viewable in our data submission to you folks right now I'm happy to Illustrate that differently or better If that would be a benefit Yeah, if you could just do a pie chart similar to The one that you did For revenue If you could do it, you know, take your total margin and break it out by payer Yep, I think we can probably come reasonably close to that without killing ourselves. So Okay, because i'm a finance guy So i'm happy to spend like four days in my office with a spreadsheet and make it super granular and super accurate But sometimes that doesn't help the story We don't want you to exhaust resources doing this. We're just If it's simple go ahead and do it Actually quite comfortable for me But I thank you for your concern So FY 2017 I just put this one example up that's it's fairly it's fairly accurate and and as a as a percentage of Of gross revenue what was medicare medicare commercial and south pay and what did we generate for total gross patient service revenue? And then what is our approximate reimbursement percentage on that gross revenue? and The resulting net patient service revenue of 47,382,000 And then I just kind of show I just to illustrate something very quickly. I took the same data So you've got this the The same gross total gross revenue to your earlier point And and I just tweaked it so that medicare went down her by a percentage point And commercial went up by a percentage point, you know, how does that change net revenue? Well, if it increases our net revenue By $426,000 And and the reason I put that out there is we could be just as busy this year as we were last year And do the same business and if no if fte's didn't change inflation didn't happen all that stuff Just by the nature of what somebody's covered with when they walk in the door Which obviously you can't control We'll swing money to our favor. And then on the next example, what I did is I took the original Example and I said, well, what if we lose 1% in in net return? And what does that mean? Well, that cost us about 650,000 dollars Again for doing the same business. So if medicare determines there's another Unallowed cost or we have we render the same care But some of it's considered non covered or not medically necessary or what have you and we lower our net return rate From 54 to 53 it cost us about 650,000 dollars to do the same business we did previously. Does that make sense? It does and while you're talking about the profit and loss another question for marine was Um, does your p&l capture the allowable cost and if it does is the difference between the interim payment then managed through the balance sheet Yes, so I'm going to talk about that. She has great questions because they match up with my slides, but But uh, all we record all expenses And we don't categorize them as unallowed until we put the cost report together So our p&l is all expenses We don't have little like, you know in radiology not non allowed radiology supplies And generally how medicare does it is they do it by a proration and appropriating funds across across the hospital the department What not and I think I'll speak a little bit to that in a minute So medicare's guiding principles for cost reports is CH receives 101 Percent of costs and I know you're thinking I thought you said you get cost light Well, it's 101 percent of what they allow to be cost But the sequestering that happened a few years ago took two percentage points off that so now we get 99 percent of cost Um allowable costs not actual costs. We've talked about that and and really they want to know That's the real definition of allowable costs. Again, if I were to oversimplify it is Are are the medicare beneficiaries getting benefit of that expense? And if if medicare feels like they're not Then that's an unallowable cost Part a benefits from medicare are part of the cost report part b services So some physician services in certain settings if we ran a dme clinic, which we don't Those types of things those will be carved out because they're paid on fee schedule and there is no settlement on cost And then just as a interesting Thing to consider because it'll be a little pertinent later in this presentation is We estimate that our fixed costs are about 87 percent And uh, I'm I'm going to take a little risk and say that many pps hospitals Depending on their size and their structure and the services they provide would run Two-thirds to three-quarters Would be fixed expense and the reason that's relevant And this is why the cost report based reimbursement works for a critical access hospital Is our end of patient care is very small And in order to run an emergency room 24 hours a day I would be lying to you if I said we had a patient in every hour every minute of every day an emergency room We have you know somewhere in the vicinity of about 30 down time in that department and that's probably far away Our our least productive department on a patient unit basis But the fact of the matter is we need to have somebody sitting at that desk We need to have a provider. We need to have a nurse 24 hours a day And we do our best to staff according to Historical usage we literally look at the time of day the number of admissions and where we should stack people Weekends versus weekdays nights versus mornings and we do the best job. We have we can do We have lower the FDs in that department to the lowest common denominator To meet the standard the reason this is relevant is when we talk about getting busier or less busy 87 percent of our costs are fixed so they don't change whether we're busy or we're not so busy And so that's why the cost report is a benefit to the critical access hospital If we did not have such high fixed costs or did not have a cost report It would be near impossible for us to recover You know our expenses When I was a Gifford I was a Gifford and converted us to a critical access hospital in 2001 the The drawdown of federal funds due to critical access was worth about 1.4 or 1.5 million dollars. So that's 18 years ago Um, I would estimate it now amount of scutney and if your number was probably more like a million there if I were to guess Um, now if I look at amount of scutney that drawdown is probably worth 2.5 million dollars So if we converted to a pps hospital We decide we want to operate at 30 beds and gave up our critical access hospital status It would probably cost us 2.5 million dollars right off the top So it's a pretty significant program And uh, which is why we spend a lot of time making sure we understand We don't want to put that at risk. It's it's a huge benefit to the community and to the state It does lower the cost shift significantly Uh, I will belabor this too too long I think the only acronym on this is md and that means doctor But uh what we do is we take all the expenses And we reclass any expenses to be in linemen of revenue We have revenue departments across many different lines of business So anybody who has an accounting background revenue falls expense expense falls revenue That's what we're doing here And uh we pull in uh what we call heart a cost Which are uh md time that is not associated with patient care Being a cmo for example heading up the quality committee things like that where there's no patient care Medicare allows us to carve that out and put that into our overhead We smush all of those together. That's a technical term smush Here and then we take all of the indirect costs like the cfo salary the human resource department And those costs get spread according to statistics across all of the revenue producing departments in worksheet b And then uh all revenues are brought in with their reclasses and we establish a cost to charge ratio So how much did it cost and how much did you uh Did you charge and a ratio was established for cost by department level and an Inpatient outpatient and at a facility level And so that is the driver of cost now all of those things that are unallowed all get carved out right here So they are not considered When medicare looks to see what is your cost as compared to charge ratio And the next page here Well, yeah, I won't be leaving this This is a sample inpatient settlement sheet where all allowed impatient costs are established here and then they are that's Divided by all inpatient days. So they come up with a per diem expense rate That per diem expense rate is then applied against the number of medicare days We add in the allowed costs for the ancillary services for those patients And we come up with a total cost of inpatient services There's a gross up which I won't take time to explain But it relates to our swing bed unit and how that interacts because we have swing bed patients in the same Area as inpatients. We don't say swing beds down that hallway and inpatients are down that hallway We try to push them together because we just for efficiency of nursing Assignments and and then they take out all the patients deductibles and co-pays Establish the cost that we should have been paid by medicare They add in any allowed expense for bad debts that we weren't paid by prior patients for medicare patients And they say and then they compare that against what we get paid all year And we either owe them or they owe us and we settle out And then we have the same calculation for swing And the same calculation for outpatient So before you before you start on this slide on the previous slide you had ccr Yes, cost to charge ratio. Okay Previous clear water rebound And so That's really they pay us all year at the rate they guess our costs are going to be at based on the prior year's cost And and then we settle up For a 9 30 year end we settle up We send in our reports on february 28th And generally they try to give us an interim settlement in april or may this year They were early it came in in april and they've established new rates From then on Effective of the next month And i'm going to skip this is the same essential math, but um What we do at a critical access hospital is we we have one of dante circles of hell And and that is five months after a year and we file our cost report. Well, that's great because you don't have to worry about it for a year Now that's not how it works. We have to test out their interim rate adjustments So when they give us our new rates for the year We have to make sure that we agree that those rates are at least reasonably close Otherwise, we're building a liability Or an overpayment that we have to reserve for immediately And we work those reserves on a monthly basis They give us a lump sum if they owed us money Or they've taken back money and uh, we we do multiple mini cost reports during the course of the year to make sure We are reserving appropriately on the balance sheet for what we expect to owe or what we expect to be paid later We do at least three a year If i had more time i would do four a year Because just keeps us right so we close our books september 30th We've got a cost report to determine if our reserve levels liability Or or receivable have all been Are all reasonably close for the final filing In feb on february 28th of the next year So there is a constant revision of our balance sheet entries And and balances throughout the year to make sure we're not taking risk And all of those adjustments run through our third party liability account which hits deductions from revenue On your on the p&l that you folks see for us Any questions on that before I roll? I haven't seen anybody quite pleased over yet So i'm glad you're enjoying it So again, this is our balance sheet management. We evaluate continuously on open years current years Generally we run two to three years behind on final settlement From medicare The audit process most years is a desk review. We send them our work papers And they review them and they give us a list of questions We answer them by email with some additional worksheets and they call it good Any adjustments that are found or made? This year we're we're blessed to have medicare actually come on site and they'll be doing not only this work But they'll also be counting how many physical beds do we have on our med surge unit? Do you really have 25? or less and So joe mentioned also inflation We we looked because as you both probably know we're we started our budget season and We looked at kind of a high level. These are our p&l line items that We we roll things up to internally and see how we're doing And looking at f y 18 expenses year to date And then looking at the this is through february 28th this data Um, we looked at our group purchasing We looked at wage studies. We got an initial look from our brokers on how benefits are going to change Utilities and and these are what we're expecting for inflation factors Relative to f y 19 budget and they're they're this assumes No change in f t e no change in volume it does Calculating raise of about three percent including market adjustments We are looking at some very Unfavorable workers comp increases again. We have a very small end. So we had two unfortunate cases that are lingering on our liability for workers comp and it's going to result in approximately 40 increase for us In fact while i'm here there's a we're meeting with the workers comp brokers Back at the shop We're assuming very tight increases for a traveler and staffing costs. We do share staff with darmuth not only mds and providers, but also some managers and So we we are looking at about a three three point five percent inflation For next year as we continue to go through the budget process that may get fine-tuned and maybe we'll beat it down to three But it's probably not going to change too far from that. Well, you're on that. That's all we prepared While you're on that slide Explain the bullet that assumes depreciation depreciation hitting annual expectations so every year We So this is what we're going to have for capital expenses And whether it's bricks and mortar or it's software or it's uh equipment for taking care of patients And every year we uh, we fall short of our goal for spending which maybe from your perspective is super good um from my perspective is a little bit concerning because we are We've had historically less than favorable financial results for say call the last 20 years And it's only recently we're enjoying some level of of success And i'm always fearful that we are not staying as current as we need to stay To maintain the quality of our work environment for our patients and our employees whether that's equipment Or or facility needs I really I always get a little bit concerned with that So what you're saying if you tie it back to the previous slide is that The bump the 68 348 bump and depreciation that you're anticipating for this year If you're having trouble meeting your 3.5 percent target then You would cut down on the additional investment in in uh Capital related items that would be one or yes What would be the other as you would look at well, I mean we've you know, it's kind of funny I was looking we're in touch process and you know, we look historically at what we've done and have those things worked out or not You know, but everybody had great cost savings ideas But then you kind of get a year or two out when you realize they didn't work the way they were supposed to or Maybe they put additional pressure on the system that you did not intend or expect and you have to back off of those things Generally speaking, I mean we have beat down our our interest expense We are on darkness group purchasing. We're not going to get lower prices that we're getting through there We've been very True with benefits we offer our folks and how we have structured Those benefits to make sure they get everything they need But that we're able to Get on that we are behind on labor Compared to the state our average wage and so we we have really We're not living, you know, fat dumb and happy on any one of those line items And we beat them down pretty aggressively every year To try to stay competitive and to do what needs to be done for the organization as well as to meet the state expectations so on the interest expense line where you have the Approximately 76,000 you've got the identical amount Um, I assume you must be paying down on principle. Does that mean that you would be I I have a really really good deal And uh darmeth was able to help us leverage that deal I have a fixed rate For infinity at this point Which anybody would die for right now And uh, and so, uh, we're we're not going to refinance So, uh, we have no plans to do any additional financing We may have a lease or two for a piece of equipment, but nothing material But but does that mean that you're never paying down the principle? You're just paying interest? Yes, we are okay, and that was the term of the note and It's actually so beneficial It's it would be ridiculous to pay it down Okay And with interest rates expected to rise that's probably a good position to be in we are in a great position In that regard and again that was something we were able to garner with our relationship with darmeth that we probably Would not have been able to get So you've talked about the expenses that you would look at to try to live within that inflationary target um If after all that Your next move would be to shift to commercial payers, correct? That's uh, generally how it's going to work out if we are unable to meet Your expectation from a budget submission standpoint and the needs of our board of trustees and doctors from here We're kind of juggling three sets of expectations You know and that's great when everything's going well and everybody's thinking the same way But we find ourselves this year going into the process saying boy, we have some divergent expectations On our facility and we're not entirely sure how we're going to make everybody So what's your trend line look like for that cost shift as far as a percentage of shift? Well, uh as of right now, it's too early in the budget for me to project that But going back over the last five years or so, I mean All right, is your cost shift staying stable or are you increasing your cost shift each year? We're increasing it. Uh, what I would call classified as slightly So, um, you know, we're we're really trying to bend Since I've been there been there five years now We're really trying to bend our pricing structure down into we're a little bit of what we are We're expensive on many issues and the items, uh, but um, we've been trying to bend that with our price increases Bend that down get warranty lined with the market And the advantage of being a hospital like we are for Black's hospital high Medicare Medicaid For a lot of services. It doesn't matter what I charge because those are, you know, heavily utilized by people who pay me fixed payments So when you're doing that analysis, you say you're expensive for what you're doing What benchmarks are you using? Who are you comparing yourself to? We have, um, uh, a piece of software that came with our EMR That gives us with about a one year lag National averages that come out of the Medicare gross charge Medpar data And uh, and then we also benchmark against Act 53 in some other world local regional We do secret shopper sometimes If we're looking at it, we have a patient complaint on a particular Uh, service, uh, we'll we'll check some websites and make some phone calls and see, you know, how how legitimate is this? We can't always fix that but it's good to know where you stand Are there particular services that you really feel you're out of line on or you know? We're actually a little bit low on inpatient if you look at Act 53. We're actually Pretty decent on most inpatient services Outpatient we struggle Because that's higher commercial so historically a lot of that got shifted And that's, you know, no one got where they are in the day This has been, you know, since DRGs and whatnot were introduced in the 1960s. This has been an ongoing Slot and so we're trying to do our best to As we perform a little better to Bend our price curve And try to keep ourselves ourselves competitive You know, I the simple example I gave a patient the other day was if 50 percent of the people who walked into Walmart to buy a toaster could get half price or less The toaster would be a lot more expensive next year And uh, it's no more complicated Yep, okay So, uh, one comment I think it's really the biggest bogey on the radar screen for critical access hospitals and for long That's how we reconcile our cost-based reimbursement with the all-payer model We haven't been able to get a straight answer from CMS for at least two years now that we've been fishing in that pond And I'm on the board of one care too and Have been trying to push some of our finance folks to also help answer that that question Um Right now the response from CMS is don't worry about it. It'll be fine. Just keep doing your cross report It won't be penalized based with fixed fixed payments fixed monthly payments through one care As you all know, we've got our toe in the water and Medicaid For my Medicaid next gen this year I will be working to nudge our board To agree to go to all all pre-risk programs for 2019 But we're flying blind on what that would mean for our Medicare cross report And I think anyone that tells you otherwise is Is At what type of time interviews intervals do you take an internal look? Um, especially if utilization is declining and saying are we the right size Do you do that annually or Right size as far as the services that we're offering correct. Yeah So I would I would say from my perspective daily Because we get a dashboard that comes desktop every day is how many patients have come through the clinics How many patients but there's got to be seasonality too. So yes, there is we spread our budget seasonally and Um The interesting thing is that on the inpatient side We we have generally over the last several years budgeted, you know, 19 to 20 average daily census for med surge And eight four for our rehab unit And we're pretty much right on those So we we've nailed that we don't have any variants We may have a day or two in a month that's low or whatever, but generally that's right on Emergency room has been fairly consistent over time Uh, they're you know, and you've heard so I won't go into it, but You know, we have, uh, you know providers who leave For whatever reason and if they're the only one of their kind which is pretty typical in a critical access hospital It puts a lot of pressure on us and all of a sudden now boy Are we the right size in our radiology lab because we lost that provider and their associated volume So, um, we do look at it We just had a meeting last week as part of our normal budget process Where we sit a number of senior managers and key managers in the room and we look at our foundational volume assumptions How are we doing in the clinic this year? How are we doing in inpatient? Are we meeting what we expected percentage of swing bed versus acute patients? We look at all of those things and arrive we look at three years data And we try to arrive at assumptions that will drive the rest of the budget And uh, but I guess to answer your question directly I literally look daily and if I see a trend that continues Then I grab the department head and we sit in the room and we figure it out um I think we right-sized when kevin donovan was here And we made some pretty significant adjustments. We closed our our nursing home We decided what we wanted to be when we grew up and that is community based care swing bed services community based inpatient and and rehab as a regional facility wish it is And and those have pretty much held true. We we haven't buried too far from that And uh, the volume is a little bit lighter in the clinics than we would have liked the last few years Because of provider transition and whatnot, but the rest of the hospital seems to be where it needs to be size-wise But I think it's a good question So you I think I heard the number 2.5 million would be What the loss to you would be if you lost the critical access designation All right If if I took that number and went against your gross revenue Would that percentage be similar to the other critical access hospitals in the state or is there A lot more intricacy that would have to be there is more intricacy But I think we could spend a lot of time on math and I don't think it's that bad a guess Mainly because one of the key drivers to that money coming in was physician practices being owned by the hospital And so since most of the smaller communities here, that's the model. That's the only model you're able to function because Docs aren't interested in hanging their own shingle in many cases That would be if they don't own as many Physician practices that number would be less relevant Okay questions from the board Well, thank you for the presentation and I oh as always I learned a ton and folks come in here and give us these deep dives So I have an economics background. So my world is yours is spreadsheets. Mine is incentives So I think about incentives all the time And I understand the motivation of critical access hospitals came about at a time when rural hospitals were closing and there was financial Insolvency and the need to have access to care in these in particular rural areas And but at the same time And I understand, you know, you talk about cost to light and the 99 percent reimbursement rate, but With a cost-based reimbursement, even if it's cost to light based reimbursement compared to a prospective payment system It seems to me there's less incentive to be cost effective or cost efficient as if you're in a different kind of payment model and in fact There is research out there. So I you know the geek is coming out of me but research out there that critical access hospitals are less cost efficient than similarly sized rural non critical access hospitals And in fact that the the cost inefficiencies get worse over time So if you look at one critical access hospital over time and you measure that but it actually, you know There's more cost inefficiencies over time So i'm wondering how do we balance or think about the incentives weighing the need to make sure that we have You know access to health care in these rural areas with also particularly as where we're moving to vermont with the all-pair model This need to be most cost effective cost efficient and really trying to make sure people are getting the right care at the right time At least cost away, so how do I grapple with that those incentives? I think I think with wide wide variation Just in the critical access hospitals in vermont Dave mentioned earlier we over the last five to six years we've figured versus Just prior to the dh affiliation in the years following that it's been a lot of time to figure out what we were going to be as an institution We We have a laser light focus on expense management. We look at our empty ease full empty ease for the institution Every week the spotlight is shown. I'm seeing we are responsible for his or her empty ease We don't have For the petings or neurosurgery or the other service lines that other hospitals can use to cover up their warts Which that's really been the model of small hospital finances recruit a few other peting surgeons and live high in the hog for a few years until They get tired of taking a call every other night and leave and then your finances crater I think you made a conscious effort to move away from that so The chairman mentioned you know if we can't stay with it, uh, you know Stay with it our our budget targets We can we don't have a service to cut we don't want to say Well, we're going to let those primary care doc We're going to let go of 1.5 judge surgeons that we have that manage our entire surgical population in our end of Windsor Kelly I think to get to your point there are ways that many hospitals cover up their their cost inefficiencies and it's with those hot low volume high reimbursement service lines We haven't had that luxury You know the hope is that any special service line that we get is with We have central coordination the dark pishcock to get a day of a surgeon or a day of an oncologist because that's what the volume That we see again in our part of Windsor county would would justify We gave up If you build it they will come model for for buying in in patient care because we burnt too many times And so I think that's at least from a scutiny. Yeah, we we are unable to cover up our our inefficient rewards You know, I had the story I tell and hold it at DH to the talk yesterday was Uh, someone went out on our so we have a very small supply chain department two two and a half people and they were out and Dave had to unload some trucks and Working the overnight shift on on saturday my chief operating officer, you know pushes wheelchairs around Without Asia We're pretty lean pretty flat And again, we've had to be that way because we haven't had the luxury of a repeated group or Specifically in our negative woods. There's a neurology neurosurgery group that helps keep the number of hospitals alive in the upper valley They they don't work with us God knows what historical reasons before I got there Um, and that's okay. I think it clarifies what we need to do each day on expense And I would love to tell those stories could be uh I I uh I know who took The words that always get banned me about budget season is very realizing deficiencies and um There actually was one more slide that for some reason did not get in the email that I that I sent you yesterday I know that's right. We have had a rough stop part of our affiliation with the Take advantage of the efficiencies gained by the impartial of these issues. So supply chain lab services radiology pharmacy Early in hr five big Some of our if not fixed costs, but they are high costs that never really go away We we have realized some substantial savings We've also So in our printed version of the slide decks, we do have the two pages that you don't have We have the inflation continued and then we have your challenges page, but since you said you were finished I figured we don't I do want to say one of the two I I've not seen what you have read and by the way, I do I know what it is and I'm very I'm very personal but um That that said, um one of the things and this is what I got to Gifford and and Sorry explain this to people they didn't get And um and I've gone through the same learning group with much of the management I'm out of scum But if you if you say I have I'm going to cut a hundred thousand dollars in expense that I had last year Okay, I don't care what it is paper clips people Benefits it doesn't matter if I cut a hundred thousand in theory I'm only getting $50,000 worth of benefit on that cut because I'm losing Medicare cost Which I think somewhat proves your point right so people like well I'm only getting half the game right for for doing the right thing. Why would I do that? But the the the other side of the coin is That you can unnecessarily inflate your expenses and not get the return also And it all boils down to Whether you're a good manager In a conscientious human being or you're not just like it is anywhere else in any other industry And I was I was showing joe yesterday on a related subject That when I got there, um, they had 10.8 fte's in the medical records departments We're currently operating at 5.2 We have better numbers better results Uh our quality is way out compared to where it was five or six years ago And and guess what I did I said I can cut these five fte's in a graduated process over the next two years While educating the base folks that I need to do the job So that they're more competent and more efficient and will leverage the technology We just put in we just spent three million dollars on And at the end of the day, you know, we cut hundreds of thousands of dollars from an overhead department With literally, uh, I would say no impact, but actually a better impact We're doing a much better job today than we were five or six years ago Um, I lost money on the cost report But at the end of the day I did the right thing and and now we don't even think about it. That's just the way we live and so Um, there's a company called ams that does a lot of productivity studies For hospitals healthcare in new england aren't early And we did a study with them a couple years ago and I looked at it read it laughed and threw it out because we were below them You know below staffing levels on virtually every single department Uh, and they'd say every single department and and I was like see, you know, but you could bring that to another hospital They might not have the same result At the end of the day it boils down to how does management want to run And and I'm happier to pay fewer people To do better work and pay them a little extra than having a lot of people unhappy doing poor work Let me just I'm going to put you a little bit on the spot here, but with a follow-up question. So, uh And I appreciate that you would be willing to make those choices In spite of the fact that you would lose money on your cost report and doing so I'm wondering what would be the metrics that you would use if you were if we were to reverse seats here And you were to be sitting here and looking at hospital budgets What are the metrics that we should be looking at as a board to identify the hospitals that are really cost-effective? What are those metrics to show cost efficiency? So My problem when I come to hearing here There we go My problem when I come to hearings here is is What you see is what you get with me for better or for worse Mike davis whenever he had something he couldn't figure out or wasn't sure he wanted to do the scratch and sniff on He called me because he knew I would just tell him what the deal was I come here as a cfo a consumer A taxpayer a parent I bring the whole you get all my baggage okay, uh, and uh If you know you said what things you look at well, you know, um, I think you spend a lot of time Looking at things you either can't change We can't change Um, I think there are some specific areas that I would look at Productivity would be clearly one of them. I don't think the submission that we provide you folks Speaks to that It's too high level. I don't think hospitals have the bandwidth Even uvm doesn't have the bandwidth to do a productivity study every year for you folks Um, so I think therein lies the problem Um, you know the only department that works for me directly I have clinical and financial departments that report to me The only department that I did not carve fte's out of in five years is the accounting department Because our recordings gone up Our reporting requirements have gone up and they've gone from six to 5.8 fte's over five years and and so my Most of me says well, I think there are some productivity things that could be looked at They get really cluegy in a ca h Because of the low end they're a little bit more relevant at uvm But I don't think any of us have the bandwidth to take on another 30 day stuff Which is really what would The two that we have done since I've been at mount escutney have been Shut somebody down for for a month To to produce the data Validate the data deal with the exceptions figure out what the right answer is and move on That's a big one And it's probably the best one, but I'm not sure any any of us could walk out alive when it was I think we would just be exhausted I think there are Opportunities, but they would need statewide opportunities credentialing enrollment costs. I mean things that have no value to a patient Or to a consumer and are just things we're doing because we have to do Um, and they don't nobody follows up. Nobody asks us. We keep producing the report Every every place I go to if you guys you guys look all about my age give or take and If you're young, well, we all know who ccr was so But you know my first thing I always inherited it every department every possible I've worked at except for amount of scutney actually and First thing I did was shut off all the green bar report I said print them just put them on the floor Because I want to see people actually looking at these things and if they're actually doing anything And if they actually have any benefit and anybody who didn't say i'm missing my green bar report in the 30 days We just stopped producing it because it's just a waste of time and money and resources and So, you know, I think I think you got to find five things to manage and management Price might be one productivity might be one I you know, I I had a document that I kicked around for 10 years here Unloaded at five years ago when I went to of these are five things I would do if I were in charge of the world relative to healthcare I had legislators come to my office and I spent two hours with them I said you can take 50 million out of this system like this and nobody would know Which is a good thing everybody would still get what they need and we get rid of the nonsense So I can tell you spent time with uh, joe wooden Yes Some would say too much time I spent 17 years of my life with him. Yes Thank you Any other questions If not, we'll open it up to the public Dale You're going to have to speak loud deal for them to hear you. Okay. Um, can you hear me now? Yes Okay I'm looking to see what page it is because the one the cost report continued allowable bad Yeah, 156,000 Do 93,000 And I was curious a little more What happened in terms of to Something changed and just because something changed in definition Or Yeah In this pretend these are actual real numbers from a prior year So it did go down from one year to the next and basically what we do is We take total deductibles and co-pays They were not paid by Medicare beneficiaries and any secondary insurance that they might have And uh, and then Medicare make sure we use good due process To build those to the patient and if they've gone so long then they like they allow that as a cost Okay, and year to year, you know, some people as like the The dual eligible so Medicare and Medicaid Folks, you know as as some of those programs have changed and covered more deductibles and co-pays for patients those numbers go down Likewise as those programs might get cut then those costs would go up. Can I do one quick follow-up? Sure Since it did go down. Did you also though feel that well feel is kind of subjective? Yeah, I guess I'm asking subjective Do you think the quality of care was also Something reflected and those patients that was helped in that way like the quality care went up for them So because they had better coverage, they received better or more services. Is that what you're saying? Doesn't happen to more services. Was it a better outcome? Yeah, I don't I don't think I could I could state that one way or the other I think our patient complaints and concerns has been pretty consistent year to year to year regardless of finances But And I usually do get involved in a lot of those complaints If you send somebody a bill and they have any problem at all, they're very apt to call I don't send them a bill. I might not hear from them But I generally will hear from them if they have any issue at all, whether it's the doctor or the nurse or the amount of the bill So they're pretty consistent the phones are pretty consistent with feedback So I don't have any sense that that has a Any effect on on the patient experience relative to care And I'll add to that Dale as a As a doc who sees patients that every encounter starts we are we're payer agnostic I Don't dig into the EMR to see who's paying for what that discussion does come up though It comes up if it's often patient driven if There's a recommendation for a CAT scan for an MRI often times patients that are to say I I've got I've got a significant co-pay or co-assurance or on a pocket maximum and then That does become part of the discussion on you know, what we do next But walking through the door walking into the patient room It's it's agnostic to start It's hard to find out in our EMR. It's very complicated. I don't know if I could figure out if someone was on Medicaid and Medicare at a glance It's challenging which is again from a physician perspective. I think is a good thing Other questions, Sam Mr. Chairman, I just got a comment a comment on that a question Comment is I've been in meetings like this since the middle 1980s Sorry, and it's the first This is one of the first presentations. I've ever heard that touched on what I think is Possibly the single most difficult problem that we have managing in healthcare in Vermont And that is what you're calling the High cost low volume sophisticated services and cover up the warts Um, I think that if the uh, that if this board is able to get at that issue that it will Succeed admirably and if it if not not Thank you. I just but my question is this the I'd like to just ask you whether if if you didn't have this requirement As part of the critical access hospital or what? formula That you had to have a 24 hour ER Would you have a 24 hour ER given your proximity to Dartmouth and given also the problem that And given also the problem that even if if your if your your er is open That unless the the problem is fairly minor And if it's a serious problem like a big car accident, so you're going to have to get to Dartmouth anyway So i'm just questioning whether you what you think about that and I'd also wonder if you would have any idea What percentage of the ambulance runs that operate in your area? Go to you as over against Dartmouth depending on what's in the ambulance So, uh, i'll start with the last point first, uh Our local EMS group has a few have a few conditions that are passed by Make this go straight to DH if there's a strong Um Suspicion important to keep stroke if there's significant polytrauma from say an accident on 91 That said one of my overnight shifts last summer we had a guy come in with a separate leg on a motorcycle accident number five I was dealing with that maybe not the best idea for an internist and But but otherwise ambulance companies bring to the closest available emergency room So we we get significant MIs we get less than catastrophic strokes We get folks that are accepted and what we do is we we triage them We start the necessary care and then if it's not something that we can turn around and we can be Then we do just we send them up to dh is a Very quick process But because we've had to keep our er open 24 hours a day seven days a week we had to invest In telehealth options. So if you're sick and come to our ed you get wheeled into one of our our Trauma rooms And you hit a red button that a big screen pops up and you have a An emergency room doc the emergency room nurse from dh to help with the benefit of that patient But we staff our emergency room with physicians assistants who work at concert with the folks from dh So again to get back to what davis saying earlier. We we've Shaved cost as much as we can and we could double our ER costs by putting in Emergency room doctors 247 and I know that some critical access hospitals in bravado have done that but given our volume Of 4700 to 5,000 ER visits a year the only way we keep that open Is by staffing with PA's and having telehealth support I've been an advocate for extending that to All of the affiliates with a dark fish cock as well because I think that makes sense I mean it my critical access hospital Should be able to get by with a well trained ED trained staff of PA's with telehealth backup, which is a lot to the A lot more affordable than board adopts And uh, I I agree with you. I I I think the the explosion of these high cost high tech high reimbursement procedures operating suites top to death the cost curve Happening on the picture lens and that's part of our our close to each affiliation's life is We don't have an ENT anymore and we don't have orthopedics anymore We don't do any OBGYN We moved services to To jump a fish pocket. I think it works because if you If you have those services you also pay those physicians And they can't I can't keep a cardiologist busy. I can't keep a joint surgeon busy enough Again, it'll cover up the warts for a few years, but eventually that tires and they come on And then you're right back where you started So as a follow-up to that question when you mentioned the 2.5 million dollar figure that you would lose What is that net of things that you wouldn't have to do? If you weren't a critical access hospital No, that would just be the loss of critical access hospital. That would be same businesses yesterday No cost based reimbursement so Say that uh, you were to lose your critical access status And you didn't have to do the things that were necessary to meet that status. What would the dollar figure then be? I off top my head. I couldn't tell you But you know emergency room is a subsidy if you want to think of it that way. Yep Primary care is a subsidy Most of the clinics are a subsidy Impatient is not a moneymaker Impatient rehab is break-even So you see it's a diminishing return very quickly and and and you know again we staff efficiently on impatient Because our census of 20 works for a 4 to 1 ratio a 5 to 1 ratio they devise nicely into 20 And you know, so there are areas that we've been as efficient as we can be Without putting patients at risk or staff at risk for that matter and If the numbers just happen to work out for us in a good way that being said You know, uh, it would be really hard for us to look at our Our Codry of services and say well, here's two we don't need or two we shouldn't have ER might be maybe the only one you could live to tell the story on There would be huge community Disappointment and I'm familiar with some other hospitals who have closed their ER and it's never gone well And some of them in fact have reopened But that's really the only obvious one that's not, you know, maybe we don't absolutely have to have that In the aco, you know a lot of the services being asked for the ER are subsidy based services In order to provide the care expected And and that's a problem. That's wrong for all of us. Yep Other questions or comments from the public Yes, just really quickly I wanted to say to the board that I had said we would get an american hospital Association person to come do some of this presentation And they declined to do that because they just don't testify at states, which I didn't realize was kind of a policy So I think that uh, dr. Paris and dave did an outstanding job explaining a complicated reimbursement apparatus So I thank them for their presentation. Um, I think they did an equally not better job than the aj people I was free Okay, with that I don't see any other thank you. Thank you very very much So Susan do you want to introduce our next segment our next lesson in health care financing comes to us From the fqhc the federally qualified health center We're going to hear from georgia maheris first Who is going to give us an introduction? and an overview and then we'll hear from allison caldera from the ceo Of community health centers of berlington and jave simons for cfo from the community health center of berlington So Thank you. Thank you for coming down from the berlin Thank you so much. Um, I'm going to do a brief introduction and then turn it over to allison and dave The information you actually want here I just want to know if we can send you over some additional slides that we're not going to put out that Just some background information before you walk. Um, and also, um, We view this as the start of a conversation So it's a bit higher level than the previous conversation But uh, similar to any cfo dave can go down any track you want any death you want Either now or in the future And additionally wants allison and dave are done. I'm going to talk a little bit about A hybrid which is an f2hc critical access hospital merge entity But I think it's better to talk about that after we have this part of the conversation Thanks Pointed to that laptop in the corner We are federally qualified health center We are the only federally qualified health center One of the things that I always think is interesting about the health center is how distinctive we are richly distinctive in a rural state uh, the health center is diverse Our main at our main facility and on riverside avenue 18 percent of all folks that walk in the door any given day are limited english speaking And that's pretty astonishing I think for For such a state as vermont We are also the only health care for the homeless federal grantee in the state of vermont We received that federal funding in 1988 And remained the only f2hc in the state of vermont that holds that funding Last year probably about 1500 people came through one of our eight doors and identified as being homeless Or marginally housed and as you'll see when we get a little bit further into the presentation that The needs of the homeless in the burlington area inform Our services, so that's one piece that really does distinguish us from the other f2hc The other piece that I think is always really important is that we serve The burlington area chitney county's other grand isle county serve 25 Of the state's population. We are the backbone safety net fqhc for a quarter of the state's population I like to think that I am uniquely qualified to talk about not all four decades But a good number of them and I think that one of the reasons that I really like to show this The slide is to really tell you that I I feel like I'm a first-hand witness To the power of what can happen when a federally qualified health center gets funded for the first time This is ongoing sustainable funding in the form of our grant When we first became a federally qualified health center in 1994 the grant that we got was $154,000 a year Now it's over three million dollars a year And we have earned that through competitive grants over the years and through demonstrating the needs of our community And demonstrating our ability to deliver So I think that the other piece that one thing I will say is mental health and substance abuse counseling If you look at we became integrated Around the third to fourth decade and we'll be talking a little bit more about that but that is also something that I think is Very unique to the health center But this trajectory of growth that you see as an fqhc here is very typical You start as a free clinic and then you grow over the years and you grow as an fqhc, but you grow The needs of the community As I said that we are virtually distinctive as an fqhc and I think a couple of things that A couple of things that I'm going to just pick out here because I think that it it again as an fqhc Really shows how to respond to the needs of the community and some of the more Robust programs that we have that may not be too familiar with I think the first and foremost is our access to At the health center. We have 2.5 fte's of psychiatrists. They serve all ages We have four psychiatric nurse practitioners our goal in the psychiatry program is Access every day And to meet that end we have to walk in access for psychiatry every day And I want you to think a little bit about that. I know that we've probably been hearing many things about lack of Access for mental health in the chitin county area that I want to be here to tell you That we certainly are creating access On a daily basis and I can tell you that people walk into the health center Who need a suicide plan a safety plan? And we are there to be able to support them and to be able to provide that help No small thing The other thing that I think is quite Different in that I will say that all fqhc's are required to provide dental services That's one of the services and our lengthy list of requirements as an fqhc Our dental program is Quite large and reflects the needs of the medicaid population in chitin county We have 7,000 dental patients 7,070 of those folks are Medicaid enrolled And probably would have difficulty finding particularly with adults Finding easy access to dental care in our region We also provide a school based dental center that's just for low income kids again That's something that's met that was built on the needs in the community I can tell you and who we started that clinic in 2004 I think there were a lot of us that were thinking why why do we need this there was It it didn't seem that Profound and I can tell you after that first year pulling thousands of little teeth In the burlington school district I think we all became converts And now we have over 700 kids that are being seen in that school based dental center And the beauty of this program is that the kids come into school And if they are not connected to a dental home If they are not receiving regular dental care, and if they are Medicaid enrolled in low income They are the only kids that are allowed into our clinic So if they are not receiving that care, they will be allowed into the clinic And I think the fact that there's over 700 of those kids speaks Quite soundly to the need that we have there So I thought that it might We can talk a little bit about how these programs are funded But I also think that it's important to talk about collaboration because that is a requirement Of a community health center and of an fqhc. We are required to collaborate collaborate We're required to be part of the community and be engaged and integrated with the community A really good example of this and I talked a little bit about our homeless program is that state of Vermont Several years ago in the chitin county area. I was finding that that they were providing motel vouchers For people who are homeless on cold nights. It's called the cold weather exception And these costs were very high in the chitin county area It was very clear that there needed to be not only was this a poor investment In terms of ending homelessness and to bringing people into care and treatment Which is really ultimately what someone needs Who's living on chronicling homeless and living on the street They need to have a low barrier warming shelter and a place to stop So they could get in off the street, but more or less if they could also be connected to services This is a better model So the health center and I can tell you five years ago I never would have dreamed that I was sitting there telling you that we would be One of the emergency larger emergency shelters in the city of Burlington Well during this last winter we housed 38 to 42 people a night in our low barrier warming shelter And this makes economic sense. We are contracting the state to deliver the service From November 1st to April 16th, and they're looking at this has been so successful. We're looking into a year-round Shelter We have a new medical respite partnership with the medical center hospital of Vermont This has been a Easy simple intervention, and I'm sure that it's not something maybe you hear very often the words easy and simple Well, I'm having to tell you there. This was easy and simple The hospital knew that they had folks that were languishing in hospital beds People that did not need to be in the hospital But could be discharged if they had a place to lay their head in a safe place to go They came to the health center. They came to Champlain housing trust, and they asked us to staff 24-7 for medical respite beds in a converted motel on Shelter Road called Bel Air And we now have a services contract with them and we provide 24-7 care And we have four people right now that are in those beds that would have been in the hospital We have folks that are currently homeless that had no place to prepare for colonoscopy Think about that you've ever had one Think about what you need in order to be able to prepare for colonoscopy Simple a bed and a bathroom people there to be able to take care of you. We can provide that I'll also tell you another just a quick story is that we had an outbreak of flu In the morning shelter and we literally were able to Put all these processes in motion and move out the person who had the confirmed cases of flu And move them into medical respite We had another gentleman who just walked into our safe harbor health center The other day who looked like he was yellow from head to toe Not unusual to see someone in who's been avoiding care And he came into the system Obviously with some sort of liver failure. We're able to put him in stabilize him and get him to medical respite All without getting into the hospital and for the cost of us the contract between us and the hospital right now is $50,000 a year Simple cost factor Yeah, right Pretty good. It's what an FQAC can do Um, the other thing I will talk a minute just about psychiatry because um One of the things that came to our attention About six or eight months ago was that the pediatricians in the community were facing long wait lists to get kids that they were caring for um psychiatric consults And since we were fortunate enough to be able to recruit a harder trained Psychiatrist who also provides care to all ages Once she came on board we started taking kids from that were not our patients Which is unusual for us But we decided that the community need was so dire that that was some place that we should step up to the plate That program is now now happening and the kids are getting consult and I understand it's working. Well I'm happy to come back and give you an update on that when we're a little further down the road We're also doing a pilot with vna Judy Peterson who is the cpo of the vna company Uh asking about How we could get some psychiatric care into people who were homebound People with chronic persistent mental illness Her staff are feeling overwhelmed dealing with the complex needs of these patients. We're now sending a psychiatrist Um, this is a community benefit program Funded by the community benefit to the vna and they pay us More I can we can stay tuned on that too, but again simple meeting the need One of the things that I felt was really very important to talk about and again, I can speak from first hand experience to this were The accountabilities and responsibilities and the compliance requirements of being an fqhc Uh as a person who used to do a lot of this regulatory reporting for the health center It is demanding it is robust and it is never ending We are required to write a grant It becomes come every year Every third year where we're required required to do a complete community needs assessment and basically it is competitive We can lose our grant We haven't and we won't But it is competitive So it's not something that you get the fqhc status and you can rest on your laurels Every every in between the three-year cycle of your competitive grant There is a in-person person site team that comes on site They audit your 19 program measures or your compliance manual and I believe that georgia has thoughtfully provided the compliance manual to you and uh Believe me they go through every everything that you do in Excruciating detail, I guess is the way that I'm putting As an example the last time that we had We had Several action items that we need to respond to things like our sites that were listed In the electronic handbooks We needed the sites were not correct the nursing homes were listed That was an action item And a compliance issue that they were not the right listing So it is that there's a lot of attention to detail that I do not think that people are quite aware of We have 16 required clinics with clinical quality measures that we must track We must report and we are benchmarked with other fqhc's in the state of Vermont and other fqhc's across the country The quality piece speaking of someone who's been part of fqhc for a long time Is becoming much more demanding and much more rigorous and we welcome that We are Really paying good attention to our reporting. We are checking the boxes We are a patient centered medical home level three at all of our sites I think that studies show that fqhc's provide excellent quality care We are happy to be benchmark to demonstrate this The other thing that I think is important is to understand the role of the board and the oversight that our community Majority board has yes, they need to be a majority of patients Yes, they need to reflect the community. There are some other courts in here too For instance, there is a requirement that limits the number of folks who can sit on your board Who get their income from health care? So we can't have a board of physicians We have to have a board that represents real patients from our community I think that's actually pretty remarkable When you consider how long this this model has been in place It's a it's a grassroots Look at how you assess community need Our board actually has control of details Like when are your hours? If I want to change hours at my Pearl Street Youth Health Center where at-risk kids are able to access walking care I just recently had to go to the board and explain why they made to change that The hours from 10 to 5 to 10 to 6 They had to approve that, you know why? Because if we are changing things that may Limit access in the community they want to know about it and they're in charge and again I think this is something that is Part of the model that binds all the FQHCs that I think is really important In terms of what we are accountable for So why? well I think one of the things that I can say and I think I can say this as a multi many generations frugal thrifty vermoner This saves money This is proven this is a model that I cannot tell you how many times that I have seen We had kept someone out of the hospital That our hours make it easy for someone who can't take paid time off of work can walk into access and primary care This is a investment that pays back And Georgia I think has some In the legislative day materials and other by state materials has some studies that just recently came out There was one I believe it was the journal public health Don't forget we're a major employer The health center employs over 300 people At eight different sites There isn't anyone in any one of our sites that earns under $15 an hour That is a commitment that we make to our community And the other piece says is that we got our start in the old north end of Burlington For those of you that are familiar with that area is one of the poorest areas in the state of Vermont We now have a beautiful facility there and we hire people from the neighborhood And people from all areas of chitin county It's important So I think I just wanted to say that you're designed to respond to and be part of the community we drive change from patient experience And we focus on reducing this barriers to care That is something that's shared every after you see mom And that is something that every after you have seen state of Vermont is responsible for So one of the things that I can tell you is that federal grants and expansion opportunities have been our life one at the health center for Certainly since the time that I've been there which has been over 20 years A way to grow your programs is through competitive grants and expansions These are competitive. We compete not only in Vermont. We compete across the country In 2009 The health center was the recipient of a 10.9 million dollar grant That allowed us to rebuild our building on Riverside Avenue from the ground up That was one of the most competitive fqhc grants that I've ever been I've ever participated in I believe my memory serves me. I think there were only 60 across the country And there were something like six or 800 competitive applications But we're competitive because of the needs that are demonstrated in chitney county The diversity the needs of the homeless They'll lack of access to care things like 7000 dental units that need access We can make the case and that's why our our grant has grown from 154,000 to over 3 million million dollars over those years And I think that we're going to speak to the Medicaid reimbursement One of the things that I will say is that we seem to do spend a lot of time talking about this And I know that you and Dave will get into the exhaustive details about this But one of the things I'd like to say is that it's a great value And I think that that again, that's been treated by the studies and demonstrated by the Robustus of our program. We are specialty primary care I like the way that Dave describes him And he can I think he can speak to this very well being someone that had worked for Been part of a hospital system for many years is that we are midway between Typical primary care and hospital We're required to take people who walk in an emergency But if someone walk in with an abscess in their duty Well, we need to take care of them. We can't just send them away This is proud of our accountability One of the things that maybe is not always common knowledge in the fact that we are all of our employees at The community health centers in Maryland and all of QHCs are considered federal employees Uh, at the health center, we have an OB and prenatal care program that cares for Let's say about 160 medically underserved women 70 percent of them are refugees Many of these are women that need access to support services that we provide I know example of a woman that has kids at foster care Someone who's coming out of our opioid addiction treatment program Someone who has complex mental health issues It's important that we provide a reprogram OB malpractice insurance is extremely expensive We are able to provide this service because we get FTCA malpractice insurance to the federal government Do you know how that would compare to what others would be paying? Is it a Georgia saying over $400,000 a year and I think when the last time we looked at that that seems about right I can get you that number for sure, but It would be out of reach for us And access to 340 b again day will speak It directly to what that means in terms of our closing the gaps that we have But We gave 3.3 million dollars in savings from the 340 b directly back to patients in 2017 Is that 3.3 your total savings or using some of the uh, that's just to the patient That's just what went to the patient. So you're using it as part of your revenue stream. Yes They will give you the numbers about that and go through that. Okay. This is this is in savings to the patient Imagine this this is a patient that has no coverage in their medicare recipient. That's in the door This is someone that does not have coverage for a particular Prescription, this is someone who is uninsured or that lacks the prescription coverage. This is someone that was able to access prescriptions through that program When we asked for this number, I'll tell you we were surprised This is significant Now but now the good stuff Uh, you know, I don't have fancy slides like Dave did but Well, basically what we do is show that 71 percent of our income does come from patient revenues Have that mix. It's basically 36 percent is Medicaid 27 percent is Medicare 34 percent is commercial insurance self-pay or basically uninsured patients And Dave can I ask you the same question that we asked the critical access hospital? Do you have information that would show what what that is for your margin at the center in a sense? Yes, okay What we do is we look at our pps rate. Our pps rate was actually established by this effect in 1999 It was put into effect in 2002 What we look at is how much that reimburses compared to our encounter rate Everything that we do is based on an encounter rate For the most part labs are excluded from that dental is excluded from that from the medical side to behavioral health side It is long encounter rate base What we look at is we're using our cost report We file we look at what our cost is for providing each encounter and we look at what we're getting for a pps rate So in this case for Medicaid, we're getting about 84 cents for on every dollar that we spend in reimbursement for that For on the we if you look at Medicare We're getting about 80 cents on the dollar for reimbursement and on the commercial insurances We only get about 56 cents on the dollar for reimbursement. This is where all of our funding is coming from As far as our patient income and what that then does it says that really we don't get in bottom line Or an operating margin of money or payers this way We take a loss in everything that we do Uh the south pay pro game the three percent Those most of us are on the slide. Those are uninsured patients are usually 200 of poverty or less Or we just charge a nominal fee So In that sense, no, we don't really have any margin that we're getting from this So the question is how do we get reversed or how do we get paid? How do you help me understand that commercial line? The partial line. Yeah, we are just like We get pts for medicare we get medic pts for medicaid But on the commercial line is just like as dave sample talked about we get the fee schedule This is a physician fee schedule. Those are set by the commercial insurances Sometimes they increase them sometimes they don't this year We haven't gotten any increases from any of the commercial insurances So we are stuck with whatever they decide is going to be the basically what they're willing to pay us And that's only about 56 cents on the dollar But we cost us to provide that service Do you know if you're getting the same reimbursements as others who are providing the same service? I can't say for sure because those are kept confidential But my understanding is that I think they're all pretty common to the same rate For blue cross especially Okay, and One of the things that we have found over the past few years two years is that our mix has changed tremendously With the couple new practices that have part become part of the fqhc Our blue cross our commercial base is growing considerably and that's actually hurting us financially It's a nice tab of distributed amongst different payers, but financially it's actually hindering us to some extent So how we close the gap between 21 percent Here the 71 percent the 90 percent 16 percent of it comes from our federal grants 12 percent of that is our federal grants That's the 3 million that also spoke about We have 2 percent on our state grants the state grants are primarily focused on specific programs One of those would be the warming shelter or we also have A path grant for our homeless program and that so those are specific to certain types of programs that we provide Private grants those are mainly items Like the uvm united away Blueprint and mat money for our opiate program and what we get for blueprint is now 4 percent of our budget 340b is now making up 8 percent of our budget This is what's really helping us more than anything is the 340b program The 8 percent is our share of what we're collecting on the 340b program not what we're giving to the patients So that's almost about 1.8 million dollars And that other is just kind of missing Your 70 30 split between the grants and the revenues from the traditional streams is that Typical of all fqhc's are just yours I think you will well each state to them varies tremendously on what you see and what they are getting for reimbursement I know that we have heard of some fqhc's that are relying on 40 percent of their interest on the 340b We also know that we have there are other states that are paying above the cost of Providing the care for the Medicaid program because they are looking more to pushing money into primary care to get it to expand So I think it's all going to vary depending on where you thought what state you're in and where you're located But what about here in vermont? Is it pretty typical? I think there may be some and georgia may speak to this too But I think there's also some of the newer fqhc's and some of the smaller fqhc's have much greater reliance on the grant As well Yeah, that that's correct Frankly the fqhc's who are newer and also coincidentally smaller in the state of vermont the federal grant That's 12 for community health centers in burlington fill up to as much as 24 for them as part of their total so the Kind of growth trajectory that allison laid out is important in terms of the overall reimbursement mix and how much there How many how big their patient load is how fast they're able to grow to really balance the reimbursement compared to the other The programs and other funding sources they have are there rules that require you to Provide a percentage of the 340b to the consumer versus just trying to use it as a revenue stream No, the 340b program is governed by congress and her said actually implements and There are very few Rules about how the funds can be spent other than they must be spent to the benefit of patients Um, and there's some rules about what a patient is and how you qualify And there's significant additional separate oversight for the 340b program That you'd be happy to come back and talk with you about but it's But when dave talks about other states 40 340b is that because they're making the argument They're they're keeping all the 340b savings, but making the argument that The benefit to the consumer is through reduced prices In the operation of the fqhc by the fqhc retaining that revenue Is that a legitimate reason I would not say that that's a reason I have heard it could be a reason of For my understanding of those where the 340b program is a higher percentage of their overall Operating revenue is because for example, they don't have Medicaid expansion So they don't have that revenue stream coming in so they need to offset it with something else Yeah, and the other thing to keep in mind as well as the health center are Speaking about chd. We do not have an on-site pharmacy We are part of a pharmacy network with other fqhcs and in talking with some of the other Fqhcs across the country I think that With those 40% I think you might be talking about an fqhc that is the only pharmacy And they have in-house pharmacies in there in all of their fqhc So I think that may be part of the difference as well. Okay. Okay. Thank you The one thing I did want to point out to and again looking at how we got our payment in that A profactive memory so when I was in the hospital listening to cost shifting to that We have no ability to cost shift Medicaid and medicare they go up by the medicating medicare economic index every year. So this year it's a 1.9% increase Commercials have decided, you know, whether we get an increase or not this year to zero So effectively we've got a 1.2% increase in revenues that we have from the patient income We don't have anywhere we can cost shift. We can't adjust rates We can't do things that will cause us additional funding and that's where we have a very big difference and that's where we have to struggle I think So anyways, this is where we you know This is where we have to rely on the 340 b's or that are coming in When you look at inflation and things like that what we pay our staff and that it's limited We look at what we can generate based on these types of income increases and say how can we afford to do that? This is where we vary considerably from what So I think the other thing that I'm not sure that that people that you maybe hear too much about in terms of the fqhc's The community sport is really important to the health center When I talked about the building that we got the grant for we raised $700,000 to complete that building And that was that's a huge support to the health center Not to have To have a building that's completely paid for was really important to us This is this this is not an organization that wants to take on a lot of debt or can take on a lot of debt So that was very important For instance, I could give you another Example we get individual corporate donations. We just had fundraising event a couple of weeks ago that raised over $50,000 That's big money to us. That is very important for our bottom line Capital equipment again Capital equipment is something that is difficult for us to be able to afford We needed a panel rex at our school based dental center And which is a full view Of children's mouths Best quality of care to keep the kids at the at the dental center instead of losing them when you have to send them up to the Name facility that costs $35,000 that took us a couple of years But we got a private funder to pay for that So now we have a panel rex those kinds of things are really important. We are a united way recipient So again, that's probably that ranges depending on the year It's been it's probably about 50,000 sometimes as much as 75,000 depending on the grant year We also get Community benefit money from medical center hospital From the uvm medical center And right now we get a hundred thousand dollars in operating support That provides support to our sliding fee scale our medical sliding fee scale And we also I don't know if you're familiar with our beacon apartments project, which we launched again another partnership with Champlain housing trust and with the hospital a few years ago and this was 19 Apartments that literally lifted the most medically vulnerable chronically homeless folks off the streets of berlington and put them into apartments. It's called housing Housing first or maybe you've heard or seen the video Housing is healthcare. I don't know if you remember that but what was featured there was the beacon apartments And we are the service provider for beacon apartments That beacon apartments cost probably about 150,000 dollars a year to provide onsite supportive housing support to clients as you can imagine What are many complicated issues and need hands-on support? Uh, and we are getting a hundred thousand dollars a year to support that staffing at beacon apartments. So That community benefit money is really important to us And so I think that just to just to um because I do always like to get a report for innovation and What what I think the phc brings in terms of the community is that This is a well-developed safety net structure. It is highly regulated And we represent primary care access points all across the state There's now 170 of our monitors One of the highest percentages in the country Received their primary care from a federally qualified health center in Vermont I think that that in and of itself demonstrates the need And the need in different communities to be able to access care And if you think about the hospital think about the hospital is literally half a mile away From the community health center and we've grown to attract 30,000 patients over the years And that is because of the Welcoming aspect of the services that we provide It's important when you're the boots on the ground to be able to provide that welcoming access It is the best famous bedside manner of an FQHC I guess is the way I would put it So the other thing that I did want to say is that you know when we talk about finances There isn't a the old adage in the FQHC world to be seen one FQHC. Well, you've seen one FQHC Our finances our services How we look Is very very reflective of the community that we serve If you ask Sean Tester to come down here from Merlin counties We will have the same model the same structure the same compliance Accountabilities and probably someone finances, but we would look different many of the details would be different I just want you to keep that And I guess the final thing that I'd say is that I I really do view us as the boots on the ground In the battle for doctor reform and innovation and all the things that we are looking for Before remoders or the ones that have the patients coming in we have the ones that have the patients coming in and sitting in front So I always think that that's important But this is how we're keeping the doors open Okay, we'll open it up to questions from the board. Oh, George. Did you want to say something? The hybrid model the hybrid model. Yes, um, so, uh, just like a little You know the slides that you are not being projected. Do you have a Reference to the site visit protocol that Allison I would print that out for you, but I think I would have killed many many trees But I just couldn't give you all our paper links to that. But that just goes to the accountability And regularly for requirements for an F2H state Similarly, just to quick note about the federal malpractice Covers that Allison reference while this is an amazing benefit for a hospital center. You actually have to apply To maintain that separate and apart from your regular FQHC application status So there's a super special fun piece around maintaining that Right, so moving on to the FQHC credit glasses hospital model So this is a pretty unique hybrid. There are three of these in the country We have two in Vermont, Gifford and Springfield And the final one is mini Hamilton mini like the mouse not petite Which is in west virginia. The one in west virginia was created first So we were not first out of the gate on this And the the basic framework is that an FQHC serves as a parent to a critical access hospital There and it must be in that corporate structure because federal law around FQHC requires that the FQHC Board does not have anything governing it So this consumer board that Allison referenced is in charge of the entire corporate entity in the subway chamber forum Depending on which of the three of these hybrids you're looking at there is either Emerged corporate board over the entire structure or you might have a hospital board in addition to the parent company board And then there's some kind of complicated math and things like that. I will bore you with those details We can get therapy life So why would Any entities since there's only three of these right like what what makes it attractive So the the bottom line is that it Each of these organizations has Thought that they're able to address community needs more efficiently by having this hybrid model For mini Hamilton the triggering event was that their local hospital closed And so they were basically an hour and a half from any facility for services and the community thought that wasn't good enough um in vermont there is the extra layer of Really being able to have a primary care focus and focusing on population health management and being able to commit more fully in health care former initiatives for the state That are meaningful for the two that are here in general Each of the three said that the integration of services across the continuum of care They're able to maximize their return on investment regardless of funder the reimbursement model kind of this this combination of What both days talked about Really works for the rural communities that they're in And there are some specific efficiencies. So there's you know one c-suite for example in one h.r. Department Where previously there were two organizations with all of those complexities Some specific benefits that were identified Are that there's some unique recruitment and retention opportunities. So there's a different level of attractiveness Um for some clinicians knowing that they're coming into this model There's mobility for streamlined community hope planning and collaboration with their community So kind of merging the community benefits that a hop that a nonprofit hospital has to do with the mission of the fqhc Maintaining hospital access in that rural community And also really being able to improve both the mental health and rural health service delivery So those are not profit centers by any stretch of the imagination. So by combining this These three institutions Determined that they were able to really expand on those But there are some challenges there I guess Have eight masters. I know many masters that they're serving from a regulatory perspective Dual safety net designation is is real work that they have to be so they're from an fqhc side meeting the HRSA obligations From the critical access hospital. They're meeting the medicare obligations. They're meeting your obligations on the hospital side And so there's they kind of get the complexity of all of that But again on the whole the benefit has borne out for them and their boards The another challenge is that there's a little bit of a shifting pair mix. So for an fqhc The pair mix is tends to be dominated by medicated uninsured. That's kind of the bread and butter of why fqhc is there And for critical access hospital actually tends to be slightly more in the medicare side So there's some weird patient shifting that goes back and forth that just serves as an additional challenge Because of the complexity of the regulatory oversight, there's some duplications and quality standards that you may be familiar with I won't go into detail there, but There's just a lot more reporting on that end as well as the financial And I think the final challenge that was noted is No one knows what they are As an entity are you a hospital? Are you a health center? Are you a clinical office? What are you doing? So there's a lot of explaining what the heck they're doing to regulators to patients to folks they're recruiting in And also the fact that they can't actually be everything to all people. So there's The hybrid again has I think born out to be successful for these three organizations, but As different, you know hospitals are crazy's would think about moving into it It's it's not for the faint of heart to get in there Despite the fact that actually HRSA as a fqhc regulator is trying to encourage More critical access hospitals to go in this trajectory because they find it beneficial from their oversight perspective So I will stop there Great, we'll open it up to questions from the board first Just have a couple of quick ones The part of the slide there was a reference that the cost per patient Was 13 lower for medicaid Than vermont medicaid enrollees and and the footnote refers to a national study and I just wasn't clear Whether that 13 was a unique vermont statistic or it was the national statistic Yes, that's a unique vermont statistic is a national study of eight states one of which was in brahmat was one of those Yes And the other is and I remember when I first met you georgia that you talked about we did talk a little bit about the Malpractice coverage and it was I remember the number it was four hundred thousand dollars in savings That you told me way back when it seems, you know five months ago, but um I'm just wondering on the on the other side of that has that a malpractice insurance been utilized by you folks Uh, yes, it has It basically if if we get a malpractice suit or whatever it goes to the courts courts claim that we are a federal employee And that it goes to the federal courts claims Settlement at that point in time And that's it is a coverage. It's wonderful. We don't have to pay ground practice. We do have wrap around for any services We may provide Thank you. Okay other questions robin Georgia you sort of alluded to one of my questions, but i'm going to ask it just to clarify It sounds like the three-year community health needs assessment that an fqhc does is separate from the community health needs assessment that Hospital not private hospital would do We're getting smarter about that We do need to do um, we do For the past three years either I have or health center staffer has been involved in the community health benefit program at The community health needs assessment program at the hospital and as a matter of fact, we're going through that cycle again Um, we do do something separate But we have used that to inform us and I think it makes far more sense For all of us to be working together and working off that same news assessment So that's a great question. And yes, we're getting much smarter about that And do you think that's typical around the state or do you think that's more unique to chitin county? Or if you don't know, that's fine, too I don't know. Yeah, I don't know. It makes perfect sense. I would be surprised I think most of the fqhc is really doing works closely with the hospital great, um, and then my other question was um I was wondering if you could just talk a little bit about how you calculate the encounter rate I think that's based on a cost report, but I'm not positive about that. So if you could just talk a little bit It is based on cost report. It's not the same cost report that the hospitals do. It's not as complex as the 224 form Um, it is basically what we're doing. It's looking to split our cost between Programs the medical program for dental program and labs Labs are paid on a fee-for-service or fee scale basis rather than Part of the encounter rate But then it's just once we have the cost related to the medical and behavioral health and it's just right of our total number encounters Got it. Thank you Okay, other questions If not at this time, we'll open it up to the public for any questions or comments dale I just want to compliment the presentation It sort of sounds like your group of artists that work in healthcare and you're showing us What that creativity can do But I don't know if they're all artists that just happen to work in healthcare. So But I'm just I'm trying to compliment that what you've done is that innovative beyond that If I try to think in terms of What have you given back to community for the investment community gave you? What is your salary? I don't actually answer that that's more just high-level life I know there's workforce issues that we face But you didn't mention them and yet You're doing somehow standing work from people that have to be really good so Could you comment on that too, please? I yeah, I I yes, I would very much like to comment on that. I think that The health center is in a sweet spot in terms of recruitment and shape my family As a matter of fact, sometimes I feel a little embarrassed when I talk about recruiting a Harvard train psychiatrist Sitting next to Sean Tester at Nuremberg counties and as a matter of fact, we're talking a little bit more about what we can do to be able to offer that So support to the other FQHCs I think maybe you're asking in a way. Do I pay competitively? Yes But that's not why people yes, but not quite Close but not quite When you come to work for the health center first of all loan repayment and the fact that we can offer loan repayment Is very important. I have yet to talk to a psychiatric nurse practitioner psychiatrist dentist Or family practice physician physician or intern internist that we recruit That is not very interested in that and that's very important part of it Um, people come to work for the community health center and for FQHCs because of the work When you talk it actually struck a chord with me when you talked about some sort of artistry because I will tell you that This sounds like a business healthcare sounds like a business doesn't it? Well, I'm here to tell you that there is an art to win Without developing things like trusting relationships without developing things like bedside manner without understanding The needs and wants of the person that's in front of you and to be able to provide a non-judgmental And these are all things that we don't talk very much about But that is all part of what an FQHC brings to the table So when I recruit a physician or I recruit someone is someone who wants to talk about the joy of practice It's someone who gets excited About some of these programs. It's someone who gets really excited about saying I can change something I can do it quickly I'm not in a system that's going to slow me down And yes, we never quite seem to have enough money, but there is a camaraderie about it that I think is It keeps people inspired and motivated to do the work so I will tell you that it is kind of tough in terms of, you know, I just lost it I lost two nurses to the hospital. They paid $10 more an hour than what I can pay And yet I paid our rents $3 more than some of the other FQHCs are able to pay so It is a complicated recruitment environment But I'm not going to complain because I think my fellow FQHCs in the different in the rural environment probably have a far tougher than we do Thank you Yes, ham Of course, I wonder if you could ask the Erlington people where they stand on the question of Whether they're going to participate in the all-payer model, which is the centerpiece for reform here in the state shifting from in the The engine really is a shift from fee-for-service reimbursement to capitated reimbursement and the Single biggest blocker to that it seems to me right now is the fact that several FQ many of the FQHCs not all Staying out of that program and I'm curious what Burlington is going to be I'm happy to address that. It's him, right? Yeah, hi ham Sure, um last year, uh Last year the health center actually considered very carefully whether they're joining one care I think I can I can say that I was a very new CEO. We had just come on things were very tumultuous at the health center I think that we were in a Um, we needed to be able to do some internal investments I think we were looking at an an ancient electronic medical record and some other things that were A little bit more that we needed to attend to We certainly went through the entire process of one care But in the end decided that we really need needed a year of internal investment in getting things Situated before we felt ready to be able to take on the work of one care One thing I will say is that we are already around the table If you look at the collaborative efforts that are being done in the Burlington area As a matter of fact, we had staff people through the blueprint that actually started those collaborative efforts And we're we're still at the table. We're not I think doing anything different in terms of the collaborative efforts in terms of the actual care I think for us that was really a practical issue This year again I've signed on the line to be able to look at our attributed lives And for us it's the decision whether to go in and we'll be based on will it make our care better Are we going to be able to do we have the staff in place? Do we have assistance in place to be able to do the work? Well, because I think that's really that is really important to us that we do work well And really looking at it financially in the number of attributed lives I will tell you that one of the problems that we faced last year was the number of attributed lives It's quite different than the number of folks that we were caring for and since we're going to have to provide those services To everyone who walks in the door. We're not going to be able to discriminate I think that we needed to be able to have some time to think about how that would work So the answer is we absolutely consider it Not quite the full answer you wanted, I suspect One short pop considering participation for the 2019 fiscal budget 2019 You're not in any of the 17 or 18 I believe. No, we're not. How about 19? Yes, that's what I would. Yes, I asked for the modeling and I've signed the participation to be able to take a look at what that looks like And we fully intend to go through the process with one care to see where that leads us What's the total dollars on the community assessment that uvm? funds I'm sorry You're receiving a revenue stream from uvm The community benefit money. Yes 200,000 200. Yes, that's 100,000 dollars for the medical slide d scale and 100,000 dollars that helps subsidize That's what was somewhat confusing to me because the bullets were at the same port. So I wasn't sure if they Okay, great other questions. Yes I just like to ask a follow-up to the question about whether Community health center of Burlington was considering joining one carer one of the asio model Georgia, do you know if the what's happened to the other fqc's? I know what's happening with one of them My understanding is if not all the majority of the fqc's have similar to community health centers of Burlington Sign the participation agreement to go to the exercise. Um, however, I would note that Um The majority of fqc's are really in close collaboration with their local hospitals So to the extent that their hospitals are doing something or not doing something those conversations are ongoing And as important as the conversations we want to bear with all the other modeling Okay, other questions walter It's more of a rhetorical question Not a Specific one, but I I like this presentation and I want to thank you for it Some of the numbers here. I'm a health care activist and I hear a lot of numbers And one of the things is like the thousands of homeless people that come to to these fqc's And we struggle with trying to get health care for everyone And I'm just curious what kind of a society we have here and for us to think about it If so many thousands of promoters are homeless and have to go into Fqc's or places like that And the dental issue, you know Tens of thousands don't have dental care And what is it that we're that we're doing here where so many people Are homeless? I think it's something for us to think about When we deal with health care issues and all payer models and all that the real problem that you said is that it's Art I don't agree that health care is a business. I do agree that it's an art Having been through health care the business and barely survived it It isn't It's not a business. It's more of an you know an art dead side manner take care And it's always about the person that you're taking care of And again, I just want us to think about Those numbers that you quoted And thank you for those numbers Yeah, it's just more of a rhetorical question So I guess I guess maybe I'll ask a retort I thank you for that comment Maybe my rhetorical question back for everyone else and think about this What do you think your community would look like without a federal qualified health care that too? You're right. I agree with you Okay, other questions or comments from the public If not, I want to thank you for a great presentation Thank you very much for having us And we hope that you'll be back here Well before the year is out to give him an even better answer to his question Is there any old business to come before the board? Is there any new business to come before the board? If not, is there a motion to adjourn? I'll move to adjourn Second It's been moved and seconded to adjourn all those in favor signify by saying I I any opposed Thank you, everyone