 Good morning to all of you. My name is Jessica Holmes and I'm currently serving as the interim chair of the Green Mountain care board So today is day two of our Green Mountain care board hospital budget hearing process Just as a reminder. I said this on Monday, but I'll say it again today I'll say it the start of every Hearing day that we have to conduct our analysis and ultimately make a decision for each hospital We have to look to our statute and our hospital budget rule for guiding principles Our review requires us to balance several often competing factors For example, they need to slow the growth and health care expenditures while also ensuring that our hospitals have the resources They need to recruit and retain health care workers and provide the high-quality care we expect in our communities As we're looking to balance, you know, these competing factors of cost containment access quality and health system Sustainability we have to be mindful of this year's unique circumstances And the significant headwinds that we're facing. We have historically high inflation rates work for shortages and the continuing impacts of COVID-19 So both nationally and in Vermont. We're seeing hospitals facing unprecedented financial challenges as our businesses families and individuals. So What lies before us is not easy I think we all know that our short-term task is to set fiscal year 23 hospital budgets for the 14 community hospitals and we have to do this by September 25th. I mean September 15th. Sorry With that said, I want to remind everybody that the board is working closely with the agency of human services to begin the work that outlined in Act 167, which aims to move us closer to a sustainable hospital system That's going to ensure better ensure that Vermonters have access to high quality affordable care That longer-term work is going to involve extensive data analysis and community and hospital engagement to identify Options for a more sustainable path forward. So as we return to the task at hand I want to extend a thank you to each of the hospitals presenting today for the time and effort taken to submit the documents for our review There's a few housekeeping notes for today The presentation is a public meeting. It's being recorded and transcribed. There will be a publicly available record If any hospitals leadership believes that there's confidential information that the Green Mountain Care Board should consider Either as part of the hospital's presentation or in response to board or staff questions Please alert us before responding if needed the Green Mountain Care Board has the ability to go into executive session To review confidential information from hospitals I just want to note though that executive seven sessions are limited in scope as Provided by the open meeting law and they're limited to information such as contracts and information that would be considered Confidential under the Public Records Act. So if an issue of possible confidentiality arises I'll call on the board's legal counsel to determine the scope of what could be discussed in executive session And if deemed appropriate and at the appropriate time, I'll ask the board member for a motion For us to go into that executive session So knowing we have a really tight schedule today. We have three hospitals that we want to hear from I'm gonna hold all board and staff questions until the end of each hospital's presentation And I see all the board members Tom Tom and Robin. So all our board members are here Sarah Lindberg you're on hopefully in the background Should always be checking to make sure that you're there too and your team Springfield it looks like I see Springfields team is everybody from your team all here We we are Jessica. It'll be Katie and I presenting today. Okay, wonderful. All right, perfect So in keeping with the schedule, I'm gonna Hold all of our board and staff questions until the end of your presentation, which I we have scheduled I think it was till 1 15 Russ, would you mind swearing in the Springfield witnesses for us? Great. Yeah, happy to this is Russ McCracken staff attorney with the board Bob, I believe you said you and Kata will be the two speaking today. Is that right? That's right. We may call on Mike Donnie you who is a consultant who has assisted us in the preparation So we might want to do Mike as well Okay Yeah, I think we should swear on anybody who might be who might be speaking So if you could all raise your right hand Do you solemnly swear that the evidence you shall give relative to the cause now under consideration Shall be the whole truth and nothing but the truth so help you God I do Great. Thank you. You're sworn in and it would be helpful if the first time you speak you could identify yourself by name I will help with the Recording and the transcription Great, I might add that every time you speak it might be helpful to just remind for the court reporter's sake who is speaking That'll be really helpful So thank you for coming. We look forward to hearing your presentation. Thank you for submitting all your materials to us You know, we will be we've poured over them We're gonna be pouring over them again and we look forward to your presentation today So if you want to I will turn it over to you if you've got a present your presentation You want to load that up? That would be fantastic. Thank you Thank you so much Happy to be here today to tell our hospital's story For what happened this year and what we expect to happen in the year Upcoming I would we're going to have crystal more a on our team run the slide deck So I'm not sure if crystal is trying to get access so we can put our slides up. I Don't know if somebody has to I emailed Kara for that permission Yep, Kara is the one help and drive that behind the scenes slide ship. So great It looks like her lines are coming up great Okay, so if Again, I'm Robert adcock. I go by Bob So, please feel free to use that Though we're happy to be here today and we'll get started our introduction slide We think is very representative of the status of healthcare not only in Vermont But in America right now, I mean we live in a world of chaos in healthcare with all the External and internal forces that are affecting us And then we so we believe the concrete represents the Challenging world around us and the world of chaos that we're in and the green sprig there is our is our hospital Thriving and growing in this hostile environment So we're fragile yet persevering in this world that is very much Has hospitals in America under assault So next slide, please We wanted to start off just by reminding Everyone on the call what's happening with health care not only in Vermont but across America. So we picked a few headlines All of them national headlines just to kind of emphasize what's happening with hospitals All across America hospitals are struggling with negative margins in red ink Just a few headlines here about that Every hospital in America is struggling with High rates of inflation Troubles recruiting staff difficulties in getting supplies and Many of us if not most of us are relying heavily on traveler staff to provide daily routine care at our hospitals so Chaos in the hospitals Yes, are we able we fighting and persevering through that? Absolutely. So Next slide, please We'll start with just a little introduction to introduce Springfield Hospital to everyone on the call We are a 25 bed critical access hospital located in Springfield, Vermont We have 25 med surgeons wing beds in 10 mental health beds Which are at an off-site location in bellows all Vermont Our inpatient daily census and the stats on this slide are all year physical year-to-date 531 22 so our inpatient average daily census is eight and a half on the acute side 1.2 on swing and 7.4 on mental health Our ER visits we are here today through May we are averaging About 35 visits a day although we have seen a Remarkable increase in that the last quarter. We've seen an average of 39 in May 38 in June and 37 in July. So we're definitely are seeing an uptick on emergency care Surgery volume Pre robust for us this includes 1300 cases through 531 including endoscopy cases 11,400 specialty clinics and this excludes referred outpatients, you know lab and x-ray type these are our our clinic visits We have 390 employees In that work in our hospital and we have a gigantic economic impact on our community We're expecting our payroll for 22 with benefits to be about 23 million dollars Without the four million dollars. We're going to pay this year to traveler and temporary staff that we're being forced to rely on We're budgeting that number to be about 25 million dollars for FY 23 so very large economic impact to our local economy Next slide, please And we'll start off Kind of the segue to this slide will start off with the unprecedented workforce challenges that we're seeing here in Springfield And again, this is typical not only of hospitals in Vermont, but also across America. We have seen Unimaginable traveler cost that have been required to staff our hospital this year We're projecting to spend about four million dollars To for traveler cost this year, which is up more than double what we saw in last fiscal year A year ago when we were here, we felt like this was getting better but obviously the market really really Stabilized and decompensated on us and I think that we've seen this across across every hospital in the state Again our extraordinary rate increases in travelers This slide is 531 it has 52 vacancies right now today We actually have 61 total vacancies 15 of those vacancies are registered nurses one medical technologist three respiratory and three radiology Technologists so all very scarce and difficult to recruit Positions in rural Vermont right now What are we doing, I mean we're not We're not sitting still we are very aggressively trying to impact our team here in in our our labor group We're making investments in our budget. We have a 2% cost of living increased budgeted We're budgeting additional training in workforce development. We have hired a dedicated recruiter to help us feel difficult positions and we've introduced two programs to help us try to reduce travelers one is our Premium per diem program and the other is an extra hour bonus program and both of those are designed to encourage our existing staff to accept more shifts and allow us to Divert some of that extra money to our own family rather than pay it to travelers Next slide please We will talk a little bit about about infrastructure All hospitals are are having trouble making Recapitalizing and reinvesting in their plan and equipment Right now we're we believe we have the second oldest hospital plan in Vermont At the average age of our facilities is right at 21 years The statewide average ranges from eight eight and a half years to 22 years And the national median for critical access hospitals is about 12 and a half years As we progress through the product to the process today, you'll see we've budgeted $1.5 million for priority capital reinvestment this year And in addition to that we have received some grant income that we're going to put towards The building We have several projects that are important for us this year The main ones are around our our HVAC Mechanical systems in the hospital and we believe that most of that we will be able to fund with grant Grants that we have applied for and received So we will be Reinvesting in our infrastructure this year based based on those opportunities Next slide please Talk a little bit about the environment we're working in You know the healthcare environment is very stressed right now I've made a list here of just a few of the things that are impacting us on a daily basis One of which is patients that are boarding an emergency room And I'll draw some distinctions here because there are several categories that are they're impacting us The one that is affecting us more than any have been the patients that have been here That are not meeting hospital criteria But have no just no post-acute discharge plan And many of them have not met criteria Or a post discharge Plan they just didn't have a safe discharge plan because they didn't have the right conditions at home Or they didn't have family members or any other caregivers to take care of them So we've had several of those patients, which have been with us for a considerable amount of time They are non-reimbursed while at the same time we're incurring cost Excuse me To feed them provide pharmaceuticals linen and nursing care Excuse me Just going through here. We do have our Wyndham Center psychiatric facility That does provide us with a benefit for placing mental health patients We still have challenging patients that we're not able to place That you know might be forensic or other conditions that we're not able to take care of in our own facilities Post-acute as I mentioned post-acute placements remain a challenge for us Many of of the post-acute destinations in our area are facing the same type of hurdles we have Around inflation increasing staffing costs and many of them have released their beds and capacity Excuse me We do have we have an advantage because we do have the ability as a critical access hospital to accept swing bed patients And we do accept those and we work daily with some of our partners in the area Particularly with Dartmouth and UVM to try to make our beds available to assist with their discharge planning We do have that problem sometimes that the patients they're trying to place also don't meet the criteria to be placed in our beds but we are We are in contact with those hospitals on a daily basis to make our resources available to help them as well Um, a new one that's coming up is distress. It's also being placed on the emergency medical system in our area Um, our EMS providers do a fantastic job for us But we have we're frequently in counter situations where we have to Take staff to accompany our patients when they're on an EMS transfer And uh, that's taking nursing nursing staff out of the hospital But many times to meet the clinical needs of the patient and the resources available. We're we're uh compelled to do that So, uh, that is starting to affect us as as well Next slide, please Major challenges. Well, we have a lot of a lot of a lot of challenges at the hospital Uh, in addition to quite a few opportunities, which we'll also be talking about those, but we'll talk about the challenges first Um, again, we have you know in our community We have a relatively poor payer mix And reimbursement is relatively low for the work that we do We are are now bargaining in good faith Our nurses recently voted To be represented by a union and by a collective bargaining agreement and we're now negotiating in good faith for that contract We are still working through the um the post I'm not sure what the right word isn't the post the post Work that we're doing From our chapter 11 I mean we've emerged from chapter 11 previously and as a part of that we restructured our Our organization as many of you may remember we were previously owned by the fqhc in town, which is now known as north star Health previously known as springfield medical care systems So we are we even though we have emerged from chapter 11 We have separated in two companies. We still work very closely with north star And we're still working through details of that the vestiture and that split Um again can't can't under emphasize the challenges we're facing now with workforce shortages I mean it seems like every Position in the hospital is difficult to fill Bar none. There are no positions In the hospital that are easy to recruit for right now Despite our uh competitive salaries in our benefit programs Again, we talked a little bit about travelers We're expecting to spend about four million dollars this year for travelers, which is an incredible burden for a small hospital like ours Supply chain shortages at any given day. We're looking at approximately 60 to 70 items that are backwarded And that's not always the same 60 or 70. It's moving around Our supply chain and materials management department do a fantastic job Um searching around and trying to keep all the supplies we need in the hospital One of the byproducts of this Challenge has been a lot of times now We're buying supplies that are more expensive than we bought before Because we're unable to get the ones that we were using previously And sometimes, you know, we have a very good gpo as a member of neah But sometimes we're forced to use alternative products that are more costly Inflation in rising cost again everyone's subject to inflation Uh the uh the oil we used to to heat our facilities and runner boilers Cost more than twice what it did last year. So um And then finally, um, we had quite a challenge and quite an impact in the fall When the omicron and delta variants hit our areas and um, we the last time we were before this board we were Actually, um experiencing very strong volumes at the hospital and those volumes were given us very favorable Patient revenue numbers, but when the variants hit in the fall, uh, it had a significant impact on us So if we could go to the next slide, please This slide was designed to show just how pervasive that impact was on our hospital. Um, so here You can see that the black line Is the positive number of cases Uh per day and the red line is the seven day moving average for positive cases in vermont And you can see when we presented last to you in november, you could see that our, uh, Gross revenue was actually quite strong and we were we were In the midst of a very robust recovery at the hospital Then when the variants started hitting us, uh, the revenue took quite a plunge now over in the winter and spring The revenue started turning back up again, but this big slump in the middle of the year has affected us pretty profoundly Next slide, please We have a number of operational changes that we have been working working on Um, again, I want to emphasize The fact that springfield is very very much involved in collaborating With our colleagues and our partners in the area The right hand slide of this the right hand part of this slide was designed to demonstrate that Just to show the various partnerships and relationships that we have in the marketplace Of course, our main one is with the fqhc now known as north star So even though we're not the same organization anymore, we share a very strong partnership and we do continue the The shared services agreement we're able to share costs between the two organization Um, again, you can see some of the other things that we have. I mean we partner with Dartmouth for the radiology department for our oncology service Um, we partner with uvm. They provide our pathology and oversee our laboratory Um, brown or burl has their obstetrics doctors here. Cheshire has their cardiologist here We contract with original route for emergency and hospital care, which is blue water health And then as you go through the service lines, these are these are all service lines that You know are important things to us that we provide for our community Let's see going through just to just to name a few others What's happening in our hospital? Well Last year we brought on a podiatrist. There was no podiatrist in Springfield at that time and so that provider has had a remarkable upswing and growth in his practice We're in the process now if we just increased him from eight days a month to 10 days a month on our campus Your radiology has been a one day a week service and we're in the process of expanding that to two days a week We had two a year ago. We had two part-time gynecology providers They have left our marketplace and now we're replacing them with one full-time Provider who will give us more appointments and more on-site access To allow us to better meet the needs in our marketplace for that service line And then a new program we'll be starting this year is an interventional pain management program That service is not available in springfield and we believe that there is a need for that here in our marketplace So next line Talk a little bit of about our Wyndham center We during this fiscal year. We have made a slight Restructuring to our provider model, uh, which we are phasing in more mid-level hours and more mid-level care In relying on a part-time medical director um, I want to Want to just mention that our utilization this year has been reduced We had a number of days in the winter at the height of the season where we had staffing issues primarily related to to covet among our staff or staff members that had to be quarantined due to exposure That affected our volume and our capacity quite a bit in the wintertime Um And just remind everybody the work we did with Wyndham in the two previous fiscal years when we actually put the unit on standby To be the provider for covet positive site patients for the state And so now we've been fully operational Since the spring of last year and looking forward to continue to strengthen and grow that program Particularly around meeting the needs that we have in the state. I know everybody has needs for Beads to discharge their site patients too. So we're working hard to meet that need I'll comment a little bit about oncology service. It has historically been staffed by Dartmouth Uh, we have switched that model from an on on site in-person model to a um telemedicine model And that has restricted the patients that we can provide chemotherapy for on site And so we are finishing up some patients that were in progress But we are not initiating any new chemotherapy patients with the doctors not on site Next slide, please I think this slide Really characterizes the the incredible balancing act that we're doing here in our small hospital in springfield I mean, you know, this is a very resilient critical access hospital We are in a very fragile financial position, although our operating results are Improved quite a bit from the prior year. We're still in a very fragile position We're expecting an operating margin of 0.5 percent this year We're we're projecting our operating income to be about three hundred and twelve thousand dollars And again, these numbers are based on our 531 year-to-date estimates Um, and I'll point out that these numbers also rely heavily on us taking grant funding into income for the year ARPA provided relief funding and a USDA grant And we've also received some grants for our our adult daycare program as well. So these, uh projected numbers For 22 are relying on us taking those into income Next slide, please Our goals for the for this year um Really fall around financial stabilization I mean, we've been through a lot of turmoil in this hospital to last three or four years As you recall, we have gone through significant turnover in our leadership team And that team was completely restructured um While that was going on the hospital also entered chapter 11 and went through the stress and struggles of that process While that was ongoing the covid pandemic hit the marketplace and really changed the whole dynamics of health care in in the country and Then as part of that restructuring under chapter 11, we split with our parent organization, which is the fqac So our goals though are are to move in 23 towards Continuing to improve our financial stabilization To make local and affordable access For care available to our local community to provide for patient and staff safety In the serve our community which tends to be an aging population lower income community Lower health status compared to the averages we see in the state And rising substance misuse in mental health needs So all of these things are goals for us to address in our f y 23 budget Next slide, please Our vision and mission remains the same. It's unchanged. It's to excel at providing personalized and quality care I mean our our motto is where people come first. That's our hospital for our community And our vision is to be the provider of choice By creating a professional environment Where patients want to receive care Clinicians want to practice and employees want to work And we put this photo of one of our staff members here in the rain providing We were called upon in the fall last year to test 600 children in the local school district who were possibly exposed to covid And we worked with the department of health And our community leaders and within a few days we were able to put on Like an immediate screening process And we had people bring their children in the cars while our staff stood in the rain and provided testing for that group For that group so we could Clear them So just want to just one example of the Important work that's being done at our hospital for our community Next slide please Okay, I think I'm gonna The first of kata to start talking about the financial numbers Okay, um for the reporter reporter. I'll say my name. Um, kata wescott Cot t and I in the chief financial officer for springfield hospital Um, just want to thank the board and everyone for having us here this afternoon to present the budget I will be going over the financial portion of the budget and we'll start with This slide which talks about Summarizes our net patient revenue request and our charge request um our 23 npr request You can see on the right hand side is 58.7 million Our 22 approved npr budget was 54.6 million That's a seven and a half percent increase um budget to budget Our projected npr for 22 is 51.7 That's a 13.7 percent increase From the 22 projected to our 23 npr That 51.7 projected number for for npr Was definitely impacted by the volume and lower revenues that we experienced this year As a result of the the two different covid variants that hit us I'm starting in january as bob just showed in the slide um Next slide please All right, um our npr request is or increase is made up of three different components We have increased utilization from our current services Increased utilization from a new program initiative as well as a rate increase Next slide So this slide is a breakdown Um showing the components of npr And they're in the 23 npr Um increases compared to projected and compared to budget so On the left hand side Shows the comparison of the 23 budget To the 22 projected So starting at the top and I'll just quickly walk through this our projected npr Um for 22 was 51.7 And if you go to the bottom you can see our npr budget is 58.7. That's a seven million dollar increase The components of that seven million dollar increase is 4.8 million from utilization 2.7 from rate And a decrease in npr um from our dish bad debt and charity um On the right hand side shows the increase budget to budget so from our 22 budget Of 54.6 million That's a four million dollar increase when you compare that to the budget of 58.7 million for 23 um the components of that is a 1.9 million dollar increase in utilization And a 2.8 million dollar increase in rate and we'll talk um In a few slides from now about where the utilization changes are coming from Next slide, please So this slide the next couple of slides just basically reiterate what we just saw in that side by side table Where this is just outlining the 23 npr Incremental change from the 22 projected npr Which was seven million dollars um Where 2.7 million dollars Of the seven million dollar increase is related to the rate increase. It's primarily coming from our commercial payers 4.8 million of the seven million dollar increase is coming from utilization And then we're seeing a five hundred thousand dollar Decrease in npr Which is the combination of our dish bad debt and charity care um a small portion of that is budgeted to be a decrease in the dish Most of the five hundred thousand dollar decrease in npr Is due to an increase in the bad debt and charity care as a result of the increase um In gross patient revenue Next slide um this slide is um Again a reiteration of the the table that we just saw I'm showing the change from that patient revenue. This is budget to budget Which was a four million dollar increase 2.8 million of that is the rate 1.9 million of that four million increase is utilization And then there's a seven hundred thousand dollar decrease in that patient revenue Which is a combination of dish bad debt and free care Again, the dish portion of that is relatively small The biggest part of the the seven hundred thousand is the increase bad debt and free care as a result of the increase in gross revenue Um, we're budgeting minimal changes for our fixed perspective payments Which we're in for medicaid blue cross and mvp Next slide Okay, thank you kata This slide just the goal of this slide is to outline our utilization changes, which um You know, we have a lot We spent a lot of time this year um Determining what are the needed services in our community and what are the things that are underserved And where do we need to address access and entry points in care here? And so A lot of our utilization increase is built around in strengthening our volume and Meeting doing a better job of meeting those needs in the marketplace So um a big portion of it is increase in surgery Due to adding the full-time gyn physician The increase in days for urology and for podiatry, which again are very very scarce services All three of those are very scarce services in our marketplace We have budgeted a corresponding increase Small increase in medical surgical senses as which we expect to be driven by those increases in surgery from gyn In urology Probably don't expect much from podiatry But for the other two we expect to have some a slight increase in our inpatient utilization And again, we've also budgeted an increase in psychiatry. So right now we're running about seven and a half Is our adc in psychiatry we're budgeting to move that to eight and a half in in fy 23 and we believe with um The demand that's in the marketplace we believe that's a very doable goal for us We also see increases in diagnostic imaging and in physical therapy And we in of course the emergency department we um are budgeting Any a slight increase in emergency Room visits and we feel very uh strong that that's a conservative number particularly based on the run rate We're seeing right now again in july we saw 37 a day 38 a day in june and 39 a day in may so we feel like that's a very conservative Increased that we're budgeting on the emergency department I'm our new pain management program um We're budgeting an increase with that and those are partially offset by a decrease in oncology as we Are projecting a decrease in our visits Did our visits for chemotherapy as that has now become mostly a telemedicine clinic Next slide please So these are our key utilization statistics comparing our prior year and in year over year and um You know, we've been through quite a bit of uh turmoil But if you look at our our 23 budget is the yellow column in the middle And again, we're showing a slight increase Versus 22 projected primarily based on the increase in days for the Due to the surgery increases A increase also in our swing our swing volume because we are still working very hard to make that asset available To our colleague hospitals for that to help them with their throughput challenges that they have And again, we we think that we can do better with we can We can increase our census in psych particularly if we don't Have those issues around our staff staffing shortages that we had this winter particularly Again, you can see the corresponding increases in census that we're expecting as well there in the yellow column Um So med surge uh swing psychiatry going to 8.5 in observation Actually going down a little bit from 1.6 to 1.3 in terms of census Emergency department again budgeting to go from 34.7 to 35.5 But we feel like that's a conservative number now based on the volume that we're experiencing Right now over the last quarter And again in in the operating room in our endoscopy suite, um, we're expecting, um You know increases in cases in those areas around the increase in urology and having the availability of the full-time gynecologist here one site Next slide, please actually, um, I just had a couple of comments on the the Statistics before we move on Oh, please um, I just wanted to point out, um When we're looking at the fiscal year 21 actual And then comparing to the 23 budget particularly for the psych psychiatric admissions and the psychiatric daily census you can see that they're almost in half um The admissions and the the census was half in 21 than what it is Now and what is budgeted to be for next year And that's because in 21 um The first half of the year we were operating as a coveted unit During that first half of the year. Um, we have an eight. We had an 80c of less than one patient a day um, and so The last half of 21 we became fully operational and so 22 we were fully operational and then in 23, um, you know still continuing to be fully operational um We did have less admissions, um for psych this year Not much than what we had budgeted, but we had some issues that impacted um The the census due to staff being out. Um, that had covet We also had some facility issues with one of our rooms down there, which Limited our census So just wanted to point out those couple of things on the inpatient psych Um, I also wanted to point out on the med Surge um admissions and average daily census You can see from 21 to 23 We're budgeting less admissions next year than what we had in 21 Although the average daily census is higher at 9.3. Um, it was 8.9 and 21 Some of that is due to the increased Surgeries that we're budgeting next year that bob just talked about But some of it is also due to a longer length of stay that we're seeing for our patients on the med surge unit Um, that's due to keeping the patients longer because we're having challenges Discharging patients To lower level facilities such as nursing homes and also to higher level facilities For tertiary care availability. So longer length of stay we're seeing This year and we're budgeting for next year than what we experienced in 21 Bob mentioned for the emergency department that we're comfortable with the 35.5 patients a day that we're Budgeting next year when looking at the projected this year of 34.7. That's made based on our may year-to-date When we look at our july year-to-date number that year-to-date average is 35.8. So so far this year we're already seeing Um, what we're budgeting for next year. Um, it's just not reflected on the slide Because the projected was an older number Um, and then lastly, I just wanted to comment on the or cases Um, so while the or cases are increasing compared to projected for this year due to the reasons that bob outlined um, due to urology and gynecology predominantly the Amount that's or the volume that's budgeted for 23 is still less than What we were experiencing In pre-pandemic levels, which was over 1100 cases So just wanted to point those few things out on the on the utilization Next slide please Thank you, kata. And I think when we when we get to talking about the net patient revenue, you'll see the wind of impact again Because in the prior year The change between those years on the net patient revenue will be reflected Due due to the times when wind them was closed Or offline for kovat Um, this slide is showing our net patient revenue by payer as a percentage of total npr um It we have a column for the 23 budget the 22 projected and the 22 budget Basically just demonstrating that there's no significant changes By payer as a total of the the total npr Um, not a lot To talk about on this slide other than there's no significant changes Um when talking about the net patient revenue by payer Next slide, please Um, this slide outlines our npr payer assumptions that we use when calculating the net patient revenue Basically our methodologies for calculating net patient revenue is consistent from year to year. We haven't changed our methodologies um For medicare our net patient revenue is calculated based on the critical access cost-based model Which uses our budgeted revenue and expenses Um as a critical access hospital. We are reimbursed based on one and a half Not one and a half 101 percent of our allowable costs um, and then deducted from that is about two percent of sequestration um Medicaid we're not getting or we're not assuming a lot of the um rate increase is going to be um impacted by Medicaid um, the only thing that we're The only increase that we're budgeting for from Medicaid as a 2.7 percent inflation increase which um is on top of our 22 projected payments um commercial npr is based on Gross charges and then a subject to the payment limits that are within our commercial contracts, which is there there's a wide variability of those contracts of What they are some honor the full Rate increase and some have caps So all of those are taking into consideration based on the commercial payer And then lastly self pay um For our budget assumptions. We're assuming the same bad debt and charity percentages as a percentage of gross patient revenue that we're currently seeing this year Okay, next slide. Uh, this is a A summary of our charge request Our fiscal year 22 approved charge request was 8.3 Our 23 request is 10 percent Next slide. I think bob you're talking about this slide Whoops, sorry. I was muted. I'll recap the adjustments again on the utilization side from our 22 projected again in um October of last year we launched the podiatry service and it has been a real um It's been a real success story for us starting at one day a week growing to two And you know, then we're at we've been at two days a week and now we're going in august to 10 days a month And so that schedule is very full Um when we get over to the wait times, you'll see that that's one of the areas where we needed to expand To accommodate to and improve the wait times Um, we are recruiting one general surgeon We've historically had two here at this hospital So we have one full time one now and we're um Filling in his coverage with locums physicians now But we are budgeting to add a second general surgeon in january. It would be here full time We're transitioning to two part time Gynecology surgeons that we have had for several years to one full time physician Um in september and we're also recruiting some additional support for that doctor to help in surgery help with call and um in with larger cases In urology, we've had the urology group coming one day a week and now they're increasing to two days a week That's a very a service. It's in very short supply in our area And then again pain management, uh, which um is a new service for us So this slide is talking about our other operating and non operating revenue Um budget to budget we there is a a three hundred ninety one thousand dollar increase um from 22 um 22 projected to budget We are budgeting a three million dollar decrease from the 22 projected Um this year we're projecting for 22 a five point nine million dollar Other operating revenue whereas in 23 we're projecting 2.8 And so that difference is related to what bob talked about in an earlier slide where this year we're estimating that we're going to be Um recognizing about 3.5 million dollars in covid relief funds Um one million of that is related to usda covid relief funding which we received in may of of 2022 Um, that was an application that we made or applied for back in the fall That was based on lost revenues from prior years We received that money in may and we recorded The revenue for that in may Um, there's also 2.5 million dollars related to provide a relief in arpa funding That we believe we're going to be taking into income by year end. Um, we still need to go through the calculations Um for that and probably we'll do so at year end, but we think we can take Um that as a result of our high cost and travelers that we've been experiencing um Our other operating route Operating room other operating revenue sources. We have four major sources of operating revenue Um that we're budgeting for one is our adult day program The second is our master's shared services agreement with north star health, which was formerly springfield medical care systems um That's where we share administrative staff Um with the fqhc um We also have in our other operating revenue grant revenue Um We were conservative for the grant revenue that we're budgeting for we have about 500 000 dollars in there Um that we budgeted We will be applying for the FEMA grant by the end of september Um, so we're definitely pursuing that there will be conservative. Um and what we're estimating for revenue And then lastly um provider relief funding. So we're not anticipating any new funding for 23 in our budget um, but we did receive um 2.8 million for arpa and Um provider relief funding in november and may of 21 So of that 2.8 million we estimate that we're going to um be able to recognize 2.5 million in the 22 um projected and the remainder of that 300 000 we have for um 23 And we have no significant non operating items budgeted for 23 Next slide, please Okay, so on to that was um the revenue portion so on to um operating expenses and this is compared to 22 projected operating expenses of which um We're budgeting a 2.6 million dollar increase projected to budget which is four and a half percent Um, we have included in there about 5.5 percent for inflation increases For supplies drugs outside services utilities, etc um salaries and wages um are projected to increase 2.2 million dollars and that's the largest portion of the expense increase Um, that has several components to that One which is the bulk of the salaries and wages increases that we're continuing To budget for positions that were budgeted in 22 that were not filled Um, we also have the 2 cost of living adjustment that we're budgeting for december We had a 2 cola um last december We also have market adjustments that we're budgeting for for next year As we're anticipating increases um that are necessary to remain competitive And we also had to make um Market adjustments this fiscal year In order to retain um necessary staff that we're going to go elsewhere Um, and then lastly included in the the salaries and wages increase We also have some new staff positions To support volume growth and some of the utilization Um increases that we had talked about um Travelers um projected to budget we are anticipating to decrease Um about a million dollars from where we think they're going to be this year which bob had mentioned Um, we're going to end of the year with an anticipated four million dollars in traveler expenses Next year we had budgeted about 2.8 uh 2.8 So decrease from what we're experiencing this year to next year Um, some of that is related to the programs that bob briefly talked about that we're doing with our current staff Where we have a premium per diem program An extra hours program and we're also utilize utilizing International staff in several different areas um, and that staff is um about One and a half times what we would pay um our own staff, but about 50 less than what we would pay For travelers. So we're saving a lot of money um in that Employee benefits, we're expecting to increase 481,000 um, that's related to increases in our health insurance plan um payroll taxes Related to the increased salaries and wages We also have in here a full year of our 401k match Um, which we started back up again in this fiscal year in january. So Um, only nine months of 22 we have the 401k match, but we're Including that for a full year in 23th Uh, next slide, please um again, some of our um reasons for the operating expense increase from projected Uh, medical supplies are expected to go up over 300,000 primarily volume and reflash inflation related Um, other purchase services are projected to go up over 200,000 Um, with some of our contracts that we have in security Um, our reference lab services diagnostic imaging Um, and then that 200,000 includes inflation um drugs We're expecting to decrease a net of 500,000 as a result of reducing the oncology utilization And then recruiting and advertising will increase by just under 300,000 as a result of increased Uh, marketing efforts Next slide, please So these are the this is operating expenses versus our 22 budget Um, is an increase of 4.8 million budget to budget Um, basically is the same increases that I just talked about versus projected with the wages Um inflation volume related increases Um The wage portion of that is about 1.2 million Um, the largest budget to budget increase is because of um under budgeting for our travelers for 22 Um, we had budgeted in 22 $1.3 million and like we mentioned at the end of the year, we think we're going to have $4 million for 22 projected But next year we think we're going to have less than that with $2.8 million. So Um budget to budget, however, that's a $1.6 million increase for travelers And then lastly Um, another portion of our operating expense increase budget to budget is the provider tax Um increase which is 6 percent of our npr increase And that's about roughly 700,000 Next slide, please Um, our fiscal year 23 operating margin. We're budgeting an operating margin of 1.7 million dollars, which is 2.8 percent That will cover our expenses plus our Principal debt payments It will allow us to invest in high priority capital improvements that we have not been able to make For many years, you know since chapter 11 Um, and then also to make our required annual contributions to our frozen defined benefit plan Um, our operating margin is going to allow us to basically maintain our balance sheet and cash reserves Um and stabilize them Next slide um, the 23 budget Supported by the 10 charge increase is a need need space budget And as I just mentioned only projects the hospital to maintain our cash reserves Um In summary the operating margin is based on our current volume Plus making adjustments for the utilization changes that we had talked about for 23 and builds in our rate adjustment But it also includes budgeted costs that are necessary to invest and retain our staff Make facility and capital improvements Um, also allows us to have adequate resources to care for our patients And includes the cost pressures that we've experienced in 22 That were unforeseen and then built in additional inflation for next year Next slide, please um, this is our income statement um So I will go through some of the highlights of this some of which we've already talked about um Our 21 It starts with the 21 actual in the first column Um, again wanted to point out that for gross patient revenue and net patient revenue um, our inpatient psych unit was Um operating as a coven unit the first half of that year And because we had a low adc of less than one um The gross patient revenue and net patient revenue was lower But that was offset by grant revenue that we received by the state to help support that program and that grant revenue from the state Was recorded under other operating revenue in 21 Which is why you can see that four million dollars includes about a million and a half of grant funding from the state to support um, the inpatient psych program as a coven unit Um our 22 projected Um versus the 22 budget Um gross patient revenue was down Um projected a budget about 4.5 million Net patient revenue was down about 3 million Um, as bob mentioned, we did have a busy first quarter of 22 But then we got hit in january with the lower volumes due to the covet variant Um, the volumes really quite haven't rebounded to where they were in the first quarter of the year um Our other operating revenue for 22 was the 5.9 million which includes the again the three and a half million For the usda grant and the provider relief funding um We did not budget for that in 22, which is the the bulk of the difference between the 5.9 million and projected in the 22 budget of 2.4 for other operating revenue um projected to 22 projected a 22 budget for expenses are up by about 2.3 million dollars Um, the travelers comprise most of this variance for 22 um Again, we had budgeted 1.2 million for travelers this year and we're Going to end up with uh four million dollars by the end of the year we think so that's about a 2.8 million dollar variance just for travelers um And then we project Which we've talked about in an earlier slide But we project that we're going to have about a 300 thousand dollar margin this year primarily due to recognizing the three and a half million of usda And provider relief ARPA funding Um, so you can see without that funding that we would be in a much different position Um, probably around a three million operating loss without those funds this year Um, and then lastly the the 23 budget column the last column um Budget to budget there is a large increase um for gross patient revenue Five million dollars of that is volume driven and the remainder of that is the 10 percent rate increase um, that net net patient revenue difference We had talked about in the earlier slides and what components are The utilization and the rate components of that um Other operating revenue um Basically is consistent with our 22 budget with the difference being about 300 thousand due to the the remainder of the provider relief funding that we're expecting to to take into revenue next year um Expenses um will increase 4.5 percent Um projected to budget um, that's primarily due to staffing and inflation um, and then we're Rejecting to end up as we as I just said with the operating margin with a 1.7 million dollar margin for this year um, which is a 2.8 percent margin Which we'll see in the next slide will basically um bring us to a break-even um Point in terms of cash A lot of numbers here. Okay So this is just a summary of our EBITDA and cash flow The EBITDA we're taking our operating income of 1.7 million dollars and adding back non cash items of the income statement Which is depreciation An interest that gets us to 3.1 million dollars And then removes from that amount cash obligations that are not in our income statement, which is our principal debt payments Punching expense funding and then um the 1.5 million dollars that we have earmarked for capital purchases for next year And you can see that basically is um a break-even cash flow for us um Next slide So this is the last slide that I will be going over um before turning it back to bob. This is on our days cash on hand um From year to year you can see in 2019 Which is the year that we filed for chapter 11. Um in june. We had 17 days cash on hand at the end of september um 2020 um to 23 we have basically been pretty consistent in the 40 days cash on hand range um in 2020 we received 5.4 million dollars of CARES Act funding just after COVID hit Which helped our cash And then in 22 projected That includes the receipt of 2.8 million dollars of the provider relief and ARPA funding that we received um, so overall we're projecting um To be at the end of 23 in that low 40 days cash on hand range, which is about just over a month and a half of cash Um, so we're pretty fragile um from a cash standpoint um, we have the lowest reserves in the state um at least According to the remont digger back in march That's primarily due to our chapter 11 that we had gone through Um over the last couple of years and everything else that we've gone through um We are showing that the data um, there's More than half of remont hospitals has more than six months of reserves. That was as of september 30th of 21 That's probably changed since that point um from september to now um, but it basically This is showing that we have no rainy day cushion Um with 40 days cash on hand And so we feel that the 10% rate increase is crucial to our sustainability um moving forward um I do want to point out before handing this over to bob I wanted to to give a quick overview of our budget process that we go through um And just to say there's a lot of thought and process that is put into our budget This is an extensive process for us over a five month period of time that we start late march We begin the process of our budget by Pulling together historical and budget data um We send those for our we send those to our department managers for review And we feel it's very important to involve our managers in the process of our budget so that they understand our finances um The managers review data that we give them for historical and budget and then they provide Input on the resources that they need for the 23 budget in order to provide patient care in their departments Um, they go through what fge's they need They go through what supplies they need what services they need Um, and also have input into the volumes in their department Um, they also go through a very extensive Analysis of what capital needs they need for their departments and then provide us with a list of what those needs are And break those down by high priority medium priority and low priority Um, that process is about You know up to two months and there's another two months that we spend pulling the budget together We take the volume You know the utilization we turn that into gross patient revenue net patient revenue We take the fte's that are budgeted. Um, there's a lot of time spent I'm calculating, you know, what wages are based on fte's based on current rates Adding a cola onto that And then we also have to factor in the cash needs Based on in addition to those things based on their capital needs um Then we have to Present this to our finance committee and our um, our board for approval Um, and then after that we complete all of the budget requirements for the agreement on care board submission Um, and then a month or so after that we spent on the presentation creating it and getting ready for it So I guess just wanted to point out that it's um important um, that we're a lot of time has spent putting this budget together um and For the budget that we're presenting today Thank you. Thank you, kata. And I do want to recognize the work that kata and her department have done along with um Anna smith and uh crystal moray in our office who do a lot of the work on the present Crystal does the numbers and they do a lot of the hard work on the slides and the research behind the strategies and um Also just to point out the way this has flowed into our process this year because we did complete Our strategic planning initiative in the spring where we rolled up all of our stakeholders and constituents into You know to arrive at a At a strategic planning process for the hospital Which has also rolled into this process And then the final piece of that which we'll talk about a little bit later is We have just now completed our Every three-year community needs assessment And we are now we now have those preliminary results and those Then those results will be flowing into our ongoing planning process as we go forward for the next couple of years so I was going to Stay on the agenda. I was going to talk a little bit about our um our progress that we've made with diversity equity and inclusion Which we basically in fiscal year 22 In the fall we started our training and education initiatives with our employees and with our managers and those processes Have been ongoing throughout the fiscal year We are now moving to For we're now moving to the next phase of our program Which is to actually develop our own dei committee And that committee will begin meeting in september of this year And we'll we'll work on developing our our strategies and best practices regarding racial social sexual and gender gender diversity And so again, you know that that will be paired up with our organizational wide education promotion and then we also are Joining in with our community health equity partnership Which is being sponsored by the springfield health district And we'll be participating in that to tie the hospital's efforts to those of the communities with our dei efforts So next slide, please You'll talk a little bit about our wait times. We conducted the wait time survey during the first two weeks of june and um We We learned quite a bit about this data one thing we we know we have pretty strict Uh standards that we like to return all patient Inquiries within 24 working hours Um, I think I think we were pretty pleased with some of the of the results that we got here Our specialty practices are doing a great job. Uh, there's they saw their patients within two weeks of the scheduled date um One of the ones where we had some challenges was around podiatry Which was a new service for us and because we had limited availability. Um, you know, that schedule filled up Quickly and got backlogged in a big hurry And so we're now adding days to that schedule as well And again, our podiatrist is the only one in the community. So, you know, if you if you If we don't provide that service then our patients have to leave springfield and leave the community to receive that um Cardiology we have a great partnership with Cheshire Their physician that we have helping us here is fantastic But that is a part-time service. And so that was another area where we had some wait time delays um But all the other ones. Um, we thought we thought we're pretty good. So, um Next slide please Just kind of going through a summary again of of our risk and opportunities Again continued shortage of skilled health care professionals and staff Tends to be one of the biggest challenges we have now is is recruiting staff Rise and of course this has led to rising labor costs both in terms of having to rely on travelers as well as you know driving Increasing cost in the market for us to remain competitive for staff We still have a lot of uncertainty about COVID-19. I just want to remind everybody that, you know, COVID-19 is still with us and we still have patients in the hospital That have COVID and we have patients that are coming to the emergency room that have COVID And we are have luckily we're having less of this, but we still also experience employees who are exposed That either are positive or we have to have them quarantined so that they don't expose anybody else and those shortages again Cost problems with staffing and ability to take patients in our our capacity Inflation is anybody's is anybody's wildcard? Although we believe that a lot of the inflation impacts that we felt in f y 22 Are rolled up in our run rate for those costs in 23 So a lot of that's built into the pie there supply chain disruptions And again, we've had difficult. We've also had difficulty getting supply items But to substitutes we've had to turn to many times have been much more expensive Our opportunities going forward Center around continued focused on our revenue cycle This is an area that we think we have opportunities to improve our performance as an organization Um Continuing to reduce travelers Developing and implementing new services to meet the needs of our community and improve access in our community And in our strategic planning initiative it helps us continue to understand You know, what are the needs in our marketplace and what we can see by our preliminary Excuse me Accessibility and affordability are big issues in our marketplace Talk a little bit about or a little bit more about our strategic planning process that we went through Our process Was conducted in the spring the winter and spring of this year Excuse me and it involved all of our staff. So this was a completely top up Process where we started off with soliciting input from our staff our medical staff And then we drove that data through our senior manager management team And through our board of directors and our consultants at qhr health Helped us to facilitate and organize that process So we had some really good help with some folks to do that For a living to help us um We identified three key areas of focus which we will be Emphasizing in the upcoming year first is to stabilize our finances in our processes To to identify and invest in our core services and what are the things That are are needed in spring field and what access is necessary here Um, what what should we provide and can we do that affordably here at our facility? And then our probably our most important one is to continue to develop our people in our culture You know as a small hospital we have a very very much family Atmosphere here at this hospital and that is one of the things we do best is to Is to have neighbors taking care of neighbors and have a family oriented culture here And so we'll be aligning those Um those Products from our strategic planning process will be aligning those with our community health needs assessment And again the two biggies that we're seeing come out of that are Access to care in our community of in affordability for care in our community Those are those that are pulling two of the biggies that are coming out as preliminary findings Next slide our value based participation. We are We have agreed to continue participating In 23 and the same products that we were in in 22, which is one care and the medicaid product blue cross and mvp We were going to not participate in medicare And in as we as we look at any of these value based products We want to make sure that they support, you know positive cash flow And provide, you know stability And and reduce our risk because you know, we have been in such a fragile financial position I mean we have to constantly Evaluate how much risk we can accept as a hospital Next slide, please Talk a little bit about our capital investment plan This slide Roles up our key capital initiatives that we are projecting to undertake at this time The first one is the renovation of our nuclear medicine department Our equipment there is quite old and unreliable and we Matter of fact don't hardly ever do any nuclear med Now because of the condition of that service and we are we're we are now evaluating Replacing that equipment and it will require the renovations to the room and to the radiology department to accommodate that Also anticipating acquiring a new c-arm for our operating room that's used by several of our specialties, most importantly urology and orthopedics We have a couple of aging pieces of equipment in the lab our blood culture and chemistry analyzers We're also Having a community fundraising effort right now to replace our IV pumps that are used around the hospital and we're anticipating having to Focus some capital on that As well as some either a replacement or some refurbishment to our nurse call system And then we've put 270,000 Aside from miscellaneous and unanticipated capital items that will either be replacements or or things that You know in some cases some of these may be revenue Generating opportunities that we don't have equipment for now And as I mentioned earlier over on the building side, we have two or three Important building projects that we're going to focus on this year. Most of them involve our HVAC equipment and the mechanical engineering systems in the building But we expect Of most of that expenditure to be funded through the usda grant that we mentioned earlier So that covers our capital priorities for the year And then we have on slide 40. We have wanted to make a few comments about the supplemental data monitoring Um, we spent a fair amount of time analyzing the data that we were provided Um, and if we had some interesting findings, uh, the one thing I want to point out most importantly about about our analysis was The decrease in market share that we've experienced during this time And we've had several things happen, of course, and we talked about them earlier I mean, we've been through a senior leadership change in this hospital which rolled over into the hospital declaring chapter 11 And then while we were in chapter 11, we were in the midst of taking care of the community during the pandemic And then during that process at emerging from chapter 11 We split with our parent organization Which required a large amount of restructuring which by the way again that there's still we're still working on on the relationship and Getting that That finished and right. There's still some parts of that that are not completely finished And so And and we think about the changes in absolute So those things have all had a negative impact on our volume Plus we've had some other things that were more systemic changes as part of our reorganization We did close to childbirth center. So if you look at us from a service standpoint Um, a lot of the the tough things that That were done here structurally on the hospital were done during the chapter 11 process um The windham center was closed temporarily for renovations Which reduced utilization Then the center became the covet positive unit for psychiatric patients for the state And again as kata mentioned, um our census was very very low there and the uh Fees the state was the state was paying us for to hold the unit on standby Those were not counted as net patient revenue. They were counted as other operating revenue. And so that We've also seen some declines with our partner the fqhc They've seen a decline in visits Particularly around the same time that we saw our volume plunge as a result of the delta and omicron variants So their volume also went down during that period also, um And then we also had a change a couple of years ago in our emergency department providers And that impacted our net patient revenue because the previous provider the hospital was doing the billing And the net patient revenue was flowing through our model And now the provider builds separately So that that was a shift in revenue too. So we we believe that these are significant things that affected, um The data in the supplemental data portion Let's see next slide, please Few other market share points just to make um the the data does exclude Vermont residents That are seeking care out of state and in our region of the state here in the connecticut valley That's pretty significant because a lot of uh tertiary services That we don't offer are provided in new hampshire. And so a lot of those that Volume and that revenue flows across the state line Um in that direction Um Many of our service line numbers are not statistically significant because we have small numbers because we're such a small hospital And again, again, we've had service line changes which have affected our overall volumes in terms of the emergency department Urology the closure of the ob service um So a lot of these numbers are not are very very small After those changes are taken into consideration And then finally if you look at our population our population is Is older and our um poverty is increasing in our marketplace. So these um You know, so I think our health determinants social determinants of health in our marketplace Are um also a challenge for us in our hospital facing my book around so uh Just reiterate the impact of coven on our hospital. Um, you know, we've experienced um you know reduced staffing Throughout the year due to covet exposure people that were ill with covet or were quarantined For protective purposes. So that's affected our staffing and in those downturns and staffing have affected our volumes on many days um We have been hit like everyone else in the country with the great resignation. Um, we've had staff who have just left and um Hopefully they're going to return to the healthcare marketplace because we need their uh skill and training The timing of the delta and omicron variants and how that affected our utilization I mean our patients stayed home in droves when those variants hit us and that definitely affected us on a revenue standpoint um We did learn a lot about our incident command and how to work very well as a team Both internally and externally with the various other agencies in the state and across the region And with our partner hospitals. And so we have we're certainly much better at doing those than when we started And again the value of our relationships with the local hospitals or colleague hospitals agencies in with the state Can't say enough about how strong That process is work during covet and it's really been one of the things that set for mon apart The success we've had here. It's been one of the things that set us apart from some of the other states Is being able to work together and coordinate those things um Still have lots of vulnerability due to supply chain disruptions Uh and unexpected expenses due to covet. We still don't know what's out there or what's going to happen and um You know, how will inflation continue to affect us when it's winter in vermont? We don't know we can't predict what heating oil is going to cost today when it's when it's winter in vermont and By the way, my first winter in vermont was quite cold. So I'll just mention that so Okay, next slide please So this brings us to to to the conclusion of our presentation. So We're we're still in a very challenging marketplace the world for healthcare is still a pretty hard world of that But as you can see our Our resilient hospital is continuing to thrive despite these challenges and we're continuing to grow and Just consider how far we've come in the last four or five years Due to the hardships and challenges that this hospital has has encountered And so I really want to thank all of our team here at the hospital for their hard work in extra efforts that they have put in to Get the hospital where it is today because it's certainly been a big challenge And we would not have been successful without the hard work of our team here and the support We've received from our community from our board and um from the state And every and everyone that has been behind us cheering for us during this challenging time So, uh, thank you So, well, thank you. Um, and let me echo that You know gratitude for all the hard work that you've been doing and Continue to do and all the work that your community is doing as you know, your staff your frontline workers You certainly springfield does face unique challenges. I think with the chapter 11 restructuring the leadership changes that you've experienced Um, and thank you for coming in and and taking over that uh ship um And you know in addition to that the acuity the demographics the socioeconomic status of the the patients that you serve only magnifies the hardships That I think all hospitals are facing right now in particular for springfield. So Thank you for what you are doing And I skipped over that process. We we are now analyzing our acuity and our cmi And we have over the last five years. We have seen a consistent Gradual increase in our case mix index in the hospital. So our patients today Are sicker than they were when we started this process And so we we've been looking at we we're getting into Repealing that back and looking at that because when we go on the floor and we we talk to the caregivers And we look at the staff the patients on paper. We can see that they are getting sicker and You know, we are we're rising to the challenge of that change in acuity here Yeah Well, I as one more rumor I can tell you that I appreciate that work Um, I am at this point. I'm going to open it up to the questions from the board and I've I've been starting with robin I'm going to continue to do so so board member lunch Thank you. Um, thank you bob and kata for your presentation Um, so one question that I'm going to ask all the critical access hospitals is to talk a little bit about uh, your fiscal 22 Uh, financial pressures and how those will flow through into your medicare cost report and in your particular situation it sounds like Um, at least some of the travelers costs may be reimbursable through some of the federal funds that you receive So, how does that all interact the federal funds the increased expenses in the medicare cost report? Well, that's a complicated question. Um That's why I'm asking you guys We've had we've had a again we've had we've had a lot of unexpected increases and um where we are today is Is different than where we thought we would be a year ago Um, you know, I'll probably have to defer to kata We do we are planning on taking some of the grant income in the grant proceeds into income Because those are will be taken versus additional covet expenses So we feel pretty confident that we will be able to comply with that Which is why we have built it into our projection for 22 to we've anticipated that we will be able to take that income um From a cost report standpoint Um, kata, what is our number? What is our number now? We're about uh Maybe i'll ask mike. What are we at mike 38 percent now? On the cost report factor Um, oh patient wise it's uh about 38 percent inpatient and we really don't calculate it on a percentage It's calculated on a per diem Uh, the one thing me I'd like to answer the question about the cost report impact when it used to be we hospitals would wait until They file the cost report to know the impact of the cost reports and um We put together a cost reporting model That we use quarterly to determine what the impact Of the of the year to date Medicare cost report effect is And we actually book it to our general ledger And then Five months after the close of the year we file the cost report We we compare the asphalt cost report to our preliminary projections american adjustment to the asphalt cost report So When we did the budget this year we took the model We we we rolled in the budgeted trial balance We rolled in the budgeted volumes And we calculated what the impact of the medicare cost report would be and we incorporated into the net patient revenue from medicare and it's it's a It's a pretty Intensive program But once it's set up it works pretty well and it can be utilized for Like I said a quarterly review A comparison to the asphalt cost report in to be able to Calculate what the budget impact would be on the changes we made so It did have a little bit of impact. I believe it improved improved The reimbursement a little bit in terms of Outpatient In in the in the budget Thank you. Thank you. That's helpful Robin I'll just mention that kata Kata just no sent me a note that she was uh kicked out of the system for for a moment So she's she's attempting to log back in so she's missing for a moment Okay Well, if we need her for a question we can I can move on to a different question. We can circle back if that works for you Okay, certainly the the other option of course is to just note it and you can uh come back after the hearing if needed Okay So I wanted to talk a little bit more about Um any cost savings Initiatives you have underway and or that are reflected in the 23 Budget, so could you speak a little bit to how you approach approach cost savings year to year and this year in particular? Well, this again this hospital went through quite a bit of restructuring Um due to the financial difficulties. So a lot of the you know, we have become very diligent about The our expenses at this hospital. So we're very cautious about what we approve and what we authorize to spend So we're pretty tight on the things that we do We work very closely with our department level managers on expenditures During this time in particular we we have tried tried through the last few years to defer as many cost as possible And to economize on as many things as as possible The thing that's kind of caught us this year. I think is in addition to the travelers has been some of the supply issues You know, that's that's been hard and i'm i'm a little concerned about the The heating costs this winter. So hopefully That those prices will continue to go down before it gets cold so But I think it's a daily it's a to answer your question though It's a daily it's a daily task for us to to try to hold on to the cost savings that were built into our operations a couple of years ago Thank you And in terms of the travelers it sounds like you were budgeting for about 15 travelers And you've reduced the expenses a little over a million from your 22 projection um Could you speak in a little or if kata needs to talk about this and we need to do follow up? That's fine. I was just wanting to know a little bit more about Uh, how you came up with that million. Are you assuming travelers costs will come down? Are you assuming some of your recruitment recruitment and retention will? Uh, keep more employees and so you're reducing the number. Could you just walk me through that a little bit more? Well, we're we're anticipating all of those things to happen We are seeing a decline in the rates Although I don't think it's been as pervasive yet for us as some of our colleagues have noted But we believe that that is happening We also have a couple of staff members that are international staff Did have agreed to join us did have been held up in the immigration process And so we have at least two rns that are did are We are waiting to bring to springfield that have have not been able To be processed through the immigration process because the embassies and a lot of those Processes have been either closed or slowed down in their home countries And so we we know that we are hopeful that we're going to get two or three of those staff members In this fiscal year, uh, which will reduce cost um, so rates We're and we we we are focusing on our recruitment process. So we're hoping that we will People will come home to work and that we'll be able to hire some people back Thank you I had a question about one of the tables on page three of your submission um Which is so you have Table two dash one and two dash two And i'll give you a moment to to get there And this page three on the slides are on the narrative on the narrative okay And these tables show npr for fiscal year 23 change versus the first one is the approved budget and the second is the 22 Projected and I was noticing in the approved budget. There's a sizable decrease in total commercial and I was curious What was kind of driving that and I was wondering if maybe some of that was moving the medicare advantage from medicare to commercial Hi robin, um I apologize to my The key the teams kicked me off. So I was off for about 10 minutes trying to get back on ahead to restart my computer I'm sorry k des. Uh, it just happened to happen, you know right now out of all times Of course, yeah We did um Send an updated workbook With I believe changes to these particular Tables, but okay to answer your question. I do think we did move Medicare advantage, which was in the commercial bucket last year and we moved it to the the medicare bucket for this year Um, so I think that is the reason for the decrease In commercial okay, great. I thought perhaps that might be driving that but it was such a A big negative compared to the projected that I wanted to understand that better um And since you sent an updated so I did have some other questions about some of the tables and stuff But I haven't seen your updated workbook. So I think I will just pass on those assuming um that if If they're not answered in the updated workbook, then I'll talk to our staff about it um In looking at your slides and I apologize, but the printout that I have does not have slide numbers on it But it's the covet graph the covet impact on volume graph Yes um I was curious if you had any additional information under um Underneath The the trends to that could speak to what type of services you were seeing declines or flattened related to the spike in covid cases I'm asking this because one of the area one of the analyses we saw in the rate review process spoke to um They're being a pretty Direct correlation with the emergency department and urgent care utilization But that at least on the insurer side the trends seem to be that Uh reduction in other sorts of services kind of caught up within a few months. So if you looked over the course of the year um You know things sort of equalized except for that ed and urgent care And I'm wondering if you saw something similar or if you were just seeing completely different type of service trends um Rough when and when you're looking at the covet impact or whether you don't know because you didn't look at that type of analysis This the slide with the covet impact was basically us testing our hypothesis Because again when we were in front of this board a year ago um the volume trends were We're strengthening and improving and we actually had pretty good months in september october and november last year financially And then we were we were accomplishing The projections that we talked about with this board a year ago And then when the first when these variants started hitting people You know the volume went away in droves and we this this graph was intended to test to see whether that was our imagination Or whether that was true and when we crafted it against the state volume we discovered that it we we believed that it was true That you know, it definitely affected us on the volume in the revenue side um Do we do I mean we can go back and look at how it affected us I would say the big place where it affected us in this period was probably on the inpatient med surge census Now kata can speak to that if she thinks i'm wrong or right, but I think it was on the inpatient census That it hit hit us mostly um After we got past the first of the year We started having some of those capacity problems at windham with people being out and being quarantined and things like that So that that affected some of our census during that period when we would have normally been completely full Great, I guess I would just add to that so we keep our um, we have a volume trending that we keep month by month and it's by color so The green is the highest volume point of the year and the red is the lowest volume point and we call it a heat chart And in that big dip that we had in january We're seeing a lot of reds the lowest volume point for a lot of the ancillary outpatient services primarily and it was almost across the board So a lot of the diagnostic imaging departments and um outpatient departments We did see a slight decrease in the inpatient census, but it was also the the outpatient ancillaries Thank you um Related to the oncology change where you're you're switching from input patient to telemedicine Uh, which restricts, uh, the the chemo access. I'm just curious where you're where you think your patients will end up Uh, moving to for chemo. Do you think they'll go to Dartmouth directly? And if so, does that mean that they can then be served by telemedicine in the future? Or do you think they'll be switching hospitals completely or if you have any any thoughts on that? Which understandably you may not know Well, I'll have some comments on that one is we have very good partnership with darmouth And they provide the physician stamping for that program and we have worked closely with them You know, this is this change is driven by a shortage of providers on their side and So what it so what has happened is these were basically outpatient infusion therapy patients that were receiving chemotherapy and the When we when we changed the model, um, we the patients that were very stable We were able to continue to provide chemotherapy on the ones that were in pro process But they were reluctant to initiate treatments on new ones unless they were present during that time. And so Those patients are those patients for those treatments now are are going to one of the Dartmouth sites And we're trying to make the telemedicine available here at springfield for access convenience for our patients because that group is a very very, um You know fragile group and you know having them travel We're trying to minimize the travel they have to do and so if they can see their physician for a telemedicine visit rather than make the trip Then we're trying to we're trying to do that for the benefit of our patients Excuse me But none of the none of these were inpatient problem. They were all outpatient Yeah, yeah, yeah, no, I I think I understood that what I was not understanding Is how that's going to flow to the future like when you're like will there be new patients? Obviously for the initiation of treatment that should be done in person But then once it's initiated will some of those new Patients then transition to telemedicine or will they always stay in person at the other place? That's the piece of it the future looking piece that I was trying to understand Well right now the way it's working is we're expecting the ladder to happen with the new patients We're expecting them to receive that treatment at one of the adornment locations Now we will be able to do other infusions in that We will continue to do other infusions in that center other than chemotherapy because there are other drugs we infuse Other than just chemotherapy Got it. Thank you very much. Um, I think I'll given the time I'll go ahead and stop there. Thanks Great, then I'll turn it over to board member Pellum, please Thank you, and thank you both for your your presentation I'll be quick here. I want to just start briefly Kind of following up on one of Robin's questions when on page four you had the Sentences at the hospital's classifying Medicare Advantage Plans in the Medicare payer category for 23 to change from FY 22 where it was classified in the commercial payer So I went looking to try to find what that meant and I went to the payer mixed tables And you could see that the Medicare for the year over year column Was up 43% and the commercial was down 12% but there wasn't any Specificity about, you know, how much was related to this change? And so I then went to the reconciliation table Reconciliation table thinking that maybe it was under Change in accounting practices, which is one of the the lines there and That was blank. So, um, in order just to get a better sense of of how I mean because from an npr point of view, that's a zero sum game So in order to kind of understand the shifts, you know that detail I think unless it's somewhere else in the app in the application. I just missed it, but um Maybe the reconciliation table might be the place to put that So that's that um on a topic which you know, I for some reason have Gravitated toward The provider tax. I noticed that if you take your 2023 provider tax Allotment at 3,526,000 And you divide that by 6% You come up precisely to your npr fpp value So the chances of that happening by chance are I could have won the lottery or something it's uh But it you know that your allotment for provider tax divided by 6% comes to 58,778,633 dollars or something like that Which makes me think because most people are calculating the provider tax against their prior year npr fpp And so that would Put you in the position roughly of applying it to the 51,720,000 which is your 2000 and um 23 projection So I know there's a lot of nuance to the calculation of the provider tax, but I don't think it applies The to your current to to The 2023 um what you pay in 2023 in tax relates to your 2022 npr fpp but I also know that Different hospitals approach it differently and there are nuances to that like I learned today that swing bed revenue doesn't count. So there's you know, there's um Some noise there, but I I think it might work to your benefit to kind of take a deeper dive into the provider tax and the calculation method um I also was looking at kind of on the income statement where The you have fixed prospective payments And you would have them fully reserved on the income statement And so I went kind of looking for where that was and those fixed prospective payments are on medicaid um, and so i'm just wondering Why you feel you need to fully reserve um those fixed prospective payments, especially given that medicaid Um, it doesn't require you to reconcile So i'm assuming you're talking about the adaptive and how it's shown in there. Is that what you're basing the information on? So we treat it like that in adaptive because it's it's rolled up in our net patient revenue And it's including in our medicaid npr calculations, and it's not really split out So that reserve or that amount that's in adaptive is our actual payments that we receive Um, so it's to demonstrate the actual payments, but the net patient revenue For that is just kind of embedded in our in our medicaid npr. So I guess that reserve is just to show that these are the payments that we received, but this is actually in our medicaid npr um So we're not essentially fully reserving for that. It's just a presentation I guess it's how we're putting the information Yeah, so the way to so the way to read that is that your medicaid npr Includes the fixed prospective payments Um, and on the income statement you're just kind of Separating that out and neutralizing it. Um, just to kind of show Right exactly interesting Okay, well, um And then finally my final question. I as it's kind of by listening. This is our third hospital Is getting a sense of when the fever might break on travelers you know at some point in time i'm just uh, you know You read how the kind of the the multiplier that that is being paid to agencies and to travelers over regular staff and um, you know, you see numbers like You know 200 increases and 220 percent increases I mean these are big numbers and powerful forces in every hospital budget And i'm wondering if you just can get a sense as to when the fever might break From your experience that people don't want to be travelers anymore I mean if they're to make 120 of what they could make, you know at your hospital They're not coming and it's just not going to work. And so Is it How to frame this question. Do you think the traveler situation that the economics of the traveler situation? um, are long lasting over a number of years um, or will the efforts that the state is making to um In terms of its workforce efforts to um Unravel the traveler problem that those might take hold sooner than later I mean there's there's no precise answer to this but you know, I'm not in the field I'm not seeing this you at a visceral level and and you folks are and uh Just wondering when when you think this this thing might Turn around well, that is a good question One that we don't really have a a scientific answer for I mean There's no doubt that it has resulted in a seismic shift in hospital expenses and when the When the When the high tide recedes to low tide, we're still going to probably be left with a lot of increased hospital costs across the nation and not Not only driven by that, but also driven by the great resignation because Just my crystal ball I see a lot of people that are At or near a retirement age in healthcare that have stopped working during this period of time and Before they return to the labor force because they're going to be retired fully Now how do you quantify that I don't know but um You know the largest cohort of the baby boom Is probably 64 to 65 years old and to the extent that that group Stepped out of the labor market temporarily If it takes a couple years to step back in they they may never step back in You know, I think they've decided that it is time to retire because working in healthcare is pretty um It's pretty hard and it's certainly more challenging now than ever before With the uprising acuity of the patients And you know one of the things that those things that we're seeing with a lot of bedside staff now Is the impact that Violence and abuse Is taking on them because we've had a lot of people a lot of our staff have been assaulted in Either physically or verbally abused by by patients and families Because everybody is very frustrated out there now And maybe to a certain extent scared of what's going to happen But I mean certainly there's a rise of violence and abuse Among our staff so Well, thank you for that. I just I mean, I know it's too early in the process But sometimes I like to get a sense of when To tide my turn on travelers because my guess is then there's Quite a bit of one-time money or two-time money or three-time money built into hospital budgets that might be able to be redirected to um to uh You know other concerns that you have and right now you're just You know paying for the travelers but at some point this could help your capital budgets and other budgets So that's all I had. Um, thank you again. I do think I do think we have to um, we have to make working in healthcare and In being healthcare professionals, we have to make that more attractive for younger generations because it's got to start You know, it's got we've got to start training the next generation of provide of caregivers And that's got to be an emphasis for us now so Well, this process has been labeled the stabilization budget process And uh, you know, clearly there's a lot of work over the next year in terms of the legislation that was passed by the state but uh, if this if uh Um, you know, I'm I'm not quite sure that 2023 will be the stabilization year um So, um, I'll return that you know the mic back to Jess On that optimistic note. Thank you Tom Forward member walsh Thank you. Jess and hello kata mic and robert. It's nice to meet you um First I think I want to echo something jess said earlier. I want to just um, thank you for stepping into such a difficult situation and and trying to Do the best that you can to take care of your population and patients and our Vermonters, right? It's um, it's not an easy task I don't I guess my my one question was about um How are you trying to understand the needs of the Patients that increase patient volume in your ed are you taking steps to try to understand what those patients may need in order to You know not require as much urgent and emergent care Is there any are there any initiatives going on to see what might be behind? that Well, we are doing some work on that now and um, we work we're working closely with one care and with our our primary care partner, you know north star health now looking at that to try to um Look at utilization of emergency room services to be sure that it's appropriate and um You know that the care is being delivered in the right setting And so we're partnering with um with one care on that Right now good I think it's um part of trying to understand the needs of the population we serve right to make sure that we have the um the We optimize a mix of primary care and secondary services and building practice model that's Reliant on secondary services at a time when Prices are going up premiums and out-of-pocket expenses are going up as those Out-of-pocket expenses are rising for patients. They're less likely to seek care. Some become uninsured others become under insured and so That downgrading of of insurance coverage and people Not going to the hospital or not going to the care provider until it is urgent or emergent Leads to higher acuity More time in the hospital and it also Leads to more unplanned and unreimbursed care And you can see a bad cycle that would start where if our Rising prices are leading to yet less utilization Then we we try to make up the difference with higher prices again It just it becomes a big burden on on our communities And there's a big burden already with out-of-control inflation. So I think it's it's understandable when people Violence isn't understandable, but it's understandable that Patients when we're encountering them are extremely frustrated and I just I worry about Overly optimistic utilization assumptions when the out-of-pocket expenses for the community Are rising I think there's data to show that they're less likely to utilize health care unless it's emergent So that's just a note of caution about about the utilization predictions um and trying to think through what um Are we designing a system that meets the needs of the patients that we that we serve So, um, I appreciate those comments And that's exactly what we're doing and there was the preliminary results of our community health needs assessment support The strategies that we have put in this plan because what people are telling us two of the most important things That we've received from as community input is access and affordability here and and Providing the care that's appropriate for this type of hospital Locally and in a more cost-effective manner and making access more convenient for the patients And so that's kind of what this is our plan Today is built around those two or three important points for our community Yeah, I I We we share A desire to do all that Bob and again, I appreciate you stepping into the role As such a difficult time and trying to to steer a Better course That's all that I have back to you chair Holmes Great. Thank you so much So a couple of questions for you. Um, this is a question. I've been asking all the hospitals realizing that the change in charge request doesn't always or often does not Uh correlate with what the effective commercial rate experienced by the typical commercial You know patient in your hospital Some hospitals have been able to answer it in the hearing others have said I will get back to you on this So that is fine, but effectively what I'm trying to understand is what is your historical relationship between change in charge and what the typical commercial rate pair experiences Typical commercial patient experiences on the ground in terms of The rate increase that they will face Recognizing that you have a whole portfolio of payer contracts, but on average, what would we expect? The relationship to be between change in charge and effective commercial rate so that we can then get a better sense of What does this 10 percent change in charge really mean for the the commercial patient coming in your doors? so Probably directed to kata, but recognize that that may not be something that you can just pull out of the hat And if you need to just circle back with sarah linberg, that would be fine I think it's something that we'd have to you know to look at an r. And it's not something that can just I don't know that number. Um Don't think mike you do either off the top of your head Mike, I think you're on mute. Yeah, i'm sorry. Yes Uh, I think that's a good idea to put something together that shows the the impact Not only by commercial but also by What the impact on medicare medicaid patients would be as well? One thing that we do know is that for our self-paid patients, we have a very effective financial assistance program And that self-paid patients When they apply for financial assistance will will get the full resources of that plan and and Have some benefit to them in terms of being able to Afford the cost for the self-paid patient Okay, uh, that'll be the numbers aside. I'll just comment on the complexity of the mechanics Of this process because we have multiple payers with multiple contracts and there's there's notice issues and Implementation issues and you know, so it's there's a lot of parts In this process. It's not it's not simple and straightforward So no, I recognize that so I appreciate that I think it's really helpful for us to understand really what is the the real impact of this change in charge increase Um in the in the narrative you mention heavy market competition and current uh pay levels that are below the market And I you know, given springfield's location in the southeastern part of the state where there are other hospitals nearby and in particular a very very large tertiary care center that is is Rather close In distance I wanted to ask you about their new patient pavilion right with its 65 Brand new spanking beds that are slated for completion this fall opening sometime in 2023 And while I I think this is going to be wonderful for patients And it may be wonderful for relieving some of the capacity issues some of the transfer and throughput issues that we've been hearing about You know from other hospitals and reading in the narratives Uh, one of the the concerns I have is that staff may be lured Uh to work at Dartmouth-Hitchcock if they are within vicinity of both springfield and Dartmouth-Hitchcock You know, it's a brand new facility. They have deeper pockets probably better way easier ways to pay you already said in your Narrative that you know, there have been below market rates So I wonder also You know, how's that going to impact your hope to get away from travelers and to you know retain your employees? And also What impact does that large new bed tower have on your projections for average daily census? I know you walked us through some of your utilization assumptions I never heard any Comment about how your utilization assumptions will be impacted by Dartmouth-Hitchcock's expansion And I noticed that you're increasing your average daily census, you know projection for next year from this year So I wanted to know if you could speak to how you're thinking about Whether that is a risk to you in terms of staffing and whether it's a risk to you in terms of daily census Well, I think definitely any large change In the marketplace has potential for negative effect on The other hospitals in the service area I think you named the ones that we would be most concerned about which would be the effect on the of Competition into the labor market. So I think those are the ones that would affect that I'm most concerned about as we look at this You know, I still think that there are primary care services that we do very well That we're very price competitive with that we do here that Should that and it's very appropriate for us to do them here. And you know, I'm Expecting that we will remain competitive with those, you know in in the upcoming year I mean if you look at the increases in volume that we have budgeted The percentage numbers might look like look large, but when you look at when you look at what the absolute changes are They're really relatively small. So, you know, can we You know, like for example, the site change is like one one patient day And we know that there's lots of site demands all over the state We just have to kill can we can we capture those patients and can they are they the right patients for our setting in our program And the same thing with med surge, we you know, know that there's delays at certain Sometimes there's access or wedding time issues And if we can be prompt or wood appointments and prompt or if operating run times Can we do those Cases if they're appropriate for us to do so yeah, I share your concerns particularly about the competition in the labor pool But I mean, we do have a very good relationship with that hospital in terms of There are tertiary partners for the things that we don't do And you know, there's a lot of cases that we do that Are appropriate to be done here. So how will it affect us? I'm not sure Yeah, no, I can appreciate that. Um, I just didn't hear you talk about it or reference it in a list of the risks And so I wanted to bring it up And you know I do have some concerns about Some of the utilization projections Um In light of the Dartmouth-Hitchcock bed tower in light of board member walsh's comments around You know Cost sharing is going to be increasing potentially You know, we're seeing increases in health insurance premiums that may lead people to drop down in metal levels have higher cost sharing That may translate often does and purely shown translate into lower Utilizations The other piece that I think is worth You know, discussing at least is the the public health emergency to the degree that that's removed There may be some Medicaid redeterminations that take place and where those patients end up May also impact utilization to the degree that they end up uninsured and then delaying or postponing care Or even, you know in a Very underinsured You know plan So high deductible plans. So I I these are all things that I'm thinking about and I'm wondering if you know, the Medicaid redeterminations have also weighed in on your Mind in terms of utilization or a pair mix or what happens to free debt and you know Well, we're we're working very closely our partner in our market is that is valley health connections And we work very closely with them on our financial assistance Program and I know that they're doing a lot of work with this group of patients now To make sure as many people can continue to be qualified as possible It's I I I just want to fully appreciate all the uncertainties that you're trying to make a budget around So, you know, I think none of us have crystal balls But these are just areas that that strike me and I at the end of the day what I really worry about is Um, you know when there's projections in the budget that are Potentially aspirational I'll just call it that if there's utilization numbers that you're hoping that you're going to get And springfield has not always met the targets for npr But the the cost structure is built around achieving those npr targets and so then when those targets aren't met and they're built around a utilization assumption that may or may not manifest itself I worry about your Sustainability right making a margin next year and you've been successful this year with making a margin But it's largely based on grant funding, right? So You know, will you go back to negative margins? If the utilization doesn't materialize so that's You know, I'm trying to figure out. What are the error? Marchions around these utilization assumptions and given the uncertainty I think they're quite large But the swing then for springfield is is also then quite large and trying to make that margin so Any and all information I guess I would ask that you have it if you have any more Data that could support the utilization assumptions that you're making Um broken, you know, I understand it's podiatry understand its urology You know, what is the differential you had two part time ob gyn that's one full time ob gyn you said that that there's a Delta there. How big is that delta right? You went from eight days a month And I think it was I can't remember now. There's urology or podiatry announced 10 days a month. What what is that delta? Is that really going to contribute the utilization that you're anticipating? You have a general surgeon that you're recruiting for how long does it take to recruit and then Ramp that you know that provider up to the to meet those utilization assumptions So any if you have any additional data or Assumptions around that I think that would be helpful if you could share with Sarah Lindbergh and the team that would make me feel better with this with this budget that you're submitting We can do that, but I will just comment, you know, particularly on those three Those are areas where demand is current is exceeding current supply now And that's why we're increasing the availability of those specialties. I mean podiatry It has just been very underserved in this market and again We can we've throughout the course of the first year of that provider we've continued to add days due to To demand on the the appointment book and the same thing with urology urology has gone Is doubling in coverage due to the availability of patients calling and the demand for it So so it's not putting it's not putting the doctor out there It's not the it's not building and they will come it's their their calling and wanting to come But we don't have a place for them to go now. So No, I mean it sounds like you're really meeting on met need in your community I'm just wondering is Is there is their capacity to even add more to the to either of those practices, you know add more days So that you could really for sure meet those utilization numbers Well on gyn I will we will add some other We will add another provider of some sort in that specialty to allow us More call coverage and to to have another set of hands for for larger cases and more complex cases And so we are working on that second part of it right now But but those three particularly are areas where we're expanding because the demand is there Right. Yeah, I know I I appreciate that and I wasn't questioning the demand was there. I was questioning The incremental increases will you know make enough of a difference Um So I guess my last uh question is, you know, since the budget was submitted If you could share and again, this is something you can do in a follow-up any known or likely changes to any federal and state payments Any relief funds any donations or grants or any unexpected increases in Medicaid or Medicare That you have, you know, learned about since the budget submission or since, you know, that's not Incorporated in the presentation today That would be helpful if you could follow up with Sarah's team. So I think that is it from me Board members, do you have any follow-up questions before I take it over to I see shaking heads now. So Sarah Lindbergh. Do you have any Questions from our esteemed staff? No questions. Uh, Sarah Lindbergh head of the finance team here at the green mountain care board Just want to say that we'll be following up We want to make sure all your material is up to date and sorry that we haven't been as proactive and making sure that That's all in place. So that's a little bit of a growing pain for our team So I appreciate your partnership and we'll make sure the numbers are correct and tie out. So thank you very much Thank you, Sarah. We appreciate your help through this process. We know we've called you a lot. So thank you Any time happy I like to joke. I haven't been on the phone this much since the 90s. It's just refreshing Well, it was it was us calling never mind All right, great. Um, I'm gonna ask then the health care advocate, uh, if they have some questions for springfield Yes, good to be with you san paiz health policy analyst with the office of the health care advocate. Good afternoon A couple questions from our office the first thing I just want to commend you on the health equity commitments You talked about previously with the health equity initiative look forward to hearing more about what comes of those collaborations Um, but our first question refers to so on page seven of the budget narrative You talked a bit about medicare advantage plans not coming in according to contract and that you're working to resolve it I was just wondering if you could provide an update about the status of resolving that issue and what impact you imagine it might have on this current or projected budget um, I think that That question is again pertains to the mechanics of implementing the rate increases as they have been approved and which ones are Some of those contracts are subject to rate increase limits that are already built into the contract. So, um I'll let kata comment on that But I think it's referring to the mechanics and the complexity of that process. So, you know, obviously we go through Doing the larger plans In priority and then we still have some other ones that we're still working on and so there's always a timing issue with that mechanics of that process I think the thing with our medicare advantage plans is that they they pay or are supposed to pay the same rates as our medicare um Rates that were being paid and so there's always um a delay When we receive a medicare Rate letter that our rates are changing and we received two this year We had a rate change in february and another one in may At that time it's up to us to identify all of the medicare advantage payers that our rates have changed and that you You know, these are the new rates that medicare is paying us So we're not getting that increase from the medicare advantage payment payers at the time of the medicare increase It's not simultaneously time Done there's always either a 30 to 60 day lag depending on you know, the minute you get that rate letter You have to let all the payers know and then they have you know, 30 days from that day to implement So there's there's always a delay in receiving Um The payments that I guess they're supposed to be paying us because of the notification piece of it so That probably wasn't Clarified in the narrative, but that's basically what it comes down to and we received a medicare rate change in may Um, which we've notified or we notified all of our payers at that time And we're confirming now that we're we're getting the medicare rates that They should be paying but it's basically resulting around the delay Okay, that's helpful. Thank you for clarifying that Um, the next question refers to responses that you gave as a part of the supplemental data monitoring You noted during the time frame from 2014 to 2019 the springfield hospital hsa reported an aging population The percentage of people 65 plus increasing to 22 which you said was the highest of all hsa's And you've talked about today increasing poverty In your hsa and that you serve an elderly and high poverty population With these figures in mind I'm wondering if you can speak to the fact that you have the highest debt to free care ratio of all the hospitals This is based on 2021 actual Which is a ratio of 4.7 to 1 So i'm wondering if you could talk about the obstacles to providing more proportionally Free care relative to bad debt given these challenges you talked about What what is what is the ratio you you quoted saying? 4.7 to 1 of bad debt to free care And I get out again. I would refer back to our financial assistance process You know, we we handle all of these the same We have a very good partner locally in valley health connections who helps us with our financial assistance Process so people that are eligible for financial assistance are processed through the partnership with that agency And I think they do a really outstanding job of it So i don't okay. Do you have a comment on it? I don't really have a sense as you're saying that bad debt as a Percentage of the the free care is four times higher Yeah, just as a ratio It's one of the I mean this is I mean it's not surprising I think that our office is hopeful that more of that uncompensated care can be shifted to free care rather than bad debt So that's I mean we have an access and affordability concern which motivates the question Sam could I just jump in for a second? I mean, yeah at 4.7 You know, I I question whether your contractor Is actually doing such a great job because at least compared To the other hospitals in the state You are a huge outlier So I guess not to criticize that but I think That's a space to look at and given the consumer angle or the impact on consumers. I don't think it's adequate to say the Organization that's handling it is doing a good enough job Because evidence would suggest it's not And then in our last question is Related to that you talked about in the narrative on page 12 in the management and contract services line Increased costs related to a patient billing vendor. I'm not sure if that's the one that you just alluded to He said the cost of these billing services increased as a result of higher collections during fy 22 And are now included in the current run rate for fy 23 Given this seems like it would increase your own costs And we know historically from data that the likelihood of retrieving bad debt From vermoners is historically quite low We're wondering what obstacles you have Experienced rather than shifting that white like what obstacles are that are shifting that to free care rather than allocating more to Trying to increase collection activity I don't know if that's that vendor is not only doing our self-paid collections better follow-up as well So it's not just our self-paid collection. So that is referring to Those are all my questions back to you chair homes Great at this point. I would love to open it up to public comment if there's anybody here who has some public comment Yes, I see dale hack it with your hand raised take it away dale One quick one on bad debt Sometimes I wonder if the reason the person won't engage in services being offered Is that they're afraid that by the time the services are utilized There's enough of an outstanding debt that then If the collection process is aggressive That turns them off from the whole process because They get scared And I've heard this mentioned. I haven't been able to join on every hospital presentation, but If there's any feedback on that as far as Something scares them away. I I really do believe that When obviously there is Help that could be helpful But is it helpful enough or is there a negative in there that Would be very important to the consumer my second question is more about Uh, Jessica, you mentioned the beds that Dartmouth was going to open up I'm wondering how much there is communication between Vermont hospitals and Dartmouth and Dartmouth has a sensitivity to While they may have the beds helping us Keep services in Vermont that will serve Vermonters And I know I've had some situations where I've been down at Dartmouth Because services weren't available in Vermont But if they could bring somebody from Dartmouth up here as a team approach to provide those services Then you're keeping them local I know I've had physical therapy issues where I ended up at Dartmouth because the surgeon wanted me there and I strongly felt like That's what the surgeon was familiar with because as soon as I realized that that's Physical therapy could actually be done up here. I merely transferred it back here myself and said hey There's no reason for this. I can get this up there where I live And I immediately saw that as come on guys communicate And I don't necessarily want to you know travel an hour each way just to find out that I could have gotten on a bus and gone a half hour away and gotten the same service um your feedback on that in terms of I don't know my feeling as a consumer was We need better communication and I recognize there's complexities within the system that can keep what Seems very practical from happening. We seem to hear that a lot In a comment Thank you. Thank you, Dale. I don't know if Bob and team you have any comments that you might share on the bad debt Experience at springfield and then maybe talking a little bit about some of those opportunities and the relationship that you have built with Dartmouth Hitchcock with respect to sharing services To keep care local when possible Well, I'll I'll just say that we need to we need to look into the bad debt Versus free care ratio a little bit more to make sure we understand how we're Categorizing and what's in what category I do We do have an initiative that we're working with our local provider That we're working on on that right now. So I think that we have a good relationship and I think the Sir the agency does a good job for us. So we just need to look at the whole to all of it Our community health needs assessment, you know cost and affordability It was one of the top issues identified in that so we're very sensitive to making sure we meet the needs of that And I guess I guess the thing that Mr. Hackett just spoke about We were very much in agreement with and that's coordinating within the system So that we provide the right care at the right place And you know, we have a good communication with that tertiary partner and we work closely with them and you know, we Rely on them for a lot of the services that we cannot provide and they put one of the best hospitals Anywhere, you know for that but we do work very closely and communicate with them to keep care appropriate in our local community Great, I appreciate that and Dale your hand is still raised. Do I assume that you have to not put it down yet? Or do you have a second question? I do not have a second question. I just forgot to lower their hand. Thank you No worries. Okay. I see ham davis with your hand raised Go ahead ham Thank you. I just want to push your question a little bit. I want to ask the Springfield team when they've talked about utilization. They've talked about the needs in their community What's available in their market are not available in their market? I think I understand his answer to your question But I'd just like to confirm it when when he when the when springfield talks about its market Does it consider Dartmouth-Hitchcock part of its market? And we'll turn that one over to you, Bob Well, I mean, there's a lot of different ways of looking at service area. Starmuth is in our service area and you know If you look at hospital discharges from our primary service area quite a few patients Do go to Dartmouth. So there's an overlapping service area there But I'll also say because of the nature of their tertiary services Their service area is much larger because those specialties have a much larger catchment area than ours do Right, but isn't the question sir, isn't the question really when you're talking about designing your service lines And the question of which is more on the as care tends to get more Complex it tends to get more lucrative Okay, and so one of the questions in all of these smaller hospitals is Is the Is the trying to keep as much Volume inside your own your own hospital. Okay A response to the actual needs of the community or is it a response to the needs of the financial needs of the hospital? That that's my concern and I so that so I think that's what and I I'm not I don't speak I'm not speaking for Jessica Holmes. Okay, but but I I think that I think I heard that in her question That that's that is a real issue Thank you Well to the extent to the extent that a service is needed You know via patient and we believe we can provide that service and it's appropriate at our level And is to right care at the right place and hopefully It's at a cost competitive advantage And it's more convenient for the patient So I mean those are the those are some of our factors if it helps us with our cost and revenue structure then Then that's also positive because we do have certain fixed costs that we have to support here To have any hospital open I understand but I and I don't want to be mean I but one more statement It's your sir. Do you know whether the the uh the surgeries that you carry out meet the leapfrog volume Standards, I don't know that sir Thank you Okay, thank you very much ham appreciate that Um line of questioning and I think at this point it's 230. I don't see any other hands raised I'll just open it up in case there's somebody who is waiting in the wings that wants to make another public comment Is there anybody waiting? Okay, the seeing none hearing none I think what we'll do is we're going to take a 15 minute being very generous this time recess We'll come back at 245 to hear northwestern A spring field team. I want to say thank you to you all for coming and for preparing these materials and you know I know you're doing a lot of incredible work trying to to turn around the hospital and and provide care for your community So I know our questions are tough, but I do appreciate the work that you're doing So Thank you very much. Thank you. Yeah. Thank you for coming today and um, let's come back here at 245